Home Health Regulatory Roundup SDAHO Spring 2018 Presented by Annette Lee, of Provider Insights, Inc.

Lots of Changes! New COPs in full force (will talk about next session!) Updated Star ratings– now without the INFLUENZA measure New OASIS-D has been published for public comment CGS is implementing Targeted Probe and Educate edits Based on data regarding your agency How many denials did you receive on five FTF probe? Do you stand out in other data? PEPPER?

Lots of Changes Transfer of Health Information Measure- Medications IMPACT Act measure to follow if Medication information is provided to physician and patient at time of discharge Very detailed information– please speak up!! TOHPublicComments@rti

Lots of Changes! Medicare Cards without SSN will be mailed One + year transition where both are accepted Cards begin in April 2018-July 2019 Must use Medicare Beneficiary Identifier by 1/1/2020 One clinician convention is changing allowances for more collaboration https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/Downloads/OASIS-C2-Guidance- Manual-Effective_1_1_18.pdf

Collaboration “Although one clinician must take responsibility for the comprehensive assessment, collaboration with the patient, caregivers, and other health care personnel, including the physician, pharmacist, and/or other agency staff is appropriate. For items requiring patient assessment, the collaborating healthcare providers must have had direct contact with the patient”

Home Health and the IMPACT Act of 2014

Why the IMPACT Act Improving Medicare Post Acute Transformation Finding the best value Long term care hospitals, Skilled nursing facilities, Inpatient rehabilitation, and HHAs

Standardization The Act specifies that the data [elements] “… be standardized and interoperable so as to allow for the exchange of such data among such post-acute care providers and other providers and the use by such providers…to provide access to longitudinal information for such providers to facilitate coordinated care and improved Medicare beneficiary outcomes…

Assessments and Categories

So Many Uses...

Proposed Removal OASIS Items

Proposed New OASIS Items

Overhaul 2019 CMS proposing to have PAC settings collect data in the same way- Overhaul to OASIS Use GG items for function Adding cognitive items

OASIS D– Let’s Take a Look!

Medical Review Next steps will be Provider Specific Probes- 20-40 claims Formalized instruction for all medical review CMS did not specify a threshold “Providers who put the Medicare funds at risk” Be sure to request education if you had more than one error Remember- 120 days to appeal! NEW TOOL FROM CMS FOR REVIEWERS: https://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/Medicare-FFS-Compliance- Programs/Medical-Review/Downloads/Home-Health-Review-Tool-08- 30-17.pptx

Step 1 (Face-to-Face Encounter Requirement) Yes 1 Is a Face-to-Face Encounter note* present? NO YES No Yes 1.1 Was the Face-to-Face Encounter note signed and dated by an allowed provider type**? YES NO No Note Deny/ Non-Affirm reason (continue to step 2) Yes 1.2 Was the Face-to-Face Encounter performed by an allowed physician or NPP**? YES NO No 1.3 Does the Face-to-Face Encounter progress note indicate the reason for the encounter was related to the need for home health services? Yes NO YES No . Yes 1.4 Is the Face-to-Face encounter note dated between 90 before or 30 days after the start of home health services? NO YES No F2F Encounter Requirement ARE MET. Proceed to Step 2 (Plan of Care requirements) . * Face-to-face encounter note can include progress notes, discharge summary, etc. **Please refer to 42 CFR 424.22(a)(1)(v)(A) for detailed information on who can perform the face-to-face encounter.

Step 2 (Plan of Care Requirement) Yes No 2 Is Plan of Care present? NO YES No 2.1 Is the plan of care signed and dated by the certifying physician? Yes NO YES No Yes 2.2 Does the Plan of Care address all pertinent details as described in 42 CFR §484.18(a) including: Diagnoses; Mental status, Types of services and equipment required Frequency of visits, Prognosis, Rehab potential Functional limitations Activities permitted Nutritional requirements Medications and treatments Safety measures to protect against injury Instructions for timely discharge or referral, Any other appropriate items YES NO Note Deny/ Non-Affirm reason (continue to step 3) Yes . Yes 2.3a Does the Plan of Care include therapy services? NO YES No 2.3b Does the Plan of Care address; Specific procedures and modalities, Measurable therapy treatment goals, Frequency and duration of services NO YES Yes Plan of Care Requirements ARE MET. Proceed to Step 3 (Homebound) .

Step 3 Homebound Requirement Was any certifying physician and/or acute or post-acute care facility documentation submitted? NO YES Yes No 3.1 (Criteria ONE) Does the physician/facility documentation indicate that the patient requires a: mobility assist device or special transportation or assistance of another person to leave the home or has a condition that leaving home is medically contraindicated? No YES NO Yes 3.1a Do the HHA medical records or plan of care satisfy the homebound criteria ONE requirements? NO YES Yes No 3.1b Is the HHA info signed/dated by the certifying physician ? NO YES Yes No 3.1c Is the HHA info corroborated by the certifying physician and/or acute or post-acute care facility documentation? YES NO Yes No Note Deny/ Non-Affirm reason (continue to step 4) 3.2 (Criteria TWO)* Does the physician/facility documentation support that the patient has a normal inability to leave the home AND requires a considerable and taxing effort to leave the home? NO YES Yes No . 3.2a Do the HHA medical records or plan of care satisfy the homebound criteria TWO requirements? NO YES Yes No Yes 3.2b Is the HHA info signed/dated by the certifying physician ? NO YES Yes No HomeBound Requirement IS MET. Proceed Step 4 (Need for Skilled Care) 3.2c Is the HHA info corroborated by the certifying physician and/or acute or post-acute care facility documentation? NO YES Yes No Note Deny/ Non-Affirm reason (continue to step 4) . *In determining whether the patient meets criterion two of the homebound definition, the clinician needs to take into account the illness or injury for which the patient met criterion one and consider the illness or injury in the context of the patient’s overall condition.

Step 4 (Need for Skilled Care Requirement) Yes No 4 Was any certifying physician and/or acute or post-acute care facility documentation submitted? YES NO No Yes 4.1 Is skilled need (skilled nursing care, PT, SLP, or OT) supported by the certifying physician, acute care facility, or post-acute care facility documentation? YES NO No 4.1a Do the HHA medical records or plan of care support the the need for skilled services? Yes YES NO 4.1b Is the HHA medical record or plan of care signed/dated by the physician? No Yes YES NO Note Deny/ Non-Affirm reason (continue to step 5) No 4.1c Is the HHA medical record or plan of care corroborated by the certifying physician and/or acute or post-acute care facility documentation? YES NO Yes . Yes Skilled Need Requirement IS MET. Proceed Step 5 (Certification) . *Skilled need may be substantiated through an examination of all submitted medical record documentation from the certifying physician, acute/post-acute care facility, and/or HHA (see below). The synthesis of progress notes, diagnostic findings, medications, nursing notes, etc., help to create a longitudinal clinical picture of the patient’s health status.

Step 5 (Certification Requirement) Yes No 5 Is a certification statement(s)* present? YES NO No Yes 5.1 Does the physician certify that the patient requires skilled care**? YES NO No 5.2 Does the physician certify that the patient is homebound? Yes YES NO Yes No 5.3 Does the physician certify that a POC has been established by a physician who does not have a financial relationship with the HHA? YES NO Deny/ Non-Affirm (note all denial reasons from steps 1-5) 5.4 Does the physician certify that the patient is under the care of a physician? No Yes YES NO . No 5.5b Does the physician certify that the patient had a face to face encounter and did the physician document the date of the encounter? Yes YES NO 5.5a Did the certifying physician conduct and sign the face to face encounter note provided? No YES NO Yes Yes All Requirements ARE MET. Mark the case AFFIRMED or PAYABLE * A certification statement may appear in a progress note, plan or care, or any other part of the patient's medical record. It may be on any form and in any format. ** "skilled care" means skilled nursing care, PT, SLP, or a continuing need OT after the need for skilled nursing, PT or SLP have ceased. .

Top Denials 1.) Face to Face Certification/documentation 2.) No records received 3.) Therapy Downcode 4.) SN not medically necessary 5.) Recert statement with estimated end of services The physician's recertification estimate should be included on the recertification document along with other required elements of the recertification and not on any separate form or order. As indicated in the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7 Section 30.5.2, the physician must include an estimate of how much longer the skilled services will be required 

Beyond the New COPs Non-Discrimination regulations- Final October 2016 Ensure your ND statement includes auxiliary aides and interpreters Emergency Preparedness regulations- Effective November 15, 2017 Discharge and Transfers summary CONTENT PROPOSED regulations STILL WAITING (we have suggestions in IG’s) https://s3.amazonaws.com/public-inspection.federalregister.gov/2015- 27840.pdf Proposed 2019 Home Health PPS Update Released yearly in June/July as proposed Finalized after 60 day comment period reviews around Oct 31st Changes in payment, Quality Measures and new Home Health Grouping Model discussed for 2019

THANK YOU!!!  Annette@providerinsights.com