Home Health & Hospice Week

Plus: Learn about these new occurrence codes that can bring you higher reimbursement.

Your billing department will have its hands more than full with all the Patient-Driven Groupings Model changes coming next year. And even bigger billing and cash flow changes may await sooner than you think.

In a new transmittal, the Centers for Medicare & Medicaid Services follows through on its final rule provision to eliminate Request for Anticipated Payment reimbursement for certain home health agencies under PDGM. CMS will cut RAP payments only for HHAs certified Jan. 1, 2019, or later, the agency says in CR 11081 issued Feb. 1.

But remember: Even though new HHAs won’t receive RAP reimbursement, they still have to submit so-called “no-pay RAPs” at the beginning of each billing period to establish the home health period of care, a CMS official said in a Feb. 12 PDGM MLN Matters educational call.

HHAs won’t have to identify themselves as new on claims, the CMS official said in the PDGM call. The claims system will automatically identify the new providers and process the RAPs as no-pay.

Confusing: Agencies certified in 2019 will still receive RAP payments in 2019; they will discontinue receiving them in 2020, CMS indicates in its HH PPS 2019 final rule.

As for “existing HHAs, meaning those HHAs certified … prior to January 1, 2019,” they “will continue to receive RAP payments upon implementation of the PDGM in CY 2020,” CMS assures in the transmittal.

But CMS has discussed eliminating RAP payments for all agencies in previous rulemaking (see Eli’s HCW, Vol. XXVII, No. 39-40), and experts predict the agency will move in that direction.

The CMS official also noted in the call that HHAs will not submit admission source information on RAPs, as RAP payments won’t be adjusted for that information.

The staffer also pointed out in a Feb. 13 Home Health Open Door Forum the transmittal’s unusual timeframe. “I’m excited about this CR, because it’s the first time in my 20 years of doing this work that we’ve been able to issue instructions eleven months before the implementation date,” he said. While much of the technical information for Medicare contractors may go over the heads of providers, the transmittal should give HHAs “a sense of what’s going on behind the scenes” to prepare for PDGM.

Early publication of the PDGM billing instructions hopefully will give CMS a chance to issue clarifications for areas of confusion, he added.

Other billing-related information revealed in the transmittal or call includes:

• Institution status for later episodes. “Late 30-day periods are always classified as a community admission unless there is an acute hospitalization in the 14 days prior to the late home health 30-day period,” CMS explained in the presentation.

But: Those late periods “would not be classified as an institutional admission unless the patient had been discharged from home health prior to postacute stay,” CMS instructed. “HHAs have the option whether or not to discharge the patient if the patient is hospitalized for a short period of time.”

In the question-and-answer portion of the call, a CMS staffer reiterated that it is up to an agency’s discretion on whether to discharge.

• New occurrence codes. The elimination of the treatment authorization code (see story, p. 51) gives rise to a new requirement. “The OASIS assessment completion date will be required on all claims,” CMS said in the call. “Report occurrence code 50 and the OASIS item M0090 date.”

HHAs also may use new codes to report inpatient stays. Occurrence code 61 will indicate an acute care hospital discharge within 14 days prior to the “From” date of any HH claim, while OC 62 will indicate a skilled nursing facility, inpatient rehabilitation facility, long-term care hospital, or inpatient psychiatric facility discharge in that timeframe.

The discharge OC codes aren’t required, but they will help place your claim correctly into the higher-paying institutional category regardless of how long it takes the facility to bill the stay. Using the 61 or 62 code is merely “an option,” the CMS source told attendees. “If those codes are not present, Medicare systems will use the inpatient claims history to assign institutional payment groups based on the most current information we have.”

• Returns, not denials. If you use a diagnosis code that isn’t accepted by PDGM, you’ll get a second chance at it. The claims system will return — not deny — a claim for “more definitive coding” when a code “does not fall into a clinical group,” CMS explained.
• Comorbidity adjustments don’t add up. PDGM sets out three categories for comorbidity adjustments — none, low, and high. A claim will receive only one adjustment, CMS said. In other words, a claim can’t get both a low and high adjustment.

Stay tuned: This is just the beginning for PDGM preparation. This CR “represents a down payment on the revisions to Chapter 10 that are needed,” the CMS source said. “Many other sections need to be revised ... so you can expect additional transmittals later this year."

Note: The CR is at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4228CP.pdf.