Update to EPM changes Proposed rule changes announced in August: reduction in mandated geographic areas from 67 to 34 Eliminating the cardiac bundles and the hip fracture bundles – at least for now Allowing individual clinicians to be a provider Hospitals in the voluntary areas must elect to participate by Jan 31, 2018 Medicare Advantage updates – on the rise; expected to increase by 30% in next 6 years Source of changes to program: www.cms.gov Publication # CMS-5524-P August 15, 2017

HH Proposed Rule Effective January 2019 HUGE changes to payment Reduces ‘episode’ from 60 days to 30 days Uses a ‘groupings model’ = 6 new clinical groups to categorize patients based on their Primary reason for HH services Revises functional levels in OASIS Changes LUPA’s, VPB and QRP Source: www.cms.gov publication # CMS-1672-P July 28, 2017

Home Health Groupings Model (HHGM - Proposed) 30 day periods Uses clinical characteristics to drive payment (patient centered) Primary diagnosis, functional level, co-morbidities, admission source and timing Eliminates therapy thresholds Based on cost per minute + routine supplies 1st 30 days = early episodic payment 2nd 30 days = late unless there is a gap of >60 days between episodes (SNF criteria!) Admission source is where the referral came from in the 14 days prior to the start of HH care (community vs institutional) 6 clinical groups 3 functional levels which indicate higher or lower costs to the agency

HHGM continued 6 clinical groups: Musculoskeletal rehab Neuro/stroke rehab Wounds Complex nursing Behavioral health Medication management, teaching, assessment There will be adjustments for comorbidities CMS is promoting ‘front loading’ Especially with heart disease and new musculoskeletal diagnoses Also with care transition times such as hospital to home or SNF to home LUPA thresholds vary based on payment group Each 30 day episode is placed into one of 144 HHRG’s Propose using 10% of visits or 2 visits whichever is higher Approximately 7% of 30 day periods would be LUPA’s

Section GG Traditional Medicare only/ SNF setting Shows functional improvement for quality performance and payment with 2% penalty attached if submission doesn’t occur by deadline Beginnings of ensuring equal playing field across PA settings and certainly among SNF’s Resident can use assistive devices – does not affect coding When assessing ability to walk or wheel 50 feet with 2 turns: Turns must be 90 degree turns Can be in same direction or opposite

Key Points Admission and Discharge performance ratings are NOT based on staff assessment of potential ability (so cannot copy rehab goals) Assesses need for assistance and establishes d/c goals for self care and mobility Items focus on self care and mobility – entire team must set these Admission performance Discharge performance Discharge goals Definition of ‘helper’ Must be employed or contracted by facility Does not include students, hospice personnel, family, private caregiver, etc.. Cannot code using occurrences from these non-staff personnel

Section GG Admission Coding Look back day 1 - 3 and assess ‘usual’ performance Important to not just rely on therapy evaluations as we know patients often are different outside of therapy Requires TEAM to look at 3 full days and determine the persons usual performance, not the best or worst Admission coding is CRITICAL to setting the stage for payment & outcomes Coding Tips: Stay away from use of Dash (means you have no information) Discern between 07/08/09 codes and have documentation to support choice 07= patient refused around the clock for the 3 days in the lookback period 08= patient cannot currently perform due to medical reasons but was able to prior to illness/injury 09= patient never performed activity therefore no goals for this now