Home Health & Hospice Week

Source of admission occurrence code will carry risks.

If you didn’t pay attention when CMS issued its report on the Home Health Groupings Model last winter, now’s the time to focus on the drastic pay revamp.

“We encourage all agencies, if not already familiar with HHGM, to make this a high priority,” says consulting firm The Health Group in Morgantown, West Virginia.

The Centers for Medicare & Medicaid Services has refined the HHGM model in its 2018 Home Health Prospective Payment System proposed rule released July 25. The model contains a number of tweaks from the plan unveiled late last year (see story, p. 302).

For example: CMS and its HHGM contractor, Abt Associates, originally planned to have 128 case mix groups under HHGM. In the proposal, that’s changed to 144 groups.

But the basics of the HHGM system have stayed the same. Check out the steps your episodes will go through to secure their case mix category:

Step 1: Classify 30-day episodes into four categories based on timing and source of admission — Community Early, Community Late, Institutional Early, Institutional Late. Points of clarification for this step:

• Even though episodes will switch to 30 days, there will still have to be a 60-day gap between the last episode and the current one for the current episode to qualify as “early.”
• The lookback period for designating a community or institutional source of admission will be 14 days. CMS investigated a longer lookback period, but deemed 14 days sufficient. “We believe that a 14-day ‘look-back’ period is more likely to be directly related to the patients’ need for home health care than a 30-day ‘look-back’ period,” CMS says in the proposed rule. “This would also be more intuitive for HHAs, as the OASIS item M1000 specifically assesses whether a beneficiary was discharged from an institutional setting within the past 14 days.”
• “Institutional” sources of admission cover acute and post-acute institutions including acute care hospitals and skilled nursing facilities.
• The claims system will automatically adjust this factor, although agencies can use a new billing occurrence code to indicate an institutional admission.
• Warning: Using an occurrence code when there’s no institutional stay may lead to increased medical review and referral to a Medicare fraud contractor, CMS says in the rule. “We believe that allowing HHAs to submit a claim with an institutional admission occurrence code for a beneficiary with either a Medicare or non-Medicare institutional admission source would enable HHAs to receive appropriate payment for the home health services, while also allowing us the opportunity and flexibility to verify the source of the admission and correct any improper payments as deemed appropriate,” CMS says. HHAs will have to document the stay for non-Medicare sources.

This code would likely be “problematic and an easy target for things like MAC probe edits and CERT errors, and RAC and ZPIC/UPIC audits,” worries reimbursement expert M. Aaron Little with BKD in Springfield, Missouri.

Step 2: Slot episodes into six clinical groupings based on principal diagnoses reported on the claim.

• The six groupings, based on diagnosis codes, are Musculoskeletal Rehabilitation; Neuro/Stroke Rehabilitation; Wounds — Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care; Complex Nursing Interventions; Behavioral Health Care; and Medication Management, Teaching and Assessment (MMTA).

Step 3: Assign episodes as Low, Medium, or High functional levels based on OASIS responses. Points for these categories will be assigned based on OASIS items M1800 (Grooming), M1810 (Current Ability to Dress Upper Body), M1820 (Current Ability to Dress Lower Body), M1830 (Bathing), M1840 (Toilet Transferring), M1850 (Transferring), M1860 (Ambulation/Locomotion), M1032 (M1033 for OASIS C–1) (Risk of Hospitalization).

• See points assigned for each item in Table 36 of the proposed rule and potential thresholds for each level in Table 37.

Step 4: Adjust for Comorbidities based on secondary diagnoses.

• The broad categories used to group comorbidities within the HHGM include Heart Disease (11 subcategories), Respiratory Disease (9 subcategories), Circulatory Disease and Blood Disorders (12 subcategories), Cerebral Vascular Disease (4 subcategories), Gastrointestinal Disease (9 subcategories), Neurological Disease and Associated Conditions (11 subcategories), Endocrine Disease (6 subcategories), Neoplasm (24 subcategories), Genitourinary and Renal Disease (5 subcategories), Skin Disease (5 subcategories), Musculoskeletal Disease or Injury (5 subcategories), Behavioral Health (11 subcategories), and Infectious Disease (4 subcategories).

The result: One of 144 case mix groups — see groups and their potential weights in Table 42 of the proposed rule.