CY 2015 Proposed Rule, how it could affect your agency, and why you NEED to make a comment to CMS…

Point changes, case-mix weight (CMW) changes, and OASIS submission implementation requirements could have a huge monetary impact on your agency.   There is potential to lose millions of dollars in revenue if the proposed rule is implemented as it has been issued.

Case-mix weights are continuing on the rebasing train. CMS (Centers for Medicare and Medicaid Services) states they are resetting the CMW to 1.000, which they state better aligns case mix weights with episodic costs estimated from cost report data. The first phase of this project began in CY2014, with the Final Rule. To lower the original CMW by the same amount and to maintain the same relative values between the weights, case mix weights were decreased by a factor of 1.3464.

The following factors were excluded from the recalibration – RAP claims, claims without matching OASIS forms, claims with minute payment, paid days equal to 0, claims without a HIPPS code, PEPs, LUPAs, outliers, and capped outliers.

With all the CMW rebasing, the adjustment variables and scores have to be recalculated to ensure neutrality with budget changes. These changes affected 121 point giving variables, with 19 being added and 62 being dropped. Overall, the points values associated with 56 variables will increase and 28 will decrease in CY2015. With these changes, CMS is proposing to redefine clinical and functional thresholds as well, so that all changes coincide and remain reflective of each other, which was proposed as part of the CY2014 Final Rule.

To break it down, this means that over 200 codes will be losing their case-mix value – IF the Proposed Rule passes without change. The categories of change include common items, such as pulmonary, psych 1 and psych 2 and blindness and low vision. What’s the big deal…? There are thousands of codes! That’s true, however, many codes we use every day are being taken out of the case-mix status. Some examples are, COPD exacerbation (491.21) would go from giving 5 points in an early episode with 14+ therapy visits to zero points in all episodes. Diabetes (250.xx) would go from garnering points in each episode to only gaining points in those episodes with 14+ therapy visits. Low Vision/Blindness 362.xx and hypertensive heart disease will lose all (or nearly all) case-mix value if the proposed rule finalizes.

Not only will you lose points as well as case-mix weight for particular codes, but there is also potential to lose points for OASIS items as well. M1030 (option 3) and M1200 are losing points in early and late episodes with 0-13 therapy visits, M1400 (options 2, 3, 4) is losing points in early and late episodes with 0-13 therapy visits. The trend seems to be the higher number of therapy visits, the more points the OASIS item will potentially accrue.

Several other changes that are discussed in the proposed rule include therapy reassessment timeframes, face-to-face requirements, and oasis submission thresholds. These items will make tremendous changes to the way agencies are currently expected to practice.

Therapy would change from the current requirements that every 30 days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient. In addition, if a patient is expected to require 13 and/or 19 therapy visits, a qualified therapist must provide all of the therapy services on the 13th and/or 19th visits and functionally reassess the patient in accordance with 409.44(c)(2)(i)(A). The therapist will have to conduct a reassessment every 14 days – each type of therapy discipline involved must reassess each cycle of 14 days. The requirement for every 14-day reassessment by a qualified therapist will apply to ALL episodes regardless of the number of therapy visits provided. There were no other changes proposed to the therapy reassessment requirements. The proposed rule does state a special visit is not required to perform the functional assessment, but it should be performed as part of the regularly scheduled therapy visit.

Currently, conditions of payment, section 6407 of the Affordable Care Act (ACA), requires the physician must document that s/he or an allowed non-physician practitioner, had a face-to-face encounter with the patient. The goal of this provision was to achieve greater physician accountability. The face-to-face encounter had to be related to the current reason for home health services and had to occur within 90 days before or 30 days after the start of care of the home health episode. Additionally, there are requirements for the physician to be a doctor of medicine, osteopathy, or podiatric medicine; know the requirements of the patient, and include a brief narrative that “describes the clinical justification of this need and the narrative must be located immediately before the physician’s signature” (Proposed Rule CY2015, page 33).

Since the implementation of the above requirements, the home health industry continues to have concerns regarding the face-to-face narrative requirements. Some have argued, “The narrative requirement was not explicit in the Affordable Care Act provision requiring a face-to-face encounter as part of the certification of eligibility and that a narrative requirement goes beyond Congressional intent.” To balance intent with requirements, and to reduce the burden for home health agencies and physicians, it has been proposed that the narrative requirement be eliminated. It has been established that the patient’s medical records should be able to substantiate home health care therefore eliminating the need for additional physician narrative.

Another proposal is to establish a requirement for OASIS submission assessments to be implemented starting CY2015 and continuing with increases each year to CY2017. Agencies that do not meet this requirement will be penalized 2-percentage points to the HHA market basket increase. What does this mean to your agency? Section 3401(e) of the Affordable Care Act section 1895(b)(3)(B) has been amended; a new clause was added; which requires after establishing the percentage update for CY2015 (and each subsequent year), “the Secretary shall reduce such percentage by the productivity adjustment described…” In essence, the proposed CY2015 HHA market basket percentage update would be 2.6 percent, but if your agency does not submit their OASIS assessments in accordance with law, your agency will find themselves with 0.6 percent increase instead of a 2.6 percent increase!

At this point you may be wondering just how many assessments must be submitted before you have the decrease in market basket increase. This “Pay-for-Reporting” will be implemented over several years. To meet compliance, 70 percent or more of HHA quality data must be submitted during the first reporting period. Each year, the HHAs will be required to submit 10 percent more than the previous year until the requirement of 90 percent is reached. For episodes beginning on or after July 1, 2015 and before June 30, 2016, HHA’s must score at least 70 percent of the Quality Assessments only metric of pay-for-reporting performance or be subject to a 2 percentage point reduction to their market basket update for CY2017. For episodes beginning on or after July 1, 2016 and before June 30, 2017, HHA’s use score at least 80 percent on the QAL metric of pay-for-reporting performance or be subject to a 2-percentage point reduction to their market basket update for CY 2018. And for episodes beginning on or after July 1, 2017 and before June 30, 2018, HHAs must score at least 90 percent on the QAO metric of pay-for-reporting performance to be subject to a 2-percentage point reduction for CY 2019 (and EACH subsequent year).

If all changes are accepted and become final, an impact of approximately $58 million in decreased payments to home health agencies is projected! There is a list in the proposed rule of how each type of home health agency could potentially be affected by the policy changes proposed. The table lists items such as provider type, geographic region, and urban and rural locations. To determine how your agency may be impacted, please follow the link below and discover each change proposed in the rule.

A couple of additional items of interest in the proposed rule include, when documentation of a face-to-face encounter is required, survey and enforcement requirements for home health agencies, and Medicare Coverage of Insulin injections under HH PPS. Don’t be in the dark, access the Proposed Rule today and be informed.

The point changes, case-mix weight changes, and OASIS submission implementation requirements could have a huge monetary impact on your agency.   There is potential to lose millions of dollars in revenue. I encourage you to read the Proposed Rule very closely at and go to!documentDetail:D=CMS-2014-0090-0003 to leave your comments. Comments are being accepted through 5 pm on September 2, 2014.

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