Posts Tagged ‘Centers for Medicare & Medicaid Services’

CMS to Host Second ODF Call on Proposed Home Health 5-Star Rating System

January 30, 2015

Special Open Door Forum is scheduled for Thursday, February 5, 2015 at 1:30pm – 3:00pm Eastern Time

Next week, CMS will be hosting an Open Door Forum call on their proposed 5 Star ranking system for home health providers. HCAF reported on this program in last week’s edition of eHighlights regarding concerns HCAF and other association and providers have about the proposed program.

HCAF strongly recommends providers join this call and learn more about this proposed rating system. It is certain that CMS must make changes in order for consumers to be able to accurately determine the true quality of an agency using these ratings. See below for information on the FREE call and make sure to join on February 5th!

The Centers for Medicare & Medicaid Service will host a second Special Open Door Forum (SODF) call to allow consumers, home health agencies (HHAs), and other interested parties to give additional input and feedback on the planned addition of star ratings to’s Home Health Compare (HHC) web site.

The call follows up on their previous call on this topic and will include:

·       a summary of the comments received on the material presented at the earlier call and on other aspects of the methodology,

·       a presentation of their revised methodology, and

·       plans for next steps.

After the SODF presentation, the phones will be opened for comments and questions. A link to the materials for this SODF, including a slide deck, a summary of the revised proposed HHC star rating methodology, and an updated “Frequently Asked Questions” (FAQ) document will be available soon on the Home Health Quality Initiative Spotlight page here.

Comments about the star ratings system can be submitted by email after the call to the following address:

Special Open Door Forum Participation Instructions:

Participant Dial-In Number: 1-800-837-1935

Conference ID #: 73412220.

After the call, transcript and audio recording of this SODF will be posted to the Special Open Door Forum website here.

CMS Announces its Next Home Health, Hospice and DME Open Door Forum – August 20

August 15, 2014

CMS has announced that its next Home Health, Hospice and DME Open Door Forum will be held next Wednesday, August 20. NAHC members are encouraged to note that some key issues will be addressed, including the revised hospice cost report for freestanding agencies.

The link that accompanied the announcement appears to be the second version of the cost report that was issued on November 22, 2013.  It is unclear whether these will be the actual, final cost report forms and instructions for freestanding agencies that CMS has indicated will be required for cost reporting years beginning October 1, 2014, and afterward, or if CMS will release another version that incorporates some of the additional changes that were recommended by the industry during December 2013.

Below is the tentative agenda for CMS Home Health, Hospice and DME Open Door Forum:

I. Opening Remarks

Chair – Randy Throndset, Center for Medicare

Moderator – Jill Darling (OC)

II.  Announcements & Updates

  •   OASIS-C1 webinar, September 3, 2014 @2PM, Survey and Certification letter attached.

§Can be found at: http://www​ search for OASIS-C1_ICD9

  • FY 2015 Hospice Payment Rate Update Final Rule


  • Hospice Cost Report

§  http: //

  • Hospice CAHPS Survey

§  http://www.hospicecahpss​

  • HHCAHPS (Home Health CAHPS Survey)

§at URL

III. Open Q&A

**Next Home Health, Hospice & DME ODF: October 1, 2014



Open Door Participation Instructions:

This call will be Conference Call Only.

To participate by phone:

Dial: 1-800-837-1935 & Reference Conference ID: 44421630.

Persons participating by phone do not need to RSVP. TTY Communications Relay Services are available for the Hearing Impaired.  For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

Encore: 1-855-859-2056; Conference ID: 44421630.

Encore is an audio recording of this call that can be accessed by dialing 1-855-859-2056 and entering the Conference ID beginning 2 hours after the call has ended. The recording expires after 2 business days.

For ODF schedule updates and E-Mailing List registration, visit our website at



CMS Issues Several Change Requests Specific To Home Health Agencies

August 8, 2014

The Centers for Medicare & Medicaid Services (CMS) has issued four Change Requests that provide guidance to the Medicare Administrative Contractors (MACs) on several home health policy and claims processing issues.

Change request 8699Preventing Duplicate Payments When Overlapping Inpatient and Home Health Claims Are Received Out of Sequence

CMS has instructed the MACs to implement edits that will prevent home health claims from processing with dates of service that overlap an inpatient stay. In response to a 2012 Office of Inspector General report that exposed claim vulnerabilities, CMS has identified two conditions where a home health claim could process that overlap with an inpatient claim:

The edit that rejects home health claims when they have dates overlapping an inpatient stay – other than the admission date, discharge date, or a date during an occurrence span code 74 period indicating a leave of absence – does not consider inpatient stays in a swing bed (Type of Bill 018x), and

Medicare systems only identify overlaps with inpatient stays when the inpatient hospital or skilled nursing facility claim was received before the home health claim.

Effective January 1, 2015, If an HH Prospective Payment System (PPS) claim is received, and CWF finds dates of service on the home health claim that falls within the dates of an inpatient, SNF or swing bed claim – not including the dates of admission and discharge, and the dates of any leave of absence – Medicare systems will reject the home health claim. The HHA may submit a new claim removing any dates of service within the inpatient stay that were billed in error.

If the home health PPS claim is received first and the inpatient hospital, SNF or swing bed claim comes in later, but contains dates of service duplicating dates of service within the home health PPS episode period, Medicare systems will adjust the previously paid home health PPS claim to non-cover the duplicated dates of service.

For more on this change request, please click here.

Change Request 8710PreventingPayment on Requests for Anticipated Payment (RAPs) When Home Health Beneficiaries are Enrolled in Medicare Advantage (MA) Plans

Current Medicare systems edit reject claims for home health episodes when a beneficiary is enrolled in a Medicare Advantage plan.  However, Requests for Anticipated Payment (RAPs) for such episodes are currently being paid.

Effective January 1, 2015, edits will be put n place to ensure that RAPs with “From” dates falling within Medicare Advantage enrollment periods are processed, but are paid at zero percent. If a final claim is received it will be rejected, as is currently the process.  Additionally, the requirements add remittance advice coding to zero-paid RAPs processed in Medicare Secondary Payer situations, so that the two situations can be distinguished. In the future, CMS will seek a new alert remittance advice remark code to specifically identify the Medicare Advantage cases also.

For more on this change request, please click here.

Change Request 8813Diagnosis Reporting on Home Health Claims

Effective January 1, 2015, the MACs will implement edits to reject HH claims that list a manifestation code as a primary diagnosis.

An analysis of Outcome Assessment and Information Set (OASIS) records and claims for CY 2011 revealed that some agencies were not complying with the coding guidelines when reporting the primary diagnosis, in particular with regards to certain codes that require the underlying condition be sequenced first followed by the manifestation.

The principal diagnosis reported on the home health claim shall be the ICD-9-CM code that is most related to the current home health plan of care. HHAs shall not submit manifestation codes as the primary diagnosis.

For more on this change request, please click here.

Change Request 8818 –Clarification of the Confined to the Home Definition in Chapter 15, Covered Medical and Other Health Services, of the Medicare Benefit Policy Manual

In the calendar year 2012 Home Health PPS Final Rule published on November 4, 2011, CMS finalized its proposal to provide clarification to the Benefit Policy Manual language regarding the definition of a patient being “confined to the home.”

In October 2013, CMS issued change request 8444 to clarify the definition of “confined to the home” to more accurately reflect the definition articulated in Sections of 1814(a) and 1835(a) of the Social Security Act. At that time, chapter 2 of the Medicare Benefit Policy Manual was revised. Change request 8818 also updates chapter 15 of the Medicare Benefit Policy Manual to reflect the clarification of “confined to the home” definition.

For more on this change request, please click here.

Source: NAHC



OIG Study on Face-to-Face Recommendations to CMS: Standardized Form, Physician Education, Increased Oversight

April 10, 2014

The Office of Inspector General has published a study on the Medicare Home Health Face-to-Face (F2F) documentation requirement which highlights several solutions home care providers have suggested to improve compliance.

The study looked at 644 F2F encounter documents to analyze to what extent the documents confirmed encounters and contained the required elements as set out by CMS. The study sought to do three things:

  1. Determine the extent to which physicians who certified home health care documented the face-to-face encounters,
  2. Describe the nature of face-to-face documentation, and
  3.  Assess CMS’s oversight of the face-to-face requirement.

In addition, OIG interviewed the four Home Health and Hospice Medicare Administrative Contractors (HH MACs) to describe how they ensure that home health agencies met the face-to-face encounter requirements. The Office also reviewed guidance documents and policies from CMS or the HH MACs about monitoring the face-to-face requirement.

Read more in the Member’s Only section of HCAF’s website

Want access to this content? Join the premier organization representing the home health industry in Florida! The Home Care Association of Florida represents over 700 Florida home health care providers and vendors to the home care industry. HCAF strives to be the foremost resource and advocate for Florida’s home care industry and the patients our members serve. The Association is an active voice which continually interacts with state and federal lawmakers, regulatory agencies and fiscal intermediaries to interpret, challenge or support regulations that affect the home health care industry. We can help you stay in the race and get ahead of the pack!

CMS Develops New Billing Codes for Chronic Care Management Services

January 31, 2014

The 2014 final rule for the Medicare physician fee schedule included the addition of a new payment code for chronic care management to begin in 2015. The new code will allow reimbursement for non-face to face time physicians spend managing patients with multiple chronic conditions that are not reimbursed under the current Evaluation and Management codes physicians bill for office visits. These codes are in addition to the recently added Transition Care Management codes (TCM 99495-99496), which also reimburses physicians for non-face to face time association with transitioning patients to the community.

In the final rule, the Centers for Medicare& Medicaid Service (CMS) agreed to assign only one code for chronic care management services rather than two separate codes, and shorten the time frame for providing the service from 60 minutes per 90 days to 20 minutes per 30 days. The new code will read as follows:

“Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days”

The final rule sets the scope for chronic care management services to include:

  • 24-hour-a-day, 7-day- a-week access to address a patient’s acute chronic care needs.
  • Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
  • Care management for chronic conditions including systematic assessment and development of a patient centered plan of care.
  • Management of care transitions within health care.
  • Coordination with home and community based clinical service providers.
  • Enhanced opportunities for a patient to communicate with the provider through telephone and secure messaging, internet or other asynchronous non face-to-face consultation methods.

CMS accepted comments on the following proposed standards that it expects physicians to comply with in order to furnish and receive reimbursement for chronic care management services:

  • The practice must be using a certified Electronic Health Record (EHR).
  • The practice must employ one or more advanced practice registered nurses or physician’s assistants.
  • The practice must be able to demonstrate the use of written protocols by staff participating in the furnishing of services.
  • All practitioners involved in the furnishing of chronic care management services must have access at the time of service to the beneficiary’s EHR.

CMS intends to issue its final standards in the 2015 Physician Fee Schedule rule.

CMS was clear in the final rule that the TCM service codes and the Care Plan Oversight codes for home health and hospice (G181- G0182)  may not also be billed during the time period when Chronic Care Management services are billed.

To view the final rule, please click here.

Source: NAHC

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CMS Issues Policy for Recalcitrant Providers

January 17, 2014

The Centers for Medicare & Medicaid Services (CMS) has issued manual updates to address providers termed as “recalcitrant.” CMS’ definition of “recalcitrant” providers are those who have a history of prolonged program abuses and refuse to comply with Medicare coverage rules. These providers have been on a pre-pay medical review for years and continue to show no improvement in inappropriate behavior.

CMS will apply two sanction authorities that currently exist under the Social Security Act at 1128A(a)(1)(E) for civil money penalties and 1128(b)(6) for civil money penalties and/or exclusion from Medicare and State Health Care programs. Both of these sanctions are delegated to the Office of the Inspector General.

The contractors are instructed to consider the following criteria before referring a recalcitrant provider to CMS Region Office and The Program Integrity Fraud and Abuse Suspensions and Sanctions (FASS) Team for further action:

  • The provider being considered for referral by the Medical Review Unit should not be under any fraud investigation by the Program Safeguard Contractor (PSC)/Zone Program Integrity Contractor (ZPIC) or active with the OIG (the MAC and the ZPIC shall include this coordination in the joint operating agreement (JOA); and
  • The provider is currently on prepayment medical review, has been educated and continues to show a pattern of inappropriate behavior (do not include providers who are demonstrating improvement, however slight, as a result of education); and
  • The contractor demonstrates the administrative burden (i.e., volume and dollars of claims being manually reviewed, volume and dollars of claims/services being denied, and associated resource costs); and
  • The appeal history of denied claims indicate a low reversal rate (exclude potential case if claims have a high reversal rate); and
  • The Medical Director concurs with the medical review determinations and is aware that he/she may be a potential witness.

In order for CMS to approve or disapprove a notice for a recalcitrant provider the following elements will be reviewed:

  • What are the specific medically unnecessary services/items or non-covered services being provided and billed;
  • What are the grounds for these services/items being medically unnecessary or covered;
  • What education was provided to the provider to inform and correct the provider’s pattern of inappropriate behavior;
  • A description of the pattern of inappropriate behavior, including how the provider continued to provide medically unnecessary services/items or non-covered services after explicit education from the contractor;
  • Appeal history (through ALJ level); and
  • Availability of “Expert” witnesses being prepared to testify if necessary (Medical Director).
  • CMS will notify the MAC and PSC/ZPIC of approval and then coordinate with the PSC/ZPIC before they will refer the provider/supplier to the MAC for revocation.

CMS states a provider that has been on prepayment review for years could be considered recalcitrant, but does not comment on how many years the provider must be on repayment review before they are a considered a recalcitrant provider.

To view the Change Request, please click here.

Source: NAHC

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2013 Year in Review: Home Care Regulations and Advocacy

December 27, 2013

2013 was an eventful year within the legal and regulatory realms for home care providers at both the state and federal level. Along the way, HCAF has fought to best represent our members in advocating for the best regulatory environment possible. Below are the most significant developments from the legal and certain regulatory issues from this past year:

1.  HCAF successfully advocates to reduce Florida quarterly report fine from instant $5,000 to $200 per day until $5,000 limit

Until July of this year, all home care providers licensed in Florida were required to complete a quarterly report to be submitted to the Agency for Health Care Administration (AHCA) in order to help curb Medicare and Medicaid fraud. Even agencies who were not Medicare or Medicaid certified were required to complete this report. The penalty for submitting the report even one day late was an instant fine of $5,000 to the agency; a significant amount. Over the years, AHCA had collected over $6.3 million from this fine alone.

HCAF worked with our friends in the legislature, Senator Anitere Flores and Representative Jose Felix Diaz in order to pass a bill that would reduce the fine from $5,000 to $200 per each day the report is late in being submitted with a cap of $5,000. In addition, this bill spared non-Medicare and Medicaid certified providers from needing to answer the report any longer. This was a huge success for the industry in Florida and we could not have done it without our member’s efforts in joining us on our Tallahassee Legislative Days to lobby the legislature for their support.

2. Obama Administration delays the start of the employer mandate provisions of the health care reform law

Responding to the pleas of thousands of small businesses in home care and otherwise, President Obama moved the effective date of the ACA provision mandating that companies either provide health insurance to their full-time employees or pay significant monetary penalties. A NAHC study showed that the vast majority of home care companies, particularly those that provide Medicaid and private pay services, do not currently provide all full-time workers with health insurance.  HCAF has advocated for the delay, explaining to administration officials that care access would be significantly jeopardized by these requirements. Furthermore, we continue to advocate to change the definition of a full-time employee be raised from an employee that works 30 hours per week to 40 hours per week.

3.   US Department of Labor issues final rule on the companionship services overtime exemption

After maintaining a consistent policy for over 37 years, the US Department of Labor completely changed its interpretation of the Fair Labor Standards Act and revised the “companionship services” exemption from minimum wage and overtime compensation. The longstanding rule had been successfully defended by NAHC twice at the United States Supreme Court. The new rule redefines companionship services to virtually eliminate any potential application in home care by removing personal care as a central part of “companionship services.” Additionally, DoL eliminated any application of the remaining exemption to workers employed by third parties such as home care agencies. HCAF and NAHC are evaluating a lawsuit to challenge the changes while working to get payers such as Medicaid to cover any new costs.

4.   CMS Issues Home Health Rate Rebasing Rule

The Centers for Medicare and Medicaid Services (CMS) issued the Final Rule setting out payment rates for home health services in 2014. This rule includes the start of the 4-year rate rebasing required under the Affordable Care Act. CMS reduces the base episode rate by the equivalent of 3.5% of 2010 rates while increasing LUPA per visit rates by 3.5%. The Final Rule was a modest improvement over the proposed rule due to a recalibration of case mix weights and a reduction of the amount of the rate cut. HCAF continues to pursue revisions to the rebasing rule through Congress and potential litigation.

5.   Moratorium on New Home Health Agencies in Certain Areas Instituted

CMS applied the authority it was given under the ACA to establish moratoria on new home health agencies for the first time in Miami-Dade County and an area around metropolitan Chicago. It is expected that the six month moratoria will be extended another six months in both locations in 2014, and that CMS may add other geographic areas as well. HCAF supports the institution of this moratorium in helping the fight against fraud in our industry, but we do believe there are several other places in the country that would benefit from a freeze on new agencies as well.

6.   CMS Initiates Post-Acute Care Bundling Demonstrations

As the first big step towards innovation in Medicare payment policy directly affecting home health services, CMS approved, for Phase 1, a series of bundling proposals for post-acute care. These proposals including bundling with hospitalization payment and post-acute care only.

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CMS MLN ConnectsTM Conducting Call on Program Manual Updates Related to Jimmo v.Sebelius Lawsuit

December 6, 2013

On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, involving skilled care for the IRF, SNF, HH, and OPT benefits. “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”

The goal of this settlement agreement is to ensure that claims are correctly adjudicated in accordance with existing Medicare policy, so that Medicare beneficiaries receive the full coverage to which they are entitled. The settlement agreement sets forth a series of specific steps for CMS to undertake, including issuing clarifications to existing program guidance and new educational material on this subject.

As part of the educational campaign, this MLN Connects™ Call will provide an overview of the clarifications to the Medicare program manuals. These clarifications reflect Medicare’s longstanding policy that when skilled services are required in order to provide reasonable and necessary care to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. In this context, coverage of skilled nursing and skilled therapy services “…does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” Portions of the revised manual provisions also include additional material on the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care.

Program Manual Updates to Clarify SNF, IRF, HH, and OPT Coverage Pursuant to Jimmo v. SebeliusRegistration Now Open
Thursday, December 19; 2-3pm ET

To Register: Visit MLN Connects™ Upcoming Calls. Space may be limited, register early.

Target Audience: Skilled Nursing Facilities (SNFs); Inpatient Rehabilitation Facilities (IRFs); Home Health Agencies (HHAs); and providers and suppliers of therapy services under the Outpatient Therapy (OPT) Benefit.

• Clarification of Medicare’s longstanding policy on coverage for skilled services
•  No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care
• Enhanced guidance on appropriate documentation
Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.

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Goverment Shutdown Delays Release of CMS Final Rule on Home Health Rate Rebasing

October 25, 2013

Yesterday, the Centers for Medicare and Medicaid services delayed the release of the CY 2014 Home Health Prospective Payment System (PPS) Final Rule for nearly a month.

This is a delay to the original issue date of November 2nd that was announced. CMS is still a determining the effects of the partial government shutdown on their ability to complete 2013 Medicare fee-for-service payment regulations including the home health PPS rule and physician fee schedules.

The current proposed rule would cut medicare payments by 3.5% per year for four years, leading to an overall cut of 14% to the home health medicare payment rate. Despite the delay in announcing the final rule, it is still scheduled to take effect January 1st, 2014.

HCAF intends on using this additional time to educate our members at our Fall District Meetings (running from 11/12-11/25) on how they should prepare for the different possible outcomes of this final rule.

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“2 Midnights” Rule: What it Means for Home Health Agencies

October 11, 2013

The Centers for Medicare & Medicaid Services released its controversial “2 midnights” rule in the 2014 Medicare Inpatient Prospective Payment System (IPPS) final rule.

Under the “2 midnights” rule CMS has set both a benchmark and a presumption for when an inpatient satay would be considered appropriate.  If the inpatient stays spans two midnights, CMS will presume that the stay is reasonable and necessary. In addition, admitting clinicians can use the “2 midnight stay” as a benchmark in determining when it is appropriate to admit a patient as an inpatient rather than keeping the patient in an outpatient status in an observation unit.

With this provision, CMS intends to decrease the number of extended observation stays, while decreasing the number of short inpatient stays (less than 2 midnights) billed under Part A that should be billed under Part B as outpatient services. Extended observation stays have a negative impact on beneficiaries since they require a 20 % co-pay for the service and do not count towards the 3 inpatient day stay required for Medicare coverage skilled nursing facility (SNF) admissions. Payments to hospitals for inpatient services provided under Part A that should have been provided as outpatient services billed to Part B are considered Medicare overpayments to the hospital.

CMS will permit physicians to apply the time a patient spends receiving outpatient services, such as an observation unit, to count towards the “2 midnights” stay when considering whether to continue services as an inpatient.

“…we expect that the decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpatient service. In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary’s total expected length of stay. For example, if the beneficiary has already passed 1 midnight as an outpatient observation patient or in routine recovery following outpatient surgery, the physician should consider the 2 midnight benchmark met if he or she expects the beneficiary to require an additional midnight in the hospital.”

However, the count for a formal inpatient stay begins with the physician’s order for an inpatient admission, and does not include time the patient spent receiving outpatient services. Therefore, only the time the patient actually spends as an inpatient will count towards the 3 day inpatient stay requirement for a SNF admission.

“We reiterate that the physician order, the remaining elements of the physician certification, and formal inpatient admission remain the mandated means of inpatient admission. While outpatient time may be accounted for in application of the 2-midnight benchmark, it may not be retroactively included as inpatient care for skilled nursing care eligibility or other benefit purposes. Inpatient status begins with the admission based on a physician order.”

CMS will instruct medical reviewers to not focus on inpatient admissions that span greater than two midnights, since these stays will be presumed to be appropriate.  Inpatient stays that span are just two midnights will likely be reviewed to ensure appropriateness of care and that hospitals are not gaming the system. Medical review will be more intensive on claims with inpatient stays that span 1 or less midnights to evaluate whether the services are appropriate to be billed as inpatient services under Part A.

If an inpatient stay that has been billed as Part A is determined that it should have been under Part B, claims adjustment will be made and the hospital will receive a lower reimbursement rate for the care, in addition to having to collect any co-payments due from the Medicare beneficiary.

So what does all this mean for home health agencies? Well, a lot will depend on how hospitals respond to the “2 midnights” provision and the strategies they develop. A hospital that has a high number of short inpatient stays might adjust their admission policy to increase their observation stays.  Conversely, a hospital that has a high number of lengthy observation stays will want to review their admission policies to increase the number of patients that are treated as inpatients.

If hospitals have shorter observation stays there will likely be less outpatient physical therapy (PT), occupational therapy (OT), and Speech Language Pathology (SLP) services provided by hospitals that fall under home health consolidated billing rules. In other words,  therapy that was provide as an outpatient would now be provided as an inpatient, the hospital claims will process and agencies will not be pressured  to reimburse the hospital for denied therapy services.

On the other hand, if a hospital increases observation unit admissions, agencies could see more bundled therapy being provided. However, even though the observation stays might be more frequent, the length of the stays will be short in duration. Further, agencies are not required to reimburse the facility for bundled therapy if there is no arrangement with the facility to provide the service.

For hospital inpatient claims that are denied under Part A and billed to Part B, CMS, in the final rule, agreed that PT, OT, and SLP services could be billed as an Inpatient–Part B claim. The National Association for Home Care & Hospice is waiting to hear from CMS regarding whether therapy billed on an Inpatient–Part B claim will paid if the patient is under a  home health POC or will the hospital claim be edited against the  home health agency’s claim and be denied?

Another outstanding question is how agencies are to treat hospital transfers for the purpose of completing the OASIS. Regardless of how hospitals react to the “2 midnights rule”, it is expected that there will be an increase in the number of patients that are initially admitted to outpatient observation that will be admitted as inpatients during the hospital stay. Agencies are required to complete the Transfer and Resumption of Care (ROC) OASIS whenever a patient is a hospitalized for 24 hours or more, for reasons other than diagnostic testing.

Agencies will most likely be required to complete the transfer/ROC OASIS if the patient’s status is changed from observation to inpatient.  In addition, a transfer/ROC OASIS is only required if the inpatient status is greater 24 hours. Tracking the status of these patients could prove to be a challenge for agencies. Currently, the majority of patients admitted to observation units remain in observation until they are discharged from the facility.

Click here  to view the final IPPS rule and to learn more about the “2 midnights” provision.

Source: NAHC

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