HH PPS Update for 2011 Part 2

Last week we covered the proposed changes to the payment schedule and required capitalization rates for new providers and change of ownership rules.  This week, we’ll focus on the clinical and operations aspects of the proposed changes.


To receive a full market basket update in 2012, there will be a dry run of data from at least one month in the third quarter of 2010, and HHCAHPS survey data from the 4th quarter of 2010 and the 1st quarter of 2011 must be submitted to the HHCAHPS data center. Owners of HH agencies or those who staff them would be prohibited from being approved as CAHPS vendors.

Therapy services and documentation

This area includes new functional assessment and reassessment criteria, therapy goal criteria as well as clinical documentation requirements.  Timelines are provided for visits for a “qualified therapist” (not a therapy assistant) on the 13th and 19th visits and every 30 days.  It is expected that the HH provider collaborate with the physician on decisions on therapy needs for the patient based on individual progress, restoration potential and guidance for maintenance therapy coverage criteria.  CMS believes the current therapy benefit is ill-defined and has resulted in high case-mix weights.

Physician face-to-face encounter

Changes include a requirement for the physician to have a face-to-face encounter with the patient prior to the HH certification.  The encounter is to be in the time period within 30 days prior to an admission and 14 days after admission to the agency. This face-to-face encounter can be completed by an NP, PA, CNS or nurse-midwife, and documented consistently in the physician’s medical record as well as the HH certification.

Diagnosis Coding

Benign hypertension(401.1)  and unspecified essential hypertension (401.9) will be removed as a case mix diagnosis.  Revised guidelines from the AMA resulted in more frequent reporting of hypertension as a HH diagnosis when treatment was not indicated.  NAHC’s position is that removing hypertension case mix diagnoses will result in an additional case mix creep adjustment.

Additional claims data required

This change will require assignment of “G” codes that will identify PT and OT assistants, PT, OT, and SLP maintenance therapy, observations and assessment and a new code for training and education of the patient.

Quality Reporting

The penalty imposed to HH agencies that fail to report 12 months’ OASIS data will be a market basket update minus 2 percent.  This is a continuation of previous CMS policy. CMS plans to reconcile OASIS submissions with claims data to ensure compliance. They will also continue to publicly report HH quality data through Home Health Compare.

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