PPS-Final-Rule-Q-&-A

2013 PPS Final Rule Webinar Q&A For Home Health Care

Home Health Regulatory Review.

HEALTHCAREfirst conducted a webinar in November about the 2013 PPS Final Rule and what it means to home health care agencies.  Many great questions were asked during the webinar, and I have compiled answers to these questions for your review.  I am still working on a few of the answers and hope to have this updated shortly.

You can download the webinar handout here.

1. What happens to claims that overlap the 10/1/14 date pertaining to ICD-9 and ICD-10 codes?
ICD-9 codes would no longer be accepted on claims (including electronic and paper) with FROM dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2014.  Claims containing ICD-9 codes for services on or after October 1, 2014, would be Returned to Provider (RTP).

A claim cannot contain both ICD-9 codes and ICD-10 codes. Medicare will RTP/return as unprocessable all claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim. For dates of service prior to October 1, 2014, submit claims with the appropriate ICD-9 diagnosis code.  For dates of service on or after October 1, 2014, submit with the appropriate ICD-10 diagnosis code.  For claims with dates of service prior to October 1, 2014, submit with the appropriate ICD-9 procedure code.  For claims with dates of service on or after October 1, 2014, submit with the appropriate ICD-10 procedure code.

2. How will these coding changes affect organizations that will be utilizing your billing/coding services?
HEALTHCAREfirst’s billing and coding services staff will be trained in advance on the changes so there will be no impact on the service we provide you.

3. When does the coding of “fracture codes only” go into effect?
The changes themselves apply to episodes ending January 1, 2013 or after. The grouper logic will be changed to award points when fracture codes in the payment diagnosis field are paired with v-codes in either the primary or secondary diagnosis fields.

4. What is FDL rate?
The wage-adjusted outlier threshold amount is computed by summing the case-mix and wage-adjusted episode payment amount and the wage-adjusted fixed dollar loss (FDL) amount (the national standardized 60-day episode payment amount multiplied by the FDL ratio, adjusted to account for area wage differences).

5. Regarding the M1024 changes, can you tell me in what section this is located so our coder can be aware?
It starts on page 67111 of the final rule under section:  G. International Classification of Diseases, 10th Edition (ICD–10) Transition Plan and Grouper Enhancements.

6. Where can I access NQF & the 54 questions provided to families?
NHPCO’s website has several resources regarding the survey; here is a link to one of their FAQ’s.

7. Where can I access the quality measures for hospice?
Information regarding the current quality measures is available on our Regulatory blog.  One of the articles that we have includes a timeline.  Information regarding potential future hospice quality measures can be found on slide 16 of the webinar handout.

8. Will firstHOMECARE Enterprise Edition still track therapy visits?
Yes, firstHOMECARE Enterprise Edition will still track therapy visits.

9. Is it up to the billing department to check if the reassessments are done in compliance and if not, is it up to the agency to make those visits non-billable in our billing?
Depending on your internal processes or if your software has any tools that can assist you with staying in compliance,  you may want to have your billing department review visits to make sure that they meet the covered criteria otherwise they will need to be listed on the bill as non-covered.

10. If the therapy reassessment was done late will another assessment need to be done immediately after for the 19th visit or will that reassessment that was done late be counted for both?
You would have technically missed the 13th required reassessment and therefore incurred non-covered visits until a reassessment is performed. The reassessment that you finally did perform after the 13th but before the 19th would count for the 19th and would kick back off the covered visits.  It doesn’t truly count for the 13th per say, as you truly missed meeting that requirement and your non-covered visits must stay non-covered.

11. Will the reassessment every 30 days still play into the new regs or is it just based on the visit numbers now?
30 day reassessments are still required and no changes were made to them in the 2013 rule.

12. What are the CMS acceptable reasons for missing a Therapy assessment?
CMS has not defined all possible instances of “circumstances beyond an agencies control” in missing a therapy assessment. The one known reason was included in the 2013 regs and it stated that in the case where one of the therapies has a frequency or modality such that would not permit them to occur on the 11th, 12th or 13th visit or 17th, 18th, or 19th visit, CMS does not expect an agency to perform an extra visit or hold up the other therapies in trying to get the reassessment performed.

13. How do you know when the updates are going to take place that holds your claims?
The Medicare Administrative Contractors all have listservs that you can sign up for and will normally announce prior to any updates being applied.

14. When you have multiple therapies in one cert period does each therapy type have to have a reassessment at the 11th, 12th and 13th visits?
Any therapy that will be crossing the 13/19 visit threshold must complete the reassessment visit.

15. What is the Sequestration?

The 2% across the board (to all provider types) Sequestration cuts are scheduled to go into effect in February 2013 if a last minute lawmaking effort is not put in play to prevent it.   Additional information can be located here: www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/stareport.pdf.

16. Please define PECOS.
PECOS is the Provider Enrollment, Chain and Ownership System.  Physicians and others who are eligible to order and refer items or services MUST establish their Medicare enrollment record and MUST be of a specialty that is eligible to order and refer.

17. Are there PECOS-exempt physician groups such as Veterans Administration physicians?
There may be exempt groups. The following document is a fact sheet regarding PECOS.

18. Does PECOS rule only refer to the signing MD for 485 or does this rule include all MDs who might/do write orders for a particular patient?
PECOS includes all MDs.

19. How do I check PECOs eligibility in firstHOMECARE?
In the firstHOMECARE software, you can run your Physician list report to see which physicians already have been verified as enrolled and which still need to be verified. Once you have the list that need to be verified, you can use the report to enter them here and once verified you can check the physician record. Not all versions of HEALTHCAREfirst software are currently automated to perform this check for you. For those that are not, we are working to automate them in the future.

20. When in 2013 is the official start of these regulatory changes, specifically the increase in discipline rates and payment rates?
The rate changes themselves apply to episodes ending January 1, 2013 or after.

21. What’s the difference of payment rates and discipline rates?
The payment rate is the base episodic payment amount. The discipline rates are the per visit rates that used to calculate LUPA and outlier episodes.

22. What is the criteria for “not submitting quality data”?
The criteria is not completing and submitting OASIS to your state OASIS.

23. Do you have a link/reference for the Therapy reassessments topic?
CMS recently indicated to the National Association of Home Care (NAHC) that they plan posting an update to the Therapy Questions & Answers on its website in mid-December.  As soon as this is posted, HEALTHCAREfirst will notify all members of the regulatory blog.  Other than the final regulation documentation itself, there are currently no other links available on this.  The link to the final rule is here.  Page 124 of the final rule was the central focus point of several of my slides.

24. Regarding multiple therapy reassessments, what if the PT is about to do the reassessment but the thing is, he only got 1 visit after the initial assessment? So it’s like the first visit was the initial and after the next visit, it will be the reassessment again. The thing that made him to do the reassessment so right away is that patient refused to see him, and the other therapists (OT and ST) were able to see the patient continuously (without missed visits), and then when it’s now his turn to visit, it so happened that that visit shouldn’t be a routine/regular visit anymore but now should be a reassessment. What should be done then?
Unfortunately, CMS currently has not defined all possible instances of circumstances out of an agency’s control. My recommendation would be for the PT to immediately notify the office when a patient refuses so the remainder of the schedule can be adjusted as need be and the required therapy reassessments can still be met in this case meaning the PT would only have two visits before the 13th, an initial and a reassessment.

December 5, 2012

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