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«DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 409, 424, and 484 [CMS-1560-F] RIN 0938-AP55 Medicare ...»

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As discussed in section II.B., “Outlier Policy”, of the CY 2010 proposed rule, and finalized in section II.A. of this final rule, in our final policy of targeting outlier payments to be approximately 2.5 percent of total HH PPS payments in CY 2010,

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include the national standardized 60-day episode payment rate.

As such, to calculate the CY 2010 national standardized 60-day episode payment rate, we first increase the CY 2009 national standardized 60-day episode payment rate ($2,271.92) to adjust for the 5 percent originally set aside for outlier payments. We then reduce that adjusted payment amount by 2.5 percent, the final target percentage of outlier payments as a percentage of total HH PPS payment. Next, we update by the final CY 2010 home health market basket update percentage of 2.0 percent.

As previously discussed in section II.C., “Case-Mix Measurement Analysis”, of the proposed rule, our updated analysis of the change in case-mix not due to an underlying change in patient health status reveals additional increase in nominal case-mix. As discussed, we are moving forward with our existing policy to reduce rates by 2.75 percent in CY 2010.

Consequently, to calculate the CY 2010 national standardized 60day episode payment rate, we then reduce the rate by 2.75 percent, for a final updated CY 2010 national standardized 60day episode payment rate of $2,312.94. The final updated CY 2010 national standardized 60-day episode payment rate for an HHA that submits the required quality data is shown in Table 1.

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payment rate for an HHA that does not submit the required quality data (home health market basket update of 2.0 percent is reduced by 2 percent) is shown in Table 2.

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c. National Per-Visit Rates Used To Pay LUPAs and Compute Imputed Costs Used in Outlier Calculations In calculating the CY 2010 national per-visit rates used to calculate payments for LUPA episodes and to compute the imputed costs in outlier calculations, we start with the CY 2009 national per-visit rates. We first adjust the CY 2009 national per-visit rates to adjust for the 5 percent originally set aside for outlier payments. We then reduce those national per-visit

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payments as a percentage of total HH PPS payment. Next we update by the current CY 2010 home health market basket update percentage of 2.0 percent. National per-visit rates are not subjected to the 2.75 percent reduction related to the nominal increase in case-mix because they are per-visit rates and hence not case-mix adjusted. The final updated CY 2010 national pervisit rates per discipline are shown in Table 3.

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discussed, we are returning 2.5 percent back into the HH PPS rates, to include the LUPA add-on payment amount, as a result of our final policy to target outlier payments to be approximately

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then reduce that amount by 2.5 percent, the final target percentage of outlier payments as a percentage of total HH PPS payment. Next we updated by the current CY 2010 home health market basket update percentage of 2.0 percent. The LUPA add-on payment amount was not subject to the 2.75 percent reduction related to the nominal increase in case-mix because it is an

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The final updated CY 2010 LUPA add-on payment amount is shown in Table 4 below. Just as the standardized 60-day episode rate and the per-visit rates paid to HHAs that do not submit the required quality are reduced by 2 percent, the additional LUPA payment should be reduced by 2 percent also. In neither the CY 2008 nor the CY 2009 HH PPS rulemaking did we include such an adjustment to the LUPA add-on payment amount. For CY 2010, the add-on to the LUPA payment to HHAs that submit the required quality data will be updated by the full home health market basket update.

The add-on to the LUPA payment to HHAs that do not submit the required quality data will be updated by the home health market

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e. Non-Routine Medical Supply Conversion Factor Update Payments for non-routine medical supplies (NRS) are computed by multiplying the relative weight for a particular

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Next we update by the current proposed CY 2010 home health market basket update percentage of 2.0 percent. Finally, we then reduce that adjusted payment amount by 2.75, to account for the increase in nominal case-mix. The final updated CY 2010 NRS conversion factor is shown in Table 5a below. The NRS conversion factor for CY 2009 was $52.39. For CY 2010, the NRS

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The payment amounts, using the above computed CY 2010 NRS conversion factor ($53.34), for the various severity levels based on the updated conversion factor are calculated in Table

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For HHAs that do not submit the required quality data, we again begin with the CY 2009 NRS conversion factor. We first adjust the CY 2009 NRS conversion factor ($52.39) to adjust for the 5 percent originally set aside for outlier payments. We then reduce that amount by 2.5 percent, the final target percentage of outlier payments as a percentage of total HH PPS payment. Next we update by the current CY 2010 home health market basket update percentage of 2.0 percent minus 2 percent) for a 0.00 percent update. Finally, we then reduce that adjusted payment amount by 2.75, to account for the increase in nominal case-mix. The final updated CY 2010 NRS conversion factor for

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0.9725 The payment amounts for the various severity levels based on the updated conversions factor, for HHAs that do not submit

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D. OASIS Issues

1. HIPPS Code Reporting In the proposed rule we clarified our policy regarding the submission of the Health Insurance Prospective Payment System (HIPPS) codes to CMS via OASIS. §484.250 requires HHAs to submit to CMS the OASIS data described in §484.55(b)(1) and §484.55(d)(1) in order for CMS to administer the payment rate methodologies. Also, as described in §484.20, HHAs must electronically report all OASIS data collected in accordance with §484.55 as a condition of participation, and HHAs must encode and electronically transmit the completed OASIS assessment to CMS in the standard data format as described in §484.20(d). For those OASIS assessments required for payment,

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HHA to CMS includes a HIPPS code, generated by grouper software at the HHA. When an HHA electronically transmits OASIS assessments to CMS (via the State agency), the CMS OASIS submission system performs a validation check of the transmitted OASIS items, including the submitted HIPPS code. If the CMS OASIS submission system validation determines that the submitted HIPPS code is in error, it informs HHAs of that error via the Final Validation Report which is returned to HHA. The Final Validation Report will include the valid, CMS OASIS submission system calculated HIPPS code. We have become aware of a proliferation of incidents where the HIPPS code submitted to CMS on the OASIS does not match the HIPPS code, which is calculated by the CMS OASIS submission system. The HH PPS Grouper Software, which is used by the CMS OASIS submission system in its validation, is the official grouping software of the HH PPS, and thus the HIPPS code produced by the CMS OASIS submission system is the HIPPS code that should ultimately be billed on the claim. Consequently, in the interest of accurate coding and billing, we proposed that the HHA be required to ensure that the HIPPS code billed on the claim is consistent with that which CMS’ OASIS submission system calculated. In the case where the

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different than the HIPPS code submitted to CMS by the HHA on the OASIS, the HHA must ensure that the HIPPS code from the Final Validation report is the HIPPS code reported on the bill.

Comment: Commenters were supportive of our proposal to require that the OASIS HIPPS code match that on the claim.

However, one commenter noted that some software cannot identify claims that need to have the HIPPS codes reconciled, and suggested we allow time for vendors to accommodate, and time for providers to develop internal procedures. This commenter also asked that we clarify if greater detail what is meant by noncompliance. If the proposal is finalized, and enforced on an individual claim basis, this commenter suggested that after a delay for systems changes, we allow for testing of individual claim edits by generating warning messages. The commenter suggested this occur during a trial period to give providers time to test out procedures and software.

Other commenters wrote that if we move toward requiring claim-by-claim verification of the HIPPS codes against the OASIS data repository, the system should be constructed to avoid delays in payment. One commenter stated that the proposed rule wasn’t clear about when the trend toward incorrect HIPPS coding

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refinement, did we consider factors outside of HHA control, such as the effect of item M0110, which impacts the HIPPS code. HHAs may not have enough information to answer M0110 at the start of the episode, but the FI may automatically change the HIPPS code due to more current information related to M0110 in CWF which was not available to the HHA at start of care. The commenter asks how we will ensure that the HIPPS codes match in this scenario, and how agency oversight would occur. Another commenter asked what the consequences would be if a few claims had minor discrepancies, and would like us to provide additional information on the implications and consequences of policy statements regarding the differences in HIPPS generated by OASIS and HIPPS on the claim.

Some commenters expressed concern that some vendor billing software used by HHAs is not currently able to identify situations where the HIPPS code submitted on claims needs to be reconciled to the HIPPS code calculated by State OASIS systems.

The commenter requested that CMS allow additional time for vendors and HHAs to make changes to their software and that CMS systems generate warning messages during a trial period.

Response: HHAs do not necessarily need to change their

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If HIPPS codes generated by the HHA’s software do not match the code calculated by State OASIS systems, the HHA currently receives a warning message alerting them to this problem. HHAs should use these warning messages as a trigger to correct any HIPPS code submitted for payment by either canceling and resubmitting any paid Request for Anticipated Payment (RAP) or adjusting any paid claim. Since canceling or adjusting claims are routine billing processes, we do not believe additional time is necessary to allow HHAs to prepare for them.

In the future, enforcement of this requirement may be implemented on a pre-payment basis. HHAs should seek to improve their compliance and their internal processes now in order to prepare for any future pre-payment requirement. Specific information about future enforcement mechanisms will be provided by Medicare program instructions with sufficient time for HHAs to prepare for them.

The information that highlighted the errors in HIPPS code reporting reflected all 2008 claims. However, the information compared the HIPPS codes the HHA initially submitted on claims with the HIPPS codes calculated by the State OASIS system for the same episode. Both the HHA and the State system were using

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changes in that information could not affect the results. CMS will consider the effect of M0110 information in any future enforcement mechanism.

As such, in the interest of accurate coding and billing, we are implementing the provision that the HHA be required to ensure that the HIPPS code billed on the claim is consistent with that which CMS’ OASIS submission system calculated. In the case where the Final Validation Report returns to the HHA a HIPPS code which is different than the HIPPS code submitted to CMS by the HHA on the OASIS, the HHA must ensure that the HIPPS code from the Final Validation report is the HIPPS code reported on the bill.

2. OASIS Submission as a “Condition of Payment” Section 484.20 requires that HHAs must electronically report to CMS (via the State agency or OASIS contractor) all OASIS data collected in accordance with §484.55 as a condition of participation. Additionally, §484.250 requires that HHAs must submit to CMS the OASIS data described at §484.55(b)(1) and (d)(1) in order for CMS to administer the payment rate methodologies. Building on the above clarification for HHAs to ensure the HIPPS code reported on the bill is consistent with

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to be consistent with §484.250, in the proposed rule, we proposed to require the electronic reporting of OASIS to CMS as a condition of payment in §484.210. Currently, as a requirement for pay for reporting, HHAs are required to submit quality data (that being OASIS data) in order to receive the full home health market basket update to the rates. The burden associated with the requirement for the HHA to submit the OASIS is currently accounted for under OMB# 0938-0761. Making OASIS submission a condition for payment is consistent with both OASIS submissions being a condition of participation and a requirement to receive full market basket updates under pay for reporting.

Comment: Several commenters supported our proposal to require OASIS reporting as a condition of payment, calling it an appropriate step toward ensuring agreement between the HHRG on OASIS and that reported on the claim. However, these commenters were confused because they wrote that the proposed regulatory language and the language in the current regulation are the same. They also requested that we clarify how the proposed change would affect current procedures for RAPs and claims submissions, saying that currently HHAs are required to have OASIS data ready for transmission before submitting a RAP, but

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