1)      This decidedly delinquent edition resumes our series on the 2011 PPS Final           Rule.    Subsequent articles will address the items included in the Rule on a more specific level.

 

     2)      The HHSM Newsletter is proud to announce the introduction of a nursing-based series of topics and articles. The first of these articles will address the G-codes of the 2011 PPS Rule regarding nursing care.

 

Part Two: Elements of the 2011 Final Rule

 

     2011 PPS Final Rule: A Roadmap for Change

 

          CMS delivered the final version of the Proposed 2011 PPS Rule on November 2^nd, 2010, after completion of the comment phase allowed for modifications based on provider input. Many of the more progressive proposals survived, and the resultant refinements will challenge all homecare participants, from providers to physicians and clinicians, regarding how they provide care to homebound clients under the CMS benefit. Practices that have become commonplace since the initial introduction of the Prospective Payment System in 1999, will need contemporary re-wiring to address decreased funding, therapy requirements, and coding and billing changes included in the Final Rule. 

 

          Today, in Part Two of our series on the 2011 PPS Rule, we will examine the areas where Home Health proposals survived, were modified, or eliminated from the Final Rule.

 

$960 Million Funding Reduction – Nearly a billion dollars removed from the funding for Part A Home Health in 2011 (during the initial baby boomer wave); cost control-based specifics are listed below.

60 Day Episode Payment Rate Reduction – This adjustment was mandated by the Patient Protection and Affordable Care Act (PPACA) of the Healthcare Reform bill. It proposes a 4.9% net decrease from the 2010 rate ($2312.94) to the 2011 rate (2198.58).

Case Mix/Coding Adjustment – A response to the well-documented “case creep”, CMS establishes a 3.9% coding reduction for 2011, and an additional 3.9% for 2012.

Hypertension Change Rescinded – Initially proposed to eliminate the top two ICD-9 codes from reimbursable coding, this was rescinded to allow CMS to gather additional data on the subject. Expect to see this topic re-visited in future PPS Rule Proposals.

Market Basket Update Reductions – A decrease in the Market Basket Update results in a reduction from the yearly Market Basket increase.

LUPA Alterations/Rural Add-ons – While the annual LUPA add-on was decreased by approximately 3%, the rural add-on was increased by 3% (PPACA mandates these increases to continue through 2015).

 

Face to Face Encounters – Initial Home Health certification will require face to face physician encounters (90 days prior-30 days after SOC) to certify homebound status and reasons for homecare. This significant change will require agencies to manage the interface between client, referral source, and community physician. Initially proposed with 30 day prior – 14 days post SOC parameters, expect to see this requirement evolve and expand to re-certifications in subsequent PPS Rules. CMS has announce that these changes will not be enforced prior to 4/1/11.

Enrollment Ownership Limitations – Intended to decrease profiteering and marketing of CMS Home Health agencies, this element of the 2011 PPS Rule limits the sale or transfer of new Home Health provider numbers for three calendar years. If violated, a full survey is required to activate the transferred or sold provider number. Also allows for a moratorium on new Home Health provider numbers.

Quality Data Reporting – These modifications to the requiredareas of quality data reporting are connected to a 2% Market Basket Update reduction if not reported.

Non-Routine Medical Supplies – The 2011 PPS Final Rule reports a decrease in the NRMS conversion factor, from $53.34 (2010) to $50.70 (2011).

Physician Certification – Provider Enrollment Chain and Ownership System (PECOS) requires physicians to obtain National Provider Identification (NPI) numbers to provide reimbursable Home Health referrals. Phase Two of this program (not slated for earlier than 7/1/11) will deny claims for episodes not certified by PECOS-credentialed MDs.

Outlier Limits – The outlier pool was reduced to 2.5% of total CMS Home Health payments, and capped at 10% of any provider’s total billings.

Additional Claims Data Collection/HH CAHPS Data Requirements – Additional Claims Data Collection includes G-codes for billing that addresses therapy, therapy assistants, maintenance evaluations, and nursing-specific activities (see the next HHSM Newsletter for specific G-code breakdowns for nursing). In addition, CAHPS survey reporting requirements are necessary for the Market Basket Update.

Therapy Coverage Requirements – These sweeping changes mirror long-established therapy controls that other care providers must incorporate. Specific evaluation requirements (utilizing best-practice established tests and measures), routine visit documentation requirements (that reference the initial eval tests), timely and routine re-evaluation requirements (that mirror SNF re-eval protocols in effect since 1998), combine with transient decline non-coverage limitations to alter therapy delivery in the homecare environment. CMS has announced that these changes will not go into effect until 4/1/11.

 

            In the next edition of the HHSM series on the 2011 Final Rule, we will study the specifics of the Rule and attempt to determine the specific CMS goals for the industry that are addressed by the changes. In addition, we will propose future refinements that may help us identify where the Home Health benefit may be headed next.