Home Health & Hospice Week

PPS case mix creep, billing problems, NPIs also addressed in Open Door Forum.

Your outcomes measures may look different starting in August.

The Centers for Medicare & Medicaid Services is updating its risk adjustment methodology for outcome measures in outcome-based quality improvement reports and on Home Health Compare, CMS' Debora Terkay said in the May 13 Open Door Forum for home care providers.

Old way: Currently, 30 of the 41 outcome measures on home health agencies' OBQI reports are risk adjusted using methodology implemented in 2003, reported CMS contractor University of Colorado in the forum that drew more than 600 listeners. That includes one measure that is not adjusted on OBQI reports but is adjusted on Home Health Compare. All Home Health Compare measures are risk adjusted.

New way: Starting in August, all OBQI report measures will be risk adjusted using 50 risk factors, they noted. Current risk adjustment methodology uses 42 risk factors. CMS will eliminate the OBQI descriptive report which currently contains non-adjusted measures and all measures will go on the risk adjusted report.

However, risk adjustment for six of the measures isn't up to the standard for the rest. Those measures, which have so-called "R-squared" factors of less than 0.10, will be denoted with an asterisk on the risk adjusted OBQI reports, noted University of Colorado's Eugene Nuccio. R-squared factors de-note adjustment predictability.

New factors: The new methodology uses additional factors such as V and E codes and payor status, particularly for HMOs, noted University of Colorado's David Hittle. It also eliminates some factors, including patient length of stay which was deemed too influenced by agencies.

Home Health Compare will display the new risk adjusted measures starting in September. But don't expect your numbers to look too different. "Most agencies' risk-adjusted outcome rates will be comparable to those calculated using the current risk models," University of Colorado says in its slide presentation about the change.

The slide presentation with more details is at www.cms.hhs.gov/HomeHealthQualityInits/Downloads/HHQIODF20080513.pdf. CMS will post more detailed information about the methodology in June, Terkay said.

Other issues addressed in the forum include:

• PPS technical report. CMS released its PPS technical report from PPS contractor Abt Associates on April 30, CMS' Randy Throndset noted in the forum. The report includes details on PPS data analysis used to formulate the revisions for this year.

The industry has been calling for release of the report, which contains details about how CMS calculated the so-called case mix creep cut. "The basis of the case mix creep cuts of nearly 12 percent has been shrouded in mystery after CMS dropped its original method for reviewing changes in coding weights," notes the National Association for Home Care & Hospice.

"The release of the technical report will allow us to thoroughly examine the bona fides of the CMS process," says director of NAHC's Center for Health Care Law William Dombi. "If, as we be-lieve, the process used by CMS is completely different from the process proposed, we will pursue a class action lawsuit in federal court."

The report could also support current legislative efforts to require CMS to use a better process to determine reasons for case mix weight change, NAHC adds.

The report is available online at www.cms.hhs.gov/center/hha.asp.

• PPS billing. A fix for the current PPS episode sequencing problem will come in July, said CMS' Wil Gehne. The claims system is failing to recognize 2007 episodes when determining "early" or "later" status based on M0110. That has caused all episodes under the PPS revisions to score as early.

Because the solution requires complicated programming, the fix has to wait for implementation until July, Gehne reported. But regional home health intermediaries will automatically correct claims for episodes that should've been designated as later, he added. CMS will issue more information on those adjustments in an upcoming transmittal.

Plus: HHAs can also now download the new PC Pricer manual at www.cms.hhs.gov/PCPricer/05_HH.asp --scroll down to "Downloads."

• NPIs. Get ready for possible claims slow-downs. Providers have only a few short days until CMS will require NPI-only claims on May 23. "I'm hoping all of you have done what it takes to get into compliance with the NPI," a CMS rep said in the forum. "Everything is on track for full implementation on May 23."

CMS' recent "legacy-free day" showed that most claims with only NPIs were able to process with no hold-ups, the rep added.