Public Comments Can Make a Difference

On Friday, we submitted our public comment on CMS's Home Health PPS Rate Update for CY 2013. You can too. Formal comments are being accepted until September 4, 2012. 

As we noted in our blog post on August 8, we are concerned about restricting the use of OASIS field M1024 to fractures only. If implemented as written, we believe there is going to be a significant case mix (CM) decrease with unintended consequences for patients.

Our public comment offered the following solution: 

1. Fully implement what “Attachment D” was meant for by collaborating with HHA industry expects and revising and updating Attachment D annually as both coding rules and HHA payment regulations are updated on an annual basis. 
   
2. Do not restrict diagnoses codes limited to M1024 other than what is the intention of Attachment D. If it is the intent of CMS to control CM by limiting diagnosis to this field, a full cost analysis is needed prior to implementation. 
   
3. Mandate that only CM codes are placed in M1024 and not allow EMRs to allow otherwise. Have MACs audit for accuracy. 
4. Acknowledge the use of certified coders in homecare. Give them the ability to correct inaccurate coding by clinicians, with specific documentation on what was corrected and why.

View our comment on the Federal Register's website. Let us know if you plan to submit a comment.

NAHC Report: Diagnosis Coding Changes Proposed in 2013 PPS Notice Carry Negative Impact

At Daymarck, we are pleased that the National Association for Home Care and Hospice (NAHC) is also concerned about CMS' proposed prohibition of reporting any diagnosis codes other than fracture codes in OASIS at M1024. The NAHC Report Article published on Aug. 21 (and attached below) discusses their concerns and urges home health agencies to evaluate the impact of these proposed changes.

According to William Dombi, Vice President for Law at NAHC, "The proposal may affect two to four percent of episodes as much as $200 per episode. That is a material impact that should require CMS to drop this idea or recalibrate all the case mix weights to make sure the change is budget neutral."

We are are pleased to offer a reprint of the article below.  Read what Daymarck has to say on this important issue, including our public comment to CMS.

NAHC Report Article

Issue# 2026, 8/21/2012

Diagnosis Coding Changes Proposed in 2013 PPS Notice Carry Negative Impact
NAHC Urges Agencies to Review the Rule Change

In the 2013 Prospective Payment System (PPS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) revealed a plan that would result in the prohibition of reporting any diagnosis codes other than fracture codes in OASIS at M1024.

In the July 13 Federal Register notice, CMS stated that when they updated and released Attachment D: Selection and Assignment of OASIS Diagnoses in December 2008 “this guidance was designed to ensure that providers limited the number of diagnoses assigned to M1024.” M1024 replaced M0245 in OASIS C. M0245 was the OASIS data field created to record case-mix diagnoses ICD-9 Coding rules required that V codes be used in primary and secondary diagnoses in order to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements. According to CMS, an analysis of home health claims found that many home health agencies don’t comply with Attachment D guidance.

CMS Position

According to Attachment D, home health agencies are limited to reporting Fracture, Diabetes, Neuro 1 and Skin 1 codes in M1024. However, Diabetes, Skin 1, and Neuro 1 codes may be reported in M1010 and M1020. Fracture codes are the only codes that may not be reported as primary or secondary diagnosis. As a result, CMS has proposed two enhancements for the HH PPS Grouper:

Restrict M1024 to only permit fracture (V-code) diagnoses codes which according to ICD-9-CM coding guidelines cannot be reported in a home health setting as a primary or secondary diagnosis.
Pair the fracture codes (V-code) with appropriate diagnosis codes to limit the award of grouper points only when these pairings appear in the primary and payment diagnosis fields.

Revise the HHRG logic to permit equivalent scoring when the Diabetes, Skin 1 or Neuro 1 codes are submitted immediately following the V-code in the M1020 position without requiring utilization of the payment diagnosis field.

Shortcomings of CMS Proposal

In its efforts to update the HH PPS case-mix system, CMS had its contractor analyze home health claims and OASIS data from the first five years of the PPS to determine whether the case-mix system required revisions. As a result of this analysis the original diagnostic categories of Diabetes, Neuro, Ortho and Skin were expanded, and several new diagnostic categories were added that included: blindness, blood disorders, cancers, gastrointestinal disorders, heart disease, and hypertension. The data analyzed led to the determination that these additional diagnostic conditions were indicators of home health resource utilization. Much of the information about the impact of these diagnoses on resource utilization was collected from the period of time prior to the implementation of the HIPAA. Therefore, the diagnoses were reflective of coding practices at that time, including the reporting of conditions that were resolved by surgery or recovery, but for which home health patients received aftercare.

For example, such gastrointestinal disorders, as acute appendicitis and cholelithiasis are never conditions for which a Medicare beneficiary would receive home health services. However, prior to HIPAA and the establishment of M0245, and even into 2004, reporting of conditions resolved by surgery as primary and secondary diagnoses was the longstanding practice of home health agencies providing post-surgical care.

These CMS proposed changes to the HHRG will deprive home health agencies of case-mix points and payment for services for care to patients whose conditions are resolved by surgery, disregarding the fact that these diagnoses were found to impact resource use. Included are the majority of gastrointestinal conditions, cancers and orthopedic conditions treated by surgery as well as resolved infections that require post-acute care in the home for (e.g. meningitis). Furthermore, prohibiting reporting of diagnoses that require V code reporting in the primary and secondary fields in OASIS M1024 will eliminate all vehicles for capturing important public health and health planning data sources about underlying medical conditions that require post-acute home health services.

The National Association for Home Care & Hospice (NAHC) has identified a vast array of diagnoses that will no longer be eligible for case-mix points if removed by surgery, including conditions in the following ICD-9 categories: 140-199, 213-234, 320-329, 414, 440,530-562, 564-567, 569 and 570, 574-577, 685, 707, 711, 713, 715 and 716, 720-724, 726 and 727, 730, 731, 733, 741, 785, and 831-838.

NAHC urges home health agencies to evaluate the impact of these proposed changes. To learn more about this proposal and other proposed rule changes and payment updates for 2013 the Federal Register notice can be accessed at http://www.gpo.gov/fdsys/pkg/FR-2012-07-13/pdf/2012-16836.pdf. Comments about this proposal and other changes to home health regulations (F2F encounter, therapy reassessment requirements) must be submitted to CMS by 5PM on September 4, 2012.

Home Health PPS Rate Update for CY 2013

Changes to OASIS Field M1024

On July 6, 2012, CMS announced proposed changes to the Medicare home health program for 2013 that, as they noted in a press release, “would foster greater efficiency, flexibility, payment accuracy and improved quality.” 

We wish that were the case. 

As many of you know already, by law CMS has to update the payment rate every year. While many of the primary focuses of the proposed changes are expected, and in fact will do some good, there are a few major items that are receiving very little attention and should be of concern to home healthcare agencies and their patients and families. Specifically, we are very concerned about proposed changes restricting the use of OASIS field M1024. While on the surface the rule would appear to simplify coding of this section, if implemented there is going to be a significant case mix (CM) decrease, with unintended results affecting patient care. 

The proposed rule addresses what CMS sees as an overuse of diagnoses assigned to M1024. Basically, M1024 is an additional optional area of the OASIS form where codes are put in to help with payment calculation. Its use should only be used on a limited basis, but because of poor direction and management from CMS in the past, plus ongoing issues with EMRs, home healthcare agencies (HHAs) have been inconsistent on how they have used this field over the years.

 

CMS also states in the proposed rule that many HHAs are not complying with the guidelines of “Attachment D” which was published in December 2008. It is true that adoption of Attachment D by the home healthcare industry has been spotty. But CMS is also not acknowledging its lack of proper implementation of Attachment D. First of all, they published these guidelines 11 months after the PPS changes went into effect which these guidelines covered.  When they were first published, they were full of errors and the examples that they had within the document did not even follow their own guidelines. They later revised these guidelines but, as industry experts will tell you, they still continue to provide confusing and conflicting guidance. In 2010, HHA switched to OASIS-C, however, Attachment D still uses the language of OASIS-B (i.e. M0246). 

 

How does CMS expect an industry to follow the guidelines when they are riddled with errors, offer conflicting guidance and are out-of-date?

Other ongoing issues have also contributed to the use of M1024 that CMS fails to address in this rule. Many EMR systems, for example, are not setup properly and require every V code to have a corresponding code in M1024.  In the past, CMS has told agencies that this is “okay” as they are limited by their EMR system, instead of demanding that the EMR system fix the problem.

Lastly, if there is a coding error, and it is the difference between a clinician and a coding specialist, CMS has stated in the past that they would rather have incorrect coding from a clinician rather than proper coding from a trained professional. Yes, you read that correctly. [See Quarterly CMS Q&A question 44.1 from category 4 located here on page 29 ]

With this proposed rule, CMS is taking an extremely narrow worldview and wants to limit the CM diagnosis categories to fractures only. One example where an agency is at significant risk is in the case of a status post-mastectomy patient who is not receiving additional treatment for cancer. Typically, an aftercare code would be used in M1020/M1022 and the Breast Neoplasm code would go in M1024. This would add CM points and non-routine supply points to the episode. Based off the proposal, these patients would receive less reimbursement. This may be an oversight of CMS or it could be intentional to lower the overall CM average.

Bottom line, this rule will affect reimbursement for a significant population of patients within the industry and there has been no discussion of it. Instead of legislating, let’s take a step back and offer a sensible solution that fixes the problem, not make it worse. We call on CMS to…

• Fully implement what “Attachment D” was meant for and not restrict diagnoses codes limited to M1024 other than what is the intention of Attachment D.
• Form a committee of homecare industry experts to fix Attachment D. Mandate that only CM codes are placed in M1024 and not allow EMRs to allow otherwise. Have MACs audit for accuracy.
• Acknowledge the use of certified coders in homecare. Give them the ability to correct inaccurate coding by clinicians. Allow them to make the change, with specific documentation on what was corrected and why. 

Read the entire rule published in the Federal Register on July 13, 2012 here.CMS will accept comments on the proposed rule until Sep. 4, 2012. We are already working on ours.