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Changes and updates are occurring rapidly, this information is as best we understand on 05/07/20. We will continue to monitor the situation and update as we are able.
As we are facing the pandemic of the century, home health and hospices are on the frontline of this Public Health Emergency (PHE) along with hospitals, physicians and all other healthcare workers. We at Healthcare Provider Solutions, Inc. would like to take this moment to thank each and every one of you for your true dedication to treating patients and helping the world to be a healthier place.
The Trump Administration has taken extraordinary steps in getting relief passed in the form of The CARES Act and CMS has in turn taken the initiative to speed up the rulemaking process in providing temporary waivers for home health to benefit from the changes outlined in the CARES Act Relief Package. There were also numerous waivers that were initiated before the CARES Act that provided relief from all the red tape and making room for patient care to be the focus without extensive concern for timeliness of paperwork.
Face-to-Face (FTF) for Home Health & Hospice
With the release of the Medicare Telehealth FAQs, 03/17/20 and the Medicare Telemedicine Fact Sheet the CMS Q&A, updated 03/23/20, the Home Health Face-to-Face Encounter requirement, at the Start of Care, is permitted to be conducted by the physician or NPP utilizing telehealth – this must consist of two way audio and video. This is for the time of the PHE only. No other changes are in place, for the FTF, during this crisis.
For hospice, the relief for the FTF includes that telehealth visits are now allowed by physicians or nurse practitioners that are employed/compensated by the hospice and billed by the hospice. The use of telephones is allowed, however, the technology must have two-way audio/video capabilities. HIPAA compliance concerns are waived for these purposes (home health and hospice) and services such as Skype will be allowed.
Quality Reporting Requirements
A CMS Memo dated 03/27/20, updates the exact timeframes that are impacted for quality reporting during this PHE. HHAs and Hospices are excepted from the reporting of data on measures, CAHPS surveys (HHA & Hospice) and Hospice HIS. Understanding that OASIS is still required for home health payment.
HHAs–Home Health QRP
- October 1, 2019–December 31, 2019 (Q4 2019)
- January 1, 2020–March 31, 2020 (Q1 2020)
- April 1, 2020–June 30, 2020 (Q2 2020)
- October 1, 2019–December 31, 2019 (Q4 2019)
- January 1, 2020–March 31, 2020 (Q1 2020)
- April 1, 2020–June 30, 2020 (Q2 2020)
Home Health Value-Based Purchasing (HHVBP) Model, CMS is waiving enforcement of the following reporting requirements under the Model:
- April 2020 new measures submission period (data collection period October 1, 2019 – March 31, 2020)
- July 2020 new measures submission period (data collection period April 1, 2020 – June 30, 2020)
The exceptions to the HH QRP and HH CAHPS reporting requirements will impact the calculation of performance measures under the HHVBP Model. CMS will address this issue with HHVBP Model participants as that becomes necessary.
Home Health Certification Requirements:
- A definition of the home health “homebound” requirement that means that any individual determined by their physician to be at high risk of contracting COVID-19 due to a compromised health condition, meets the homebound requirement because it is “medically contraindicated” to leave the home.
- CMS is utilizing enforcement discretion to permit non-physician practitioners (NP, PA, and CNS) to certify eligibility for the home health benefits and to establish and manage the Plan of Care provided such is allowable under state practice laws. This will be applied to all periods with THRU dates of March 1, 2020 and later. This change was mandated at part of the CARES Act. However, CMS has been able to accelerate its implementation through its enforcement discretion authority for it to be implemented. As of now this is through the PHE, but due to the legislation containing this change it should be made permanent by CMS after this crisis has passed.
Waivers Under the Conditions of Participation (CoPs)
Many of the waivers that are included in the following update are summarized in the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers
The following conditions that must be met in order fulfill the Home Health CoPs have been relaxed during this PHE:
- The initial evaluation under 484.55(a) may be conducted during a telehealth visit or through medical review of the chart. THIS IS NOT TO BE CONFUSED WITH THE COMPREHENSIVE ASSESSMENT, which is still required to be completed from an in-person visit.
- CMS is waiving the 14-day onsite visit requirement for Home Health Aide Supervisory visits. They encourage agencies to use virtual technology to conduct these supervisory visits, but they are NOT requiring it.
- There will be no penalties during survey for transmission of OASIS that exceeds the 30-day requirement
- The 5 days allowed to complete the comprehensive assessment has been increased to 30 days during this PHE and will not carry any penalties for being past 5 days.
- Agencies may provide visits through telehealth or any two-way audio/visual technology and the technology is not subject to HIPAA compliance. The visits must be ordered by the physician and included in the care plan of the patient as telehealth visits. Agencies will not receive reimbursement for telehealth visits.
- The most recent update to the 1135 waivers for the PHE is the allowance of an Occupational Therapist to conduct the Start of Care Comprehensive Assessment of the patient and establish the qualifying skill when the home health referral is for therapy services only or for nursing and therapy cases, but NOT in nursing only cases.
- Update: CMS is waiving the requirement at 42 CFR §484.80(h)(1)(iii) for HHAs, which require a registered nurse, or in the case of an HHA a registered nurse or other appropriate skilled professional (physical therapist/occupational therapist, speech language pathologist) to make an annual onsite supervisory visit (direct observation) for each aide that provides services on behalf of the agency. In accordance with section 1135(b)(5) of the Act, we are postponing completion of these visits. All postponed onsite assessments must be completed by these professionals no later than 60 days after the expiration of the PHE.
- Update: Quality Assurance and Performance Improvement (QAPI). CMS is modifying the requirement at 42 CFR §484.65 for HHAs, which requires these providers to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. Specifically, CMS is modifying the requirements at §484.65(a)–(d) to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events. The requirement that HHAs maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program will remain.
- Update: Detailed Information Sharing for Discharge Planning for Home Health Agencies. CMS is waiving the requirements of 42 CFR §484.58(a) to provide detailed information regarding discharge planning, to patients and their caregivers, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, (another) home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term care hospital (LTCH) quality measures and resource use measures. This temporary waiver provides facilities the ability to expedite discharge and movement of residents among care settings. CMS is maintaining all other discharge planning requirements.
- Update: Clinical Records In accordance with section 1135(b)(5) of the Act, CMS is extending the deadline for completion of the requirement at 42 CFR §484.110(e), which requires HHAs to provide a patient a copy of their medical record at no cost during the next visit or within four business days (when requested by the patient). Specifically, CMS will allow HHAs ten business days to provide a patient’s clinical record, instead of four.
The following conditions that must be met in order to fulfill the Hospice CoPs have been relaxed during this PHE:
- CMS is waiving the requirement of the use of volunteers (including at least 5% of patient care hours).
- The requirement that the comprehensive assessment of the hospice patient has been relaxed to require that this be updated at least every 21 days, where the current requirement is 15 days. THIS DOES NOT IMPACT THE PLAN OF CARE UPDATE REQUIREMENT…THE PLAN OF CARE MUST STILL BE UPDATED EVERY 15 DAYS.
- The requirement for hospices to provide certain non-core hospice services during this PHE is waived, including physical and occupational therapies and speech-language pathology.
- CMS is waiving the onsite requirement for the Hospice Aide Supervisory visits that are currently required every two weeks. They encourage agencies to use virtual technology to conduct these supervisory visits, but they are NOT requiring it.
- The most recent update includes that Hospice Aide competencies can now be conducting using pseudo patients vs. live patients.
- The newest information also includes that Hospice Aide 12-hour annual in-services training requirement is waived during this emergency.
- Update: CMS is waiving the requirement at 42 CFR §418.76(h)(2) for, which require a registered nurse, or in the case of an HHA a registered nurse or other appropriate skilled professional (physical therapist/occupational therapist, speech language pathologist) to make an annual onsite supervisory visit (direct observation) for each aide that provides services on behalf of the agency. In accordance with section 1135(b)(5) of the Act, we are postponing completion of these visits. All postponed onsite assessments must be completed by these professionals no later than 60 days after the expiration of the PHE.
- Update: Quality Assurance and Performance Improvement (QAPI). CMS is modifying the requirement at 42 CFR §418.58 for Hospice, which requires these providers to develop, implement, evaluate, and maintain an effective, ongoing, hospice-wide, data-driven QAPI program. Specifically, CMS is modifying the requirements at §418.58(a)–(d) to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events. The requirement that hospices maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program will remain.
- Update: Annual Training. CMS is modifying the requirement at 42 CFR §418.100(g)(3), which requires hospices to annually assess the skills and competence of all individuals furnishing care and provide in-service training and education programs where required. Pursuant to section 1135(b)(5) of the Act, we are postponing the deadline for completing this requirement throughout the COVID-19 PHE until the end of the first full quarter after the declaration of the PHE concludes. This does not alter the minimum personnel requirements at 42 CFR §418.114. Selected hospice staff must complete training and have their competency evaluated in accordance with unwaived provisions of 42 CFR Part 418.
- Update: Inspection, Testing & Maintenance (ITM) under the Physical Environment Conditions of Participation: CMS is waiving certain physical environment requirements for Hospitals, CAHs, inpatient hospice, ICF/IIDs, and SNFs/NFs to reduce disruption of patient care and potential exposure/transmission of COVID-19. The physical environment regulations require that facilities and equipment be maintained to ensure an acceptable level of safety and quality. For additional information on these updates see the Interim Final Rule Link.
- Note that with the halting of current medical review, this does not include a ceasing of a review that is a fraud investigation. The OIG has released a statement that healthcare providers currently under an OIG audit, including Corporate Integrity Agreements, need to contact the head auditor and instructions will be given as to updated deadlines, etc.
- All Medical Review programs have been halted at this point. Specifically, Targeted Probe & Educate (TPE) and all Additional Development Requests (ADR) will cease. Any ADR requests that are active will have the claims released for payment. No date as to when the TPE and other reviews will resume. This halt on medical review does include any Supplemental Medical Review Contractor (SMRC) or Recovery Audit Contractor (RAC) audits.
- The Review Choice Demonstration (RCD) that is currently active in 3 states and was set to be implemented in two more has been updated. Florida and North Carolina were set for implementation May 4, 2020 and this has been indefinitely be postponed. Also, for the states that are currently in RCD, the most recent update includes that any agency that is currently under the Pre-Claim Review (PCR) option of RCD can choose to forego the PCR process to obtaining affirmation, but as of right now, if they choose that option all the claims that are paid during that time without a UTN will be subject to 100% ADR review of the full chart once the RCD resumes.
The Medicare Learning Network Article Number SE20011, updated 03/20/20 outlines many of the 1135 waivers and specifically addresses the following:
- There are no changes to the requirements of required signed orders, etc. to bill a final claim in home health. There is also the requirement of the OASIS being transmitted to the database prior to billing the final claim. This has not been waived.
- To ensure the correct processing of home health emergency related claims, Medicare Administrative Contractors (MACs) are permitted to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs). Check with your Medicare MAC to ensure the application of this. It has been confirmed that the MACs are extending the RAP auto-cancellation to be an additional 90 days from when the RAP is paid.
- The claims processing system has also been updated to accept and process claims where the physician information on the claim corresponds to a PECOS enrolled NPP as is now allowed in home health.
Diagnosis Coding for Home Health and Hospice
There has been a code officially approved to be used in ICD-10-CM for COVID-19 for the USA and that is U07.1. This diagnosis code went into effect April 1, 2020 and can be used as the primary diagnosis of the patient in home health and hospice. This code is NOT in effect prior to April 1 and would not be accepted for dates of service prior to that. Home Health – please note that this code is being implemented into the MMTA – Respiratory Clinical Grouping in PDGM and is in a LOW comorbidity category is the code is a secondary diagnosis of the patient. The grouper in the claims processing systems was updated April 6. Any RAPs & Finals prior to that would not allow this diagnosis as primary. Your EMR will have to update this code in their acceptable primary list in order for you to receive the correct HIPPS code and the EMR to allow a claim with this code as primary. Please see the AHIMA Q&A regarding this.
Medicare Cost Report Filing Due Dates
CMS has instructed that the Medicare Cost Report will have extended due dates due to this PHE. The following are the new due dates:
Initial Due Date
New Due Date
Medicare Credit Balance Reports
The Medicare Credit Balance Reports are typically due 30 days following the end of the calendar quarter. Palmetto GBA has announced that the first quarter reports due on April 30 will now have a due date of July 30. In essence the first 2 quarters will both be due on July 30. IF you are a CGS or NGS provider you will need to check with your MAC to determine this deadline.
Clarifications and updates are occurring quickly and HPS is trying to keep abreast of all of them in order to keep you informed. Please continue to check our website for updates. We will be providing an update of the Advanced Payment option that CMS has issued, the CARES Act Provider Relief Funding, as well as loan options from the Small Business Administration as some agencies will be suffering from strapped cash flow.
We will be providing an update of the Accelerated Payment Program that CMS has issued and the Small Business Administration loan options. Many agencies will need access to supplemental cash as a result of the impact that the PHE is having on cash flow.
Healthcare Provider Solutions is dedicated to providing the Home Health and Hospice industries with the education and resources necessary to keep you performing at the highest level of success. We are in this together, if we can help you during this trying time please don’t hesitate to contact us.