Home Health & Hospice Week

Know the difference between telehealth and telecommunications for cost reporting purposes.

As if home health agencies don’t have enough on their plates in 2020, now they have additional issues to worry about under their newly finalized Medicare cost report form.

Reminder: In the new home health cost report form released Oct. 2, the Centers for Medicare & Medicaid Services pushes back its effective date six month, to “Cost Reporting Periods Beginning on or After January 1, 2020 and Ending on or after December 31, 2020,” CMS says (see HCW by AAPC, Vol. XXIX, No. 37).

But that still leaves HHAs on a calendar-year cost reporting time frame — which is the majority of agencies — a full 10 months into the reporting year, says finance expert Dave Macke with VonLehman & Co. in Fort Mitchell, Kentucky. HHAs that didn’t look at the proposed forms and prepare for the changes are going to have issues with accurate data, Macke warns.

One of the form’s biggest changes is collecting data that CMS will be able to use to calculate hourly wages. In Worksheet S-3, Part V – Occupational Wage Data, CMS asks for “paid wages and salaries for the specified category of HHA employees including overtime, vacation, holiday, sick, lunch, and other paid-time-off, severance, and bonuses” for direct care workers, according to the updated cost report instructions accompanying the new form. The data is reported for each discipline, including — for the first time — supervisors and nurse/therapy assistants. For direct workers, HHAs also report “the amount of fringe benefits.”

HHAs then must report “the number of paid hours corresponding to the amount reported” for that discipline and divide the salary amount by the paid hours to arrive at an “average hourly wage,” the new worksheet and instructions show.

“That worksheet scares me,” Macke tells AAPC. The data reported on it “may be the genesis of of some kind of rebasing” of HHA payment rates, with the rebasing bringing rates down.

CMS doesn’t “just collect data for the sake of collecting data,” Macke cautions. As it did with hospices, CMS is almost surely going to use the hourly wage data to bring payment rates in line with what it says HHA costs are.

The problem: The hourly wage data is going to be lacking in accuracy — definitely at first, and even in the longer run, experts maintain. HHAs will have a myriad of difficulties in collecting and reporting data, ranging from failing to capture accurate time data from their own employees — especially if paid per visit rather than per hour; to not receiving accurate time data from contractors regardless of pay structure; to implementing ways to keep track of supervisors’ time.

“It’s going to be a challenge,” Macke sighs. That’s particularly true if agencies haven’t been collecting such data all along this year.

Other data accuracy complications HHAs may encounter under the new form and instructions include:

• Telecommunications Technology. One of the additions to the General Service Cost Center list in Worksheet A is Telecommunications Technology, renamed from Remote Patient Monitoring in the proposal. This category may prove confusing on a number of fronts.

Definition: Eligible costs are “allowable administrative costs related to telecommunication technology, referred to as remote patient monitoring,” the instructions say. “Remote patient monitoring is defined as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency.”

Usage: Further, “if remote patient monitoring is used by the home health agency to augment the care planning process, the costs of the equipment, set-up, and service related to this system are allowable only as administrative costs. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, or training the patient on the remote patient monitoring equipment, without the provision of a skilled service are not separately billable,” the updated form instructions say.

Telehealth confusion: Telecommunications and remote patient monitoring are not the same as telehealth. “Telecom­munication Technology does not include telehealth services, which are reported as non-reimbursable services,” advises consulting firm The Health Group in Morgantown, West Virginia. “Telehealth services are subject to certain criteria,” The Health Group explains in its electronic newsletter.

“Often agencies use these terms interchangeably,” Macke points out. But they are different, and are treated accordingly  

in the cost report. “Do not report telehealth services on this line,” CMS instructs of the Telecommunications cost center. Telehealth comes from a physician and is not covered under the home health benefit, Macke highlights.

• Nursing Administration. Another General Service Cost Center addition is Nursing Administration. HHAs have been recording that type of data under the Administrative and General cost center, and are likely to have trouble detangling those two categories, especially the first year, Macke predicts.
• Medical Records. Yet another addition to the list is Medical Records. While larger agencies may have a separate medical records department, smaller agencies often have staff performing records duties at point of care and don’t have the duties included in their back office, Macke observes. That will prove a challenge for separating out those costs.
• Vaccine Administration. An addition to Worksheet C is the “Cost of Administering Vaccines.” It also appears under HHA Reimbursable Services on Worksheet A. This new category may prove tricky, Macke forecasts. That’s because nurses often give the vaccines as part of their usual home health visits.

“Enter the cost of administering pneumococcal, influenza, and hepatitis B vaccines, and osteoporosis drugs,” CMS instructs for the item. “Attach a schedule detailing the methodology employed to develop the administration of these vaccines.”

“The cost of travel is not permissible as a cost of adminis­tering vaccines, nor is the travel cost includable in the A&G cost center,” CMS cautions in the instructions. “The cost of adminis­tering pneumococcal, influenza, and hepatitis B vaccines is reimbursed under the outpatient prospective payment system (OPPS). The cost of administering osteoporosis drugs is reimbursed under the home health benefit.”

One method might be to develop a proxy for the time it takes a nurse to give the vaccine, Macke suggests.

Which Supplies Count?

The cost report changes aren’t all bad, though. Seemingly in response to comments, CMS has added the phrase “Charged to Patients” in the “Medical Supplies” category of HHA Reimbursable Services in Worksheet A, Macke highlights. This will help agencies remember that they are supposed to include the costs for nonroutine supplies in this category, but not the costs for routine supplies, he expects.

“These supplies are generally specified in the patient’s plan of treatment and furnished under the specific direction of the patient’s physician,” CMS explains in the updated instructions. “Medical supplies not reported on this line are those minor medical and surgical supplies not expected to be specifically identified in the plan of treatment or for which a separate charge is not made.” Examples are small things like cotton balls and alcohol prep, which are reported in the A&G cost center, CMS adds.

Watch for: Once the new cost report changes settle in, don’t be surprised to see CMS institute new cost report edits, Macke says.

For example: On the vaccine side, CMS may say that agencies can’t report vaccine costs in the “Drugs” line on Worksheet C without also reporting costs in the Costs of Administering Vaccines line, Macke predicts.

Note: Links to the new form and instructions are at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Transmittals/r1p247.