If you aren’t up to speed on PDGM’s No-Pay RAP requirement changes, it’s not too late. We’re working hard to help home health agencies, like yours, understand exactly how the changes will affect you and ultimately avoid payment reductions, as a result of non-compliance. We’ve rolled out a plan to support you through these upcoming changes, including weekend support for coding and billing, and increased service levels for increased efficiency. Read on as we breakdown these regulatory requirements into comprehensive bites, provide an example of the potential impact to your revenue, and offer you some actionable items for your workflow to help you best prepare. 

The change: A breakdown of the new No-Pay RAP requirement

In last year’s CY 2020 Home Health Prospective Payment System Final Rule, the Centers for Medicare and Medicaid Services (CMS) finalized split percentage payment changes that decreased the upfront split percentage payment for 30-day periods of care from 60/50 percent (depending on whether the period of care is the initial or subsequent period) to 20 percent in CY 2020 for existing home health agencies (Home health agencies). CMS finalized the phase out of RAPs across CYs 2020-2022 with the implementation of the No-Pay RAP in CY 2021 and eventual replacement of RAPs with a one-time (at start of care) Notice of Admission (NOA) requirement in CY 2022.

Starting in 2021, the split-percentage payment will be lowered to 0 percent for all home health agencies (newly enrolled and existing), however, all agencies will still be required to submit a RAP (known as a No-Pay RAP) at the beginning of every 30-day period of care. The No-Pay RAP serves an operational role for the Medicare program by establishing the beneficiary’s primary HHA in the Common Working File (CWF) and triggering consolidated billing edits needed to enforce home health consolidated billing rules.

Some good news on submission requirements of the No-Pay RAP

Since no submit the No-Pay payment will be associated with the submission of the RAP in 2021, CMS is relaxing the required information needed to RAP. Home health agencies will be able to submit the RAP as soon as the appropriate physician’s written or verbal order for the initial visit has been received, documented (as required at 42 CFR Sections 484.60(b) and 409.43(d)), and the initial visit has been made and the patient admitted. Home health agencies will no longer be required to complete the OASIS assessment or send the established plan of care to the physician prior to submission of the No-Pay RAP.

In instances where the plan of care dictates multiple 30-day periods of care, home health agencies will be allowed to submit RAPs for both the first and second 30-day periods of care at the same time to help further reduce provider administrative burden and promote RAP submission timeliness.

No-Pay RAP content considerations

For RAPs with “from” dates of January 1, 2021 and later, the 0023 revenue code line on the claim does not need to match between RAP and final claim and the “from” date on periods of continuous care is no longer dependent on the first visit date. The admission date and “from” date on the claim will match the start of care date for the first 30-day period of care in a 60-day certification period and the “from” date of a second period will always be day 31, which supports the ability to submit the current RAP for the first 30-day period of care along with the future RAP for the second/subsequent period of care. CMS will permit the “from” date on the RAP to be the service date associated with revenue code line 0023 which will prevent delaying the submission of the RAP for subsequent periods, including recertification episodes when the first billable visit in the period might be beyond the 5-day timeframe.

Only the primary diagnosis will be required next year on the RAP, and it does not need to match the final claim, but does need to be a valid PDGM diagnosis that generates the clinical grouping under PDGM; this has not changed. The other diagnosis will become optional on the RAP, as again there is no payment associated with the RAP. Home health agencies will want to make sure their primary diagnosis and all other diagnosis are accurate and included on the final claim, as rate calculation under PDGM by CMS is claims-based and this has not changed. 

Any valid PDGM HIPPS code can be submitted on the RAP, but the HIPPs code does need to match on both RAP and final claim. This matching needs to occur to make sure CMS adjusts the correct claim as beginning on January 1, 2021, the HIPPS code will be used to match the RAP to the claim in order for CMS to determine if the RAP was submitted in a timely fashion. CMS will continue to calculate the payment HIPPS from claims-based data and the functional impairment level from the OASIS, and this has not changed. 

Also, it’s important to note that RAPs will no longer be auto cancelled when a corresponding claim is not received, since there is no payment to recoup anymore. 

5-Day submission requirement and untimely submission payment reduction (penalty)

No-Pay RAPs are required to be submitted for EVERY 30-day period of care. The No-Pay RAP must be submitted and accepted by the MAC within 5 calendar days after the start of care date for the first 30-day period of care in a 60-day episode/certification period and within 5 calendar days after the “from” date for the second 30-day period of care in the 60-day certification period.

Now along with the 5-day RAP submission requirement there will be a non-timely submission payment reduction when the RAP is not submitted and accepted by the HHA’s MAC within 5 calendar days. This is calculated from the start of care for the first 30-day period of care in a 60-day certification period; and within 5 calendar days of day 31 for the second 30-day period of care in the 60-day certification period.

This reduction in payment will be equal to a 1/30th reduction to the wage and case-mix adjusted 30-day period payment amount for each late day, until the date the HHA submits the RAP. This starts with day 1 of the payment period. 

An example of a late submittal and payment reduction

The following example demonstrates the significant potential impact in lost revenue to home health agencies from a late submission by one day. This RAP was submitted on day 6, which translates to a 20% reduction in the 30-day period payment as seen in this timeline: 

  • 1/1/2021 = Day 0 (start of the first 30- day period of care) 
  • 1/6/2021 = Day 5 (RAP submitted on or before this date would be considered ‘‘timely-filed’’.) 
  • 1/7/2021 = Day 6 and beyond (RAP submitted on and after this date will trigger the penalty.) 
  • RAP submitted on day 6 is calculated as – 6 / 30 = 20% payment reduction

For (LUPA) 30-day periods of care in which a HHA fails to submit a timely RAP, no LUPA per-visit payments would be made for visits that occurred on days that fall within the period of care prior to the submission of the late RAP.

Requesting an exemption to the untimely submission payment reduction (penalty)

The payment reduction for the late submission of a RAP can be waived for exceptional circumstances. The four circumstances that may qualify for an exception to the consequences of filing the RAP more than 5 calendar days after the HH period of care “from” date are as follows: 

  1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA’s ability to operate. 
  2. An event that produces a data filing problem due to a CMS or MAC systems issue that is beyond the control of the HHA. 
  3. A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC. 
  4. Other circumstances determined by the MAC or CMS to be beyond the control of the HHA. 

Workflow and Electronic Medical Record (EMR) considerations

Home health agencies should be preparing now and evaluating the best practice approach to implementing changes within their current workflow to help ensure timely submission of RAPs within the 5-calendar-day requirement in 2021. This preparation needs to include considerations related to the referral, admission, and documentation completion workflows. In addition, modifications will be needed to workflow within the EMR to permit the RAP to be submitted in compliance with the new submission requirements and within 5 calendar days.

Under the PDGM model today in 2020, most home health EMR applications calculate the expected payment HIPPS code based on the OASIS and diagnosis within the EMR. If your EMR requires a valid PDGM ICD-10 CM diagnosis code to progress the patient record to an admitted status, that same valid PDGM ICD-10 CM code can be used on the RAP. Additionally, the EMR could assign any valid PDGM HIPPS code for the RAP submission, as long as the software vendor takes care to ensure they duplicate the HIPPS on the RAP to the claim and provide the accurate HIPPS assignment for accounting purposes.  Make sure your software is able to place a preliminary HHIPPS code on the RAP and final claim while still calculating accurate revenue. Once the RAP has been submitted within the 5-day requirement, the HHA could then continue their internal quality review workflow to ensure OASIS assessment and ICD-10 CM coding accuracy.

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These upcoming changes translate to the need for fast and efficient workflow that will result in successful RAP submissions well ahead of the 5