Home Health & Hospice Week

Warning: RAP instructions may boost your cancel rate.

As the Jan. 1 implementation date for the Patient-Driven Groupings Model gets closer, home health agencies will find out more about the system’s operational details.

The Centers for Medicare & Medicaid Services explained a number of PDGM mechanics in an Aug. 21 education call about the forthcoming payment system revamp (see Eli’s HCW, Vol. XXVIII, Nos. 29 and 30). And now it’s issued answers to some of the questions that came up in the call.

RAPs: In the August call, a home health agency asked about how to handle 30-day billing periods for patients whose service frequency is greater than 30 days — for example, patients who receive a service every six weeks.

In those cases, agencies should bill a RAP for the 30-day period with no visits, but not bill a final claim, a CMS official directed in the agency’s Sept. 18 Open Door Forum for home health agencies. That will establish the HHA as the agency of record and will help enforce consolidated billing.

“This practice of billing a RAP to let it then auto-cancel seems like it will contribute to an agency’s RAP cancellation rate,” says M. Aaron Little with BKD in Springfield, Missouri. Contractors are monitoring those rates and putting high-cancella­tion-rate providers on RAP suspension (see Eli’s HCW, Vol. XXVIII, No. 19).

The procedure “also seems to be counter-productive to the CMS goal of reducing the misuse of RAPs by actually creating a scenario where a RAP has to be billed and paid only to then never have a corresponding final claim billed.,” Little tells Eli.

The practice could be especially troubling in Review Choice Demonstration states, because agencies will most likely have to let some RAPs auto-cancel as they scramble to get their Pre-Claim Review requests affirmed.

And if CMS does phase out RAPs altogether, “there will have to be another—more appropriate—solution developed,” Little notes.

RCD: Meanwhile, home health agencies in the five RCD states — Illinois, Ohio, Texas, North Carolina, and Florida — will be keen to know how to handle 30-day billing periods under the medical review program. Each 30-day period of care will require a separate Unique Tracking Number (UTN) under RCD, the CMS staffer clarified.

Agencies in RCD states still need to know whether they’ll have to submit a separate PCR request for each 30-day period, Little points out. If so, that will double their RCD submission workload under PDGM, Little says.

OASIS: The CMS official also corrected an erroneous example provided in the August call. The scenario listed a M0090 (assessment completed) date of Dec. 30, 2019 as the occurrence code 50 date on the claim, and said the claims system would use that date to match the claim with the OASIS assessment.

In fact, there is a one-time OASIS certifi­cation instruction that negates that example, the CMS official acknowledged.

The instruction, included in an OASIS-D1 update issued earlier this year, says: “To allow for the 5-day recertification window for episodes of continuous care that begin 1/1/2020 through 1/5/2020, there may be cases where the RFA 4 - Recertification assessment is completed in the last five days of 2019. In these cases, CMS is temporarily waiving the requirement that HHAs enter the actual OASIS completion date in M0090, and instead enter the M0090 date of 1/1/2020. HHAs should be aware that in the event they attempt to submit the RFA 4 - Recertification assessment with an artificial M0090 date of 1/1/2020 prior to 1/1/2020, they will receive a fatal error preventing the transmission of the assessment. Therefore, HHAs should not transmit these assessments until 1/1/2020.”

Thus, the example provided should list Jan. 1, 2020 as the M0090 date and CMS has updated its slide presentation accordingly.

Note: Links to the PDGM call’s slides, clarification, recording, and transcript are at www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2019-08-21-Home-Health-Call.html. See the OASIS-D1 exception instructions at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/OASIS-D1-Update-Memorandum_Revised_May-2019.pdf.