SNF A Guide to Regulation and Legislation Volume Sixteen

CLA’s Regulatory Advisor Volume Sixteen offers a concise summary of the final rule and highlights key changes to payment, policies, and quality programs.

Navigating health reform

CMS Releases Final Home Health PPS Rule for 2019

  • Deb Freeland
  • Jennifer Boese
  • 11/13/2018

The Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2019 final Home Health (HH) Prospective Payment System (PPS) Rule, which also includes case-mix adjustment methodology refinements, changes to the home health value-based purchasing model, home health quality reporting program, and home infusion therapy requirements. The following includes a high level overview of key provisions in the final rule.

Payment updates

  • 2019 market basket
    • CMS provides a 3.0 percent market basket update minus a 0.8 percent productivity factor adjustment, resulting in a 2.2 percent net update.
    • For those that do not submit quality data as required, an additional 2.0 percent reduction will apply, equaling a 0.1 percent update for those entities.
    • Overall, CMS estimates this will increase payments in 2019 by $400 million.
  • Case-mix budget neutrality factor for CY 2019 will be 1.0163.
  • The labor-related share will be 76.1 percent and non-labor-related share will be 23.9 percent.
  • Rural add-on payments
    • For HH services provided before January 1, 2019, a 3 percent rural add-on will apply.
    • For HH services in calendar years 2019 – 2022, the Bipartisan Budget Act of 2018 (BBA 2018) changes the rural add-on policy and payments by defining and then categorizing rural locations as: high utilization, low population density, and all other. Once a rural area is categorized, it will remain in that category through 2022. Based on those categories, the add-on payments are listed below.
Category CY 2019 CY 2020 CY 2021 CY 2022
High utilization 1.50% 0.50%
Low population density 4.00% 3.00% 2.00% 1.00%
All other 3.00% 2.00% 1.00%

Patient-Driven Groupings Model

As required by the BBA 2018, CMS must implement a 30-day unit of service on January 1, 2020, and do so in a budget neutral manner. The BBA 2018 also required CMS to eliminate the use of therapy thresholds in the case-mix system for 2020 and subsequent years. CMS proposes to accomplish this through the Patient-Driven Groupings Model (PDGM).

CMS indicates the PDGM shares many of the features included in the alternative case mix-adjustment methodology included in the CY 2018 HH PPS proposed rule that was never finalized. As required by the BBA 2018, the PDGM would move from a 60-day to a 30-day period and would no longer base case-mix adjustment for payments on therapy levels, but solely on patient characteristics. Those clinical characteristics and the information would include, as examples, diagnosis, functional level, comorbid conditions, and admission source. In total, there are 216 different payment groups in the PDGM.

CMS is moving from the current Wage Weighted Minutes of Care to a new Cost-Per-Minute plus Non-Routine Supplies (CPM+NRS).

For the 30-day period, these will be categorized as:

  • Either “early” or “late”
  • Having one of two admission source categories: community or institutional
  • Classified into one of six clinical groups based on the principal diagnosis
    • Musculoskeletal Rehabilitation
    • Neuro/Stroke Rehabilitation
    • Wounds: Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care
    • Complex Nursing Interventions
    • Behavioral Health Care (including Substance Use Disorders)
    • Medication Management, Teaching, and Assessment (MMTA)
  • Having one of three functional levels (low, medium, high) based on the Outcome and Assessment Information Set (OASIS) items below based on a table of points whose sum results in a functional score.
    • M1800: Grooming
    • M1810: Current Ability to Dress Upper Body
    • M1820: Current Ability to Dress Lower Body
    • M1830: Bathing
    • M1840: Toilet Transferring
    • M1850: Transferring
    • M1860: Ambulation/Locomotion
    • M1033: Risk of Hospitalization
  • Incorporating a comorbidity adjustment of either no, low, or high comorbidity.

The final rule also discusses not allowing a new Home Health Agency (HHA), defined as those beginning January 1, 2019, and afterward, to receive a Request for Anticipated Payments (RAP). They would, however, still be required to submit a “no-pay” RAP. CMS also continues to request comments on potentially phasing out split pay payments altogether, which will be addressed in future rulemaking.

The rule also eliminates the requirement that the certifying physician, as part of the recertification process, provide an estimate of how much longer skilled services will be required.

Remote patient monitoring under home health benefit

As finalized in the 2018 physician fee schedule rule, Medicare began making separate payments for Remote Patient Monitoring (RPM) under CPT code 99091. CPT 99091 is paid under the Medicare physician fee schedule, which cannot be billed by HHAs, and is defined as including the interpretation of the physiologic data. CMS uses this definition as the basis for defining RPM under HH, and provides the following definition: “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the HHA.”

Although RPM is not separately billable as a HH benefit, CMS believes it can be used to augment the care planning process. It is proposing to allow RPM, if used in the care planning process, to be an allowable operating and administrative cost. This means the cost of RPM can be included on the HH agency cost report, which are then factored into the costs per visit.

Home health value-based purchasing (HHVBP)

CMS continues its HHVBP demonstration model in nine states: Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington. Maximum payment adjustments will be increased incrementally over the course of the HHVBP model in the following manner:

  • CY 2018: 3 percent (upward or downward)
  • CY 2019: 5 percent (upward or downward)
  • CY 2020: 6 percent (upward or downward)
  • CY 2021: 7 percent (upward or downward)
  • CY 2022: 8 percent (upward or downward)

Payment adjustments are based on each HHA’s Total Performance Score (TPS) in a given performance year (PY) and comprised of:

  • A set of measures already reported via the OASIS and completed Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) surveys for all patients serviced by the HHA and select claims data elements
  • Three new measures for which points are achieved for reporting data

CMS finalized the removal of the Influenza Immunization Received for Current Flu Season and Pneumococcal Polysaccharide Vaccine Ever Received, from the set of applicable measures for Performance Year 4 and subsequent performance years, and then replaced three OASIS-based measures (Improvement in Ambulation-Locomotion, Improvement in Bed Transferring, and Improvement in Bathing) with two composite measures, Total Normalized Composite Change in Self-Care and Total Normalized Composite Change in Mobility, for PY4 and subsequent performance years.

CMS is also reweighting scores and reducing the number of improvements points that can be achieved.

Home health quality reporting program (HHQRP)

With respect to the agency’s Meaningful Measures initiative, CMS is eliminating seven measures from the HHQRP:

  • Depression Assessment Conducted Measure
  • Diabetic Foot Care and Patient/Caregiver Education Implemented During All Episodes of Care Measure
  • Multifactor Fall Risk Assessment Conducted for All Patients Who Can Ambulate (NQF #0537) Measure
  • Pneumococcal Polysaccharide Vaccine Ever Received Measure
  • Improvement in the Status of Surgical Wounds Measure
  • Emergency Department Use Without Hospital Readmission during the First 30 Days of HH (NQF #2505) Measure
  • Re-Hospitalization During the First 30 Days of HH (NQF #2380) Measure

These are being removed for a variety of reasons, such as the measure is so regularly done there is no meaningful distinction that can be gained, it is not current clinical practice, or a broader measure is available.

Medicare coverage of home infusion therapy services

As required by the 21st Century Cures Act, CMS is implementing a Medicare Part B benefit for the provision of home infusion. This includes establishing one payment rate to cover items and services (professional services, including nursing services; training and education; remote monitoring, and other monitoring services), and establishing requirements for home infusion therapy suppliers and accreditation standards.

The new payment will begin January 1, 2021, but a temporary transitional payment for home infusion therapy services will be in effect between January 1, 2019, and January 1, 2021. CMS has identified Health Care Common Procedure Coding System (HCPCS) codes for transitional home infusion drugs, and these codes will be assigned to one of three payment categories for which a single payment amount will be established for home infusion therapy services furnished on each infusion drug administration calendar day. Payment category one includes antifungals and antivirals, uninterrupted long-term infusions, pain management, inotropic, and chelation drugs. Payment category two includes subcutaneous immunotherapy infusions. Payment category three includes certain chemotherapy drugs.

CMS requires remote monitoring as a continuous part of providing home infusion, but is giving leeway on how this requirement is met. CMS states, “Remote monitoring may be completed through follow-up telephone or other electronic communication, based on patient preference of communication. However, we do not propose to limit remote monitoring to these methods. Suppliers would be permitted to use all available remote monitoring methods that are safe and appropriate for their patients and clinicians and as specified in the plan of care as long as adequate security and privacy protections are utilized.”

How we can help

CLA’s payment transformation team is actively monitoring, analyzing and then preparing health care organizations for the many changes impacting the health care industry. We provide resources and a broad range of services that can help providers.