Home Health Ordering/Referring Edits Effective, January 6, 2014

The Centers for Medicare & Medicaid Services (CMS) issued a revision to the Medicare Learning Network (MLN) Matters® article SE1305, which is available in this bulletin, announcing that effective, January 6, 2014, the Fiscal Intermediary Standard System (FISS) will implement the ordering/referring physician edits.  Billing transactions and adjustments for home health services with the “FROM” date of service on or after January 6, 2014, will be denied if the attending physician National Provider Identifier (NPI) and name do not exactly match the NPI and name that is on the Provider Enrollment, Chain and Ownership System (PECOS) file. 

NOTE: The edits will compare the first four letters of the last name.  When submitting home health billing transactions and adjustments, include the first and last name as it appears on the ordering and referring file found at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html on the CMS website.  Middle names (initials) and suffixes (such as MD, RPNA, etc.) should not be listed in the ordering/referring fields.

Please review the following to learn how Requests for Anticipated Payment (RAPs), final claims, and adjustments will process in the Fiscal Intermediary Standard System (FISS) and how to prevent denials for this reason. 

Requests for Anticipated Payment (RAPs)
If the attending physician NPI and name submitted on the RAP does not match the NPI and name in PECOS, the RAP will process with zero payment.  If this occurs, you may either:

• Cancel the RAP and resubmit a new RAP with the correct attending physician NPI and name to receive the RAP payment; OR
• Submit the final claim with the correct attending physician NPI and name to receive the full episode payment. 

Final Claims and Adjustments
Final claims and adjustments will deny when the “FROM” date is on or after January 6, 2014, AND:

• The attending physician National Provider Identifier (NPI) is not found in the eligible attending physician file from PECOS; or

• The attending physician NPI is found in the eligible attending physician file from PECOS but the name on the claim/adjustment does not match the name in the PECOS file; or

• The specialty code is not a valid eligible code to order and refer.

Appeal Process
If the final claim or adjustment is denied, to receive Medicare payment, you must follow the appeal process by submitting a redetermination.  To avoid administrative costs that providers experience with filing an appeal, take action now to develop an internal process to prevent such denials. 

How to Prevent Denials

• Check the “Ordering Referring File” at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html to ensure that the physicians and non-physician practitioners from whom you accept orders and referrals have current Medicare enrollment records, and are of a type/specialty that is eligible to order or refer in the Medicare program.

• Review the “Ordering Referring File” to ensure the information that you submit exactlymatches the information as it appears in the file. 

• Review your billing transaction before submitting to Medicare, to ensure there are no typos. 

Please note the following clarifications.

• HHAs should not use the NPPES web site at https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do to verify the physician’s information

• HHAs should use the “Medicare Ordering and Referring File” at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html to verify the physician’s NPI, last name and first name reported on the home health billing transaction.  Once again, the attending physician NPI and name that you submit must exactly match the NPI and name that is on the PECOS file and displays in the “Medicare Ordering and Referring File.”

• The CGS Home Health & Hospice Customer Service Representatives cannot assist with physician enrollment issues, since we do not process their enrollment applications.  If it appears that your referring physician is not enrolled in PECOS, please ask the physician to contact his or her Medicare Administrative Contractor regarding the appropriate steps to follow.  Refer to the CMS interactive map at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html for Medicare contractor contact information. 

Medicare Learning Network (MLN) Matters® Articles

• SE1305 - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf
• MM6856 - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM6856.pdf  

Obtained from: http://cgsmedicare.com/hhh/pubs/mb_hhh/2013/12_2013/index.html#001

CGS Initiates a Widespread Home Health Probe on Face-To-Face Encounter Documentation

As a result of numerous errors identified by both CGS and the Comprehensive Error Rate Testing (CERT) contractor related to home health face-to-face (FTF) encounter documentation, CGS will be initiating a widespread edit for all home health providers.  The topic code for this review will be 52xxT (‘xx’ denotes various numbers) and the edit will select start of care home health claims equally across the provider community.  Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity compliance with all CMS coverage guidelines, correct billing and coding.

In addition, beginning July 8, 2013, CGS will begin requesting the initial certification face-to-face (FTF) encounter documentation is submitted with all home health claims selected for Medical Review. The Centers for Medicare & Medicaid Services (CMS) clarified the “face-to-face encounter requirement is necessary for the initial certification, which is a condition of payment. Without a complete initial certification, there cannot be subsequent episodes.” (CMS FAQ # 44)

The previous was from CGS website: http://bit.ly/18czZ7g. Site goes into additional details of examples of what should be included and what would be considered insufficient within FTF documentation. The site also recommends actions for agencies to prepare for this edit which will come in the form of an Additional Documentation Request (ADR) letter. They recommend:

1. Checking for claims in the Additional Development Request status/location in the Fiscal Intermediary Standard System (FISS) at least weekly.
2. Prior to submitting your documentation to CGS, ensure that it undergoes a review by a clinician at your agency.
3. Mailing your documentation for claims selected to CGS by day 30.

CMS Issues ICD-9 to ICD-10 Transition Claims Instructions

CMS published a special MedLearn Matters article addressing ICD-9 to ICD-10 transition claims instructions. The article SE1325, addresses institutional provider which includes home health and hospice providers. Providers will be required to split claims so that all ICD-9 codes remain on one claim with Dates of Service (DOS) through September 30, 2014 and all ICD-10 codes placed on the other claim with DOS beginning October 1, 2014 and later. While the processing requirements for hospice should be clean because they bill on a monthly basis, home health has several challenges and issues to clarify.

Since home health does episodic billing, will all Medicare and Medicaid patients be required to be discharged and readmitted at their first billable visit on or after October 1, 2014? Under important details in the article, Note 1 states that “creating multiple/interim claims on a single encounter is not a new concept and that these instructions will apply to relatively few claims that span this single implementation date (October 1, 2014) will be impacted.” This could impact 1/6th of all claims for 2014 impacting over 1 million Medicare episodes alone, so this would not affect a “relatively few claims”.

There is a potential that CMS would fall back to the logic stated in Note 2 and treat the episode as a single service; however not likely because of the problems this causes. If an episode starts before October 1, 2014 and the resumption of care is completed after, which code set would you use? ICD-10 should be used, then the diagnosis data will not be consistent across the episode. If ICD-9 is used, then agencies will be required to code certain claims under each of the ICD data sets during an extended period. This would result in increased confusion amongst coders and potential errors.

CMS also needs to clarify which OASIS data set (M item), is tied to the DOS; M0030 (Start of Care (SOC) Date) or M0090 (Date Assessment Completed). CMS has implemented different program changes based on each item depending on the circumstance. M0030 makes sense except in the case of recertification, since that is not used. M0090 can be beneficial, as it allows a few days of wiggle room around the October 1st implementation date. In the case of SOC, this would allow for SOC to be completed as early as September 27th, considering that October 1st will occur mid-week. This could be helpful especially if all Medicare and Medicaid patients will need to be discharged and readmitted.

Either scenario would not be pleasant. Ideally, there should be a 60 day window on either side of October 1, 2014 to allow for entering ICD-9 or ICD-10 codes. This would put the burden on the government. The agencies would have the ability to do what is best for their staff and the patients. The government would need to handle processing both types of claims during this time.  This would decrease the burden on the agencies.  There has not been any talk of this and it does appear the burden will fall onto the agencies.



 

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.

Our Response to ICD-10 Delay

The Department of Health and Human Services (HHS) announced on Thursday that they plan to delay ICD-10. With no specifics on what this delay will entail, it’s causing a lot of confusion and speculation about what is to come. We feel it was very irresponsible for HHS and the Obama Administration to make those statements without giving a clear plan. 

As we stated back in November when the AMA began opposing ICD-10, we disagree with a delay. We firmly believe conversion to ICD-10 is long overdue and delaying it will only increase health care costs and the burden on everyone.

We are very disappointed with HHS’ decision, which contradicts everything they have been saying. On CMS’ November 17^th national provider call, representative Pat Brooks said, “This is a firm implementation date, and there will be no delay.” CMS and HHS have been adamant all along that there would not be a delay. In turn, the health care community has spent a lot of time and money investing in new processes and systems. By going back on their statements, they are continuing to lose credibility.

Vendors, as well as publishers, educators, colleges, consultants, and many others, have already spent millions of dollars getting ready for conversion. It has even spurred job creation— for example new positions like ICD-10 Project Manager.  Even health care providers like hospitals and home care agencies have invested significant resources into the transition. With a delay, all of these groups will have to re-work what they've already done and it will cost more money. This added cost for vendors will be pushed down to providers, and then consumers. 

This decision also has a lot of political pressure and motives behind it. CMS’ Acting administrator Marilyn Tavenner made the announcement that they would re-evaluate the timeline at an AMA meeting. It’s important to note Tavenner is currently vying for the official appointment and AMA backed her nomination in November.

We’re also concerned about HHS’ use of the term "compliance" date, suggesting ICD-10 will be implemented per schedule, but providers will have a leeway period where they won't be found in non-compliance. In some instances a leeway period makes sense, for example with the new Face-to-Face requirements, claims were allowed to go through for three months after implementation.  But if this happens with ICD-10, it can be extremely harmful because vendors will have to work in two different sets of codes at once, in turn driving up costs and administrative burden even more.

While we anxiously await HHS’ new plan, we’ll continue our planning with the October 1, 2013 deadline in mind. We suggest no one stop in their preparations and hopefully we will quickly receive a revised plan from HHS.

Our hope is that the delay is brief because the shift to ICD-10 is a big step to improving health care in this country. It will make our healthcare system more efficient and cost effective and improve the level of care that this nation needs.

We're here to make the transition to ICD-10 pain-free and easy for home care agencies. Please contact us anytime to discuss how your organization can have a smooth transition.

Medicare Home Health Homebound Definition

One of the most common questions we get asked is: "How do you define "homebound?" If this is a question you have, review the below information sheet put together by CEO Nick Dobrzelcki to set the record straight. If you still have questions after reading the info sheet, please contact us at nick [at] daymarck.com.

Homebound Definition

     The statutory language (effective December 21st, 2000) clarified and broadened the homebound eligibility criterion in two ways:

1. Absences attributable to the need to receive health care treatment, including regular absences to participate in therapeutic, psychosocial, or medical treatment at a licensed or accredited adult day-care program, will not disqualify a beneficiary from being considered homebound.
2. Absences for the purpose of attending a religious service are deemed to be absences of infrequent or short duration. (Generally a beneficiary whose absences from the home are not considered infrequent or of short duration will not be considered to be homebound.)

The Current Homebound Definition in the Medicare Act reads as follows:

     An individual shall be considered to be “confined to his home” if the individual has a condition:

     • due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive devise (such as crutches, a cane, a wheelchair or a walker),
     • or if the individual has a condition such that leaving his or her home is medically contraindicated.
 
     While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home, that leaving home requires a considerable and taxing effort by the individual, any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be “confined to his home”. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to an absence of infrequent or short duration. [42 U.S.C. 1395n(a)(2)(F)] 
_______________________________________
 

U.S. Health and Human Services Secretary's clarification to Medicare's homebound definition: Directs providers to be more flexible in order to protect beneficiaries 

On July 26, 2002 Tommy Thompson, Secretary of the United States Department of Health and Human Services, issued a press release and changes to the Medicare Home Health Agency Manual. The Secretary directed Medicare providers and contractors to be more flexible in applying the Medicare homebound criteria. This is important to elders and disabled Medicare beneficiaries as an individual must be confined to home (homebound) in order to qualify for Medicare home health coverage.

In particular, the Medicare Home Health Agency Manual, §§204.1-204.2, was amended to include additional, not all inclusive examples of situations in which the homebound criteria is met. (Family reunion, funeral, graduation.) More importantly, the following general language was added to the Manual:

It is necessary (as in determining whether skilled nursing services are intermittent) to look at the patient's condition over a period of time rather than for short periods within the home health stay. For example, a patient may leave the home (under the conditions described above, e.g. severe and taxing effort, with the assistance of others) more frequently during a short period when, for example, the presence of visiting relatives provides a unique opportunity for such absences, than is normally the case. So long as the patient's overall condition and experience is such that he or she meets these qualifications, he or she should be considered confined to home. (Emphasis added)

While the new language does not really add to the already existing homebound criteria, it does provide important direction that the criteria are to be applied flexibly and with a broad view of the patents’ condition. Advocates should use the Secretary’s press release language and the manual language to help make these points when clients are erroneously denied coverage.

CMS’ policy about the homebound status of home health patients who can drive

Just the fact that a patient drives does not automatically make them ineligible for homecare services. They issued clarification in 2008 which many providers do not follow. Within the clarification they specifically wrote:

“Homebound status is determined on an individual basis, looking at the patient as a whole. If the net effect of driving indicates that the individual has the capacity to get their health care routinely outside of the home, then it could challenge their eligibility. The fact that a patient is fit enough to drive raises questions as to whether the basic statutory requirement is met. Because individual circumstances can vary greatly, necessitating determinations on a case-by-case basis, we are reluctant to issue a specific policy that relates to driving in every possible occurrence. Inherent in such a policy would be judgments about the particular circumstances under which it may be appropriate for an individual to operate a motor vehicle. We believe that such determinations must continue to be made on a case-by-case basis.”

Question 2: Medicare home health patient who drives

Determining homebound status is not as easy as it seems. This is in part to CMS's broad and non-specific definition. Most people within the homecare industry can recite that Medicare homecare patients have to have the condition "that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort." After this, there is definite discrepancy in what this exactly means.

As far as driving, this fact does not automatically exclude a patient from home health services. CMS answered a Q&A in 2008 to this effect. The bigger picture has to be looked at.

Question 2 does not indicate if there is a considerable and taxing effort to leave the home thus the correct answer would be not enough information to make a decision.

Advance Practice Reform

I was recently asked, why allowing advance practice providers to order and supervise patients under homecare services was needed. Here was my response:

First everyone needs to be clear what the Federal Register states:

§ 484.18 Condition of participation: Acceptance of patients, plan of care, and medical supervision states, “Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine.”

This federal regulation supersedes any state nurse practice acts that would allow nurse practitioners to provide this oversight. There are multiple reasons why H.R. 4993 bill or S. 2814 needs to be passed. Senator Collins (D-Maine) did a wonderful job outlining some of these reasons in her statement in November of 2009. Her statement can be found in one of my previous blogs.

I see this legislation being a critical first step in reforming home health care and positioning the industry to be a critical player in overall healthcare reform. There are several possible changes that will occur over the next few years as a result of healthcare reform. These changes include value-based purchasing (A.K.A. pay for performance) and post-acute bundling. I envision nurse practitioners as key solutions for these challenges.

I predict that nurse practitioners will be on staff in many home health agencies during the next decade. They will be in charge of disease management programs, case managing complex patients, and providing direct care to patients. The direct care will consist of caring for those patients exhibiting acute exacerbations of their disease. Instead of going to the ER or delaying treatment while waiting for a physician appointment, the NP would see those patients at home and order the appropriate treatment. This would decrease healthcare costs while accelerating patient outcomes and increasing patients’ overall satisfaction.

An example would be a Chronic Congestive Heart Failure patient beginning to experience an acute exacerbation. Currently, most agencies would notify the physician who then would instruct the patient to go to the ER. The ER physician, not knowing this patient feels this patient need to be hospitalized to be diuresed. After the expensive ER visit and several days in the hospital, the patient is diuresed.

Instead say that nurse notified the NP on staff. They see the patient in home and complete an assessment. Complete any necessary lab work then orders diuretics for the patient while at home. The agency increased the visits over the next few days until the patient stabilizes. This would cost a fraction of the ER/hospitalization bill.

In order to achieve this first step towards higher quality patient care, H.R. 4993 needs to be passed now. As health care reform becomes clearer, many groups will be aiming to be on top of the heap. If these bills are not passed now, I worry that physician lobbyist groups will fight much more fiercely in the future to not allow advance practice providers to practice in the homecare setting as is the case now. The home health industry is in a terrific position to become a major player in health reform. In order to situate ourselves to be a major stakeholder with Healthcare Reform, we must pass H.R. 4993.

Month one of OASIS-C

Irrational rational

Illogic logic

Just a plain, what were they thinking?

I’m a big fan of the OASIS assessment because of the practical, efficient applications that result from the data collected; PPS calculation, quality measures and a standardized tool that every agency has to use. It intrigued me to learn the relationships of the specific questions and the complex calculations which either resulted in payment calculations or risk adjusted outcomes.

Learning these relationships over the years, we have learned small but critical improvements that were needed. M0700 ambulation/locomotion needed to be more specific in order to show the improvement a patient makes from using a walker to a single hand cane. Certain questions that were nonspecific and difficult to answer were eliminated, like M0280 Life Expectancy - likely hood a patient was going to live more than 6 months. For these details and other evidence based practices learned over the decade OASIS-C was created.

New Day, New Programs

With the implementation of OASIS-C Jan 1st, agencies have the ability to do an extreme makeover and position themselves for Pay for Performance (P4P). Yes, P4P will still come despite all the other changes that are occurring. The Demonstration project ended in December. Findings will be published in the near future.

April will be the last Caspers report until this fall. Home Health Compare will also not update for 6 months. What is done with OASIS-B is done. Quality reports are going to be wiped clean and the first full OASIS-C episodes will begin your new quality report tallies. Some quality measures will remain, others will be added.

So what should agencies focus on? Continue to do business as usual. Defiantly not! Agencies need to take a step back and look at their operations to see what is working and what is not. Are you a proactive agency or a reactive agency? Proactive agencies foresee the problems as they arise and put checks and balances in place to prevent rework and poor outcomes. Reactive agencies are always looking hindsight and trying to figure out what went wrong. They are so busy looking backwards they do not see the opportunities going forward.