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OASIS Alert

Industry Notes

Published on Tue Apr 03, 2012

Expect medical review scrutiny in some new areas, the Centers for Medicare & Medicaid Services revealed at a recent industry conference.

Current problems Medicare medical reviewers are finding include old stand-by's, with homebound documentation first and foremost. About 43 percent of home health claim denials are for homebound reasons, noted CMS's Latesha Walker at the National Association for Home Care & Hospice's March on Washington conference March 26.

Other problems are medical necessity; failure to have a plan of care or physician signature for the POC; and a lack of documentation to support the services billed (for example, therapy visit frequency missing from the POC), Walker said.

But medical reviewers will be focusing on two new areas, Walker said. They will examine episodes that barely exceed the low utilization payment adjustment (LUPA) threshold of five visits. They'll determine whether documentation doesn't support the visits that push the episode out of a LUPA.

And medical reviewers will look at situations where an agency billed a low HHRG code for a first episode, but a higher one later.

Other issues CMS covered in its sessions at the NAHC conference include:
  • OASIS-C-1. If you're finally starting to get comfortable with OASIS-C, get ready for another change to the patient assessment tool. CMS will propose a rule with changes to the document, which will be known as OASIS-C-1, said CMS's Pat Sevast in the session. The changes aren't expected to be as sweeping as those between OASIS-B and OASIS-C.

The revisions are centered around the switch to ICD-10 coding, Sevast noted. While CMS has announced a delay to the implementation of ICD-10, "we are proceeding as if ICD-10 is going to be implemented Oct. 1, 2013," she said. That's because CMS's delay for the new coding set won't be official until it finishes rulemaking.
  • Rate cuts. In its prospective payment system final rule for 2012, CMS already set a 1.32 percent cut for case mix creep for 2013, noted CMS's Kristy Chu in the session. However, the average case mix under PPS continues to grow, Chu noted.

Observers expect to see an even steeper case mix creep cut in this year's PPS rules, they say.

CMS also will continue to address PPS issues that incentivize growth, Chu said.

CMS is also moving forward on its PPS rebasing project. The agency is using outside contractors including L&M Policy Research, Avalere, and Mathematica to analyze potential changes and impacts, Chu told attendees.

  • Therapy reassessment confusion. Apparently HHAs aren't the only ones confused over the timeline for therapy reassessments. Starting last year, agencies must reassess patients both every 30 days and on the 13th and 19th therapy visit timepoints (with some exceptions for rural and multi-discipline cases).

But what happens if agencies miss the 13- and 19-visit assessment? The PPS final rule for last year and manual guidance indicate that agencies can bill for the 13th or 19th visit, then resume billing the visit after the assessment visit. So if the reassessment visit is the 14th one, billing may resume for the 15th visit.

But in the presentation, CMS indicated that the 13th and 19th visits also wouldn't be billable. NAHC will seek clarification on this issue, NAHC's Mary St. Pierre told attendees.
  • P4P. Slowly but surely, a pay-for-performance element to the Medicare payment system is making its way toward home care. CMS issued a March 15 report to Congress on the incentive system, now called value-based purchasing.

CMS is on track to implement value-based purchasing in the 2014 to 2017 timeframe as planned, CMS's Kelly Horney said in the session.

You can expect National Quality Forum-endorsed outcome measures to make up the criteria for P4P, if CMS's new report is any indication. You can see the 73-page report at www.cms.gov/HomeHealthPPS/Downloads/Stage-2-NPRM.pdf.

Observers also expect components of the P4P demo that ran in 2007 and 2008 to be included.
  • RACs. Recovery Audit Contractors have announced their first home health topics. But they may be affecting HHAs in other ways as well.

Other contractors use the RACs' information and data to identify vulnerabilities in the industry, Walker explained. And all contractors are sharing information in order to be alert to "issues that pop up in one area and not others," she said.
  • OASIS training. Much of CMS's OASIS training is based on the old OASIS-B form, Sevast acknowledged. The agency is working to replace that training with OASIS-C-based modules.

CMS has posted its first OASIS-C training module, which addresses medication items, at www.cms.gov/OASIS/10_Training.asp. It will post additional sessions very soon on care planning and interventions; nuero/emotional/behavioral status items; and integumentary/pressure ulcer items, Sevast said. CMS also plans to develop a module on activities of daily living and IADLs later.
  • COPs. New conditions of participations for HHAs have been in the hopper for at least 15 years, but they continue to be on CMS's to-do list, Sevast said. The rumor is that new CMS director Marilyn Tavenner is prioritizing them.

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