NAHC Year in Review: Regulatory Policy and Issues
January 3, 2014 08:01 AM
2013 was an eventful and busy year within the regulatory area for home care and hospice providers. Below are the most significant developments for the home care and hospice community with respect to regulatory policy and issues compiled by NAHC Regulatory staff:
Face-to-Face Encounters in the Home Health Prospective Payment System Rate Update for Calendar Year 2013
The Centers for Medicare & Medicaid Services (CMS) provided additional regulatory flexibility regarding face-to-face (F2F) encounter requirements, including:
Allow facility-based NPP to perform encounter
Allow the NPP who is collaborating with or under the supervision of the certifying physician to communicate the findings with the certifying physician (i.e. inpatient or community)
Allow the facility-based physician to complete the F2F and either certify or communicate findings to the certifying physician in the community
Allow any party to title and date F2F documentation
The Home Health Prospective Payment System Rate Update for Calendar Year 2013 contained provisions to implement alternate sanctions if HHAs were out of compliance with Federal requirements. The sanctions apply to condition level deficiencies in lieu of termination.
The basis for choice of sanctions will be based on:
The extent to which the deficiencies pose immediate jeopardy
The nature, incidence, manner, degree, and duration of the deficiency
The presence of repeat deficiencies and compliance history.
The extent to which the deficiencies are related to failure to provide quality care.
The extent to which the HHA is part of a larger organization with performance problems.
The following sanctions are effective July 1, 2013:
Directed plan of correction
CMS directs the HHA on specific actions and outcomes to achieve within specific time frames
Directed in-service training
HHA training by a CMS or stated approved entity
Agency responsible for all associated costs
CMS approved entity
Agency responsible for all associated costs
The following sanctions are effective July 1, 2014 :
Civil money penalties
Suspension of payment for new admissions
Informal dispute resolution
HIPAA Final Rule
The Department of Health & Human Services (HHS) issued a long-awaited HIPAA final rule which is entitled: Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules; Final Rule.
The 2013 HIPAA Final Rule includes the following provisions on interest to home care and hospice providers:
Expands the definition of business associate to include subcontractors
Clarifies direct liability of business associates, and limits covered entity liability
Requires business associate disclosures to Secretary, and to the individual
Breach evaluation is now more standardized
Requires individual authorization for marketing
PHI of Decedents
Expands notice of privacy requirements
Addresses individuals rights to limit use of PHI, as well as access to PHI
Effective September 23, 2013, a new one year transition period for static contracts is implemented
Revised OSHA Standards
The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) has revised its Hazard Communication Standard (HCS), aligning it with the Globally Harmonized System of Classification and Labeling of Chemicals (GHS). The revised HCS will be fully implemented in 2016 and benefit workers by reducing confusion about chemical hazards in the workplace, facilitating safety training, and improving understanding of hazards, especially for low literacy workers.
OSHA's standard will classify chemicals according to their health and physical hazards, and establish consistent labels and safety data sheets (SDSs) for all chemicals made in the United States and imported from abroad.
Further information for workers, employers and users of hazardous chemicals can be reviewed at OSHA's Hazard Communication Safety and Health topics here, which includes links to OSHA's revised Hazard Communication Standard and guidance materials such as Q&A's, OSHA fact sheets, and Quick Cards.
Additional Claims Data
Effective for home health episodes beginning on or after July 1, 2013, HHAs are to use the following HCPCS codes:
Q5001: Hospice or home health care provided in patient’s home/residence
Q5002: Hospice or home health care provided in assisted living facility, or Q5009: Hospice or home health care provided in place not otherwise specified on home health claims to report where home health services were provided.
To view Change Request 8136, which included the additional claims data, please click here.
CMS Announced PECOS Activation for January 6, 2014. CMS announced the full implementation of the Provider Enrollment, Chain and Ownership System (PECOS) edits on ordering/referring providers in Medicare Part B, DME, and Part A home health agency (HHA) claims.
CMS will turn on the Phase 2 denial edits beginning January 6, 2014. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified - and that provider is not identified, is not in Medicare's enrollment records, or is not of a specialty type that may order/refer the service/item being billed.
To view the Medlearn Matters article, please click here.
Home Health Advanced Beneficiary Notice
CMS has released Change Requests 8403 and 8404 that announce changes to the Home Health Advanced Beneficiary Notice (HHABN) and instructs agencies on the use of the Advanced Beneficiary Notice (ABN) and the Home Health Change of Care Notice (HHCCN).
In their effort to “streamline, reduce, and simplify notices,” the CMS has eliminated the HHABN. The liability format of the HHABN (Option Box 1) will be replaced with the existing ABN, the form currently used by other Medicare providers to notify beneficiaries of Medicare non-coverage as required by the Social Security Act.
The HHCCN – a new form – has been created to notify beneficiaries of reductions in service for other reasons as required by the Lutwin v. Thompson decision. The HHCCN will replace both Option Box 2 and Option Box 3 formats of the HHABN.
Agencies may begin using the ABN and HHCCN now, but must use these forms to notify Medicare beneficiaries of any financial liability and /or changes in care beginning December 9, 2013. For items and services provided on or after December 9, 2013, the HHABN will no longer be valid.
To view the revised forms and instructions, please click here.
Confined to the Home
CMS released Change Request (CR) 8444 that clarifies the definition of “confined to the home” for
Medicare-covered home health services.
In the 2012 Home Health Prospective Payment System (HHPPS) rule, CMS finalized clarifications to the Benefit Policy Manual language regarding the definition for "confined to the home.” CMS claims they clarified the definition in response to the Office of Inspector General (OIG) recommendations and to more accurately reflect the definition as written in the Social Security Act.
The CR also removes vague terms such as “generally speaking”.
In order for a patient to be considered confined to the home, both the following criteria must be met:
The individual has a condition due to an illness or injury that restricts his or her ability to leave their place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated.
The condition of the patient should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
To view Change request 8444, please click here.
CMS issued manual guidance related to the Jimmo v. Sebelius lawsuit decision. The lawsuit puts an end to the Medicare contractors applying an improvement standard for Medicare covered services. CMS has consistently stated that the decision does not alter the Medicare benefit in any way, but serves to clarify that coverage of skilled nursing and therapy services does not require that the beneficiary have a potential for improvement, but rather that the beneficiary is in need of skilled care.
Relative portions of the manuals for Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) coverage have been updated.
To view Change Request 8458, please click here.
HIPPS Codes on MA Claims
The Centers for Medicare & Medicaid Services (CMS) once again delayed the edit to reject Medicare Advantage (MA) plan claims that do not have a health insurance prospective payment system (HIPPS) code for home health services. The edits will not be activated until July 1, 2014.
MA plans and HHAs have until that time to make the necessary system adjustments.
CMS initially intended to require that MA plans include a HIPPS code on all home health encounters beginning July 1, 2013. The National Association for Home Care & Hospice (NAHC) contacted CMS in June to discuss concerns regarding the failure of the health plans to communicate this directive with the provider community. Several weeks after NAHC’s call to CMS, CMS announced that were delaying the edit until December 1, 2013.
Discontinuation of Home Health Type of Bill 33X
The 033X Type of Bill will no longer be used. The 032X Type of Bill has been redefined to mean "Home Health Services under a Plan of Treatment." This Change Request defines the changes needed for Medicare systems to implement these revisions and updates the home health chapter of Pub. 100-04, Medicare Claims Processing Manual to reflect the new definitions.
To view Change Request 8244, please click here.