Frequently Asked Questions

For the 2025 HHVBP measure “Home Health Within Stay Potentially Preventable Hospitalization (PPH)”, the number of risk-adjusted potentially preventable hospitalizations OR potentially preventable observation stays that occur within a home health stay for all eligible stays at the agency will be calculated.

• Planned admissions are not counted (for example planned hip replacements, planned knee replacements)
• Whether or not the hospitalization or observations are preventable or not will be determined by the codes the hospital places on their claim

The measure-specific exclusions for this measure are:

• HH stays that begin with a LUPA claim
• Stays in which the patient receives service from multiple agencies during the home health stay
• Patients not continuously enrolled in Medicare part A Fee for Service for the 12 months prior to the home health admission date through the end of the home health stay
• Patients less than 18 years old

Reference: Specifications for the Home Health Within-Stay Potentially Preventable Hospitalization Measure for the Home Health Quality Reporting Program

The implementation of mandatory all payer OASIS Collection and Submission is for all SOC OASIS 07/01/2025 and after. You will also be required to collect and submit all subsequent OASIS for these patients (Recert, TF, ROC, DAH, DC, Other Follow Up/SCIC etc).

The Final OASIS E1 Manual states the following:

OASIS data collection and submission are required for patients with any pay source who are not exempt from OASIS data collection, and who begin receiving home health care services with an OASIS SOC M0090 data on or after July 1, 2025. The requirement includes the SOC OASIS and any subsequent OASIS time point assessments relevant to the patient’s home health stay (that is, resumption of care, recertification, other follow-up, transfer, discharge, and death at home).

• Patients under the age of 18, patients receiving maternity services, and patients receiving only personal care, housekeeping and/or chore services continue to be excluded from OASIS data collection and submission requirements.

Reference: CMS Home Health OASIS All Payer Q&As

Yes. Per the Medicare Benefit Manual Chapter 7, the 30-day reassessment is still a requirement. The documentation states “At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, and compare the resultant measurement to prior assessment measurements. The therapist must document in the clinical record the measurement results along with the therapist’s determination of the effectiveness of therapy, or lack thereof.

See the following from the OASIS Guidance Manual, Chapter 3, Item M0104 – regarding Timely Initiation of Care, which states:

• A valid referral is considered received when the agency has received adequate information about a patient (such as name, address/contact info, and diagnosis and/or general home care needs) to initiate patient assessment and confirmed that the referring physician/allowed practitioner or another physician/allowed practitioner, will provide the plan of care and ongoing orders.
• In cases where home care is requested by a hospitalist who will not be providing an ongoing plan of care for the patient, the agency must contact an alternate or attending physician/allowed practitioner. The agency will note the date the alternate or attending physician/allowed practitioner agreed to follow the patient as the referral date (M0104) unless referral details are later updated or revised.
• Enter the date of the most recent/latest referral
• If Start of Care or Resumption of Care is delayed due to the patient’s condition or physician/allowed practitioner request (for example, extended hospitalization), the date the agency received the updated/revised referral for home care services would be considered the date of referral.

The Timely Initiation of Care quality measure, as well as the CoP, will be based on whether the initial assessment was conducted either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered SOC date. If you are pursuing a physician ordered SOC date, you must contact the referring provider and get that order date within the 48-hour period, or you will be out of compliance.

Surveyors will count 48 hours from the time that the referral is received whether a physician has been verified to cover the patient or not. If there is a question as to being able to obtain the physician confirmation of home health coverage, the agency should seek documentation of a specific SOC date in the referral order.

The short answer is No, CMS does not mandate that you always discharge (and readmit if a referral is received). The rationale is a bit more complex as the decision to transfer/resume vs. discharge and readmit has to be evaluated on a case-by-case basis, and the decision to DC vs TRN based on impact to payment and quality measures.

However, IF a patient is in a facility (SNF, Acute Care Hospital/ACH, Swing Bed, etc.) on the 60th day of the certification period, the patient SHOULD be discharged.

In other cases, the decision to TRN and Resume vs DC and Readmit would be based on:

• Facility Setting (PAC vs. Acute Care) and/or
• Impact to PDGM Payment, if applicable.
• In cases where a patient is discharged to a facility – regardless of type – Medicare is now applying the regulation, to claims processing, that if the patient returns/resumes within the same 30-day period the discharge will be nonallowed for billing purposes and the claim RTP for correction
• If the patient is discharged to a facility - regardless of type – and has a new SOC on day 31 or later of the episode – the agency can receive institutional credit on that new claim if the discharge happened within the prior 14 days (this is the only way to get the credit for a SNF, LTCH, Rehab or Psych readmission)
• Note: if the patient is admitted to an acute care hospital and resumed in the last 14 days of a period the next 30-day claim will get institutional credit.

The Discharge to Community measure that was based on OASIS responses is no longer utilized in the HHVBP measure calculations. It has been replaced by the Discharge to Community Post Acute Care measure (DCT-PAC). The measure is the risk-adjusted prediction of the number of HH stays resulting in a discharge to the community (Patient discharge code 01 or 81) without an unplanned admission to an Acute Care Hospital or LTCH or death in the 31 days post-discharge observation window. This is a measure that will cover two years of data and it will be derived from hospital claims. See the model guide at this link for more information.

The CMS regulations allow the patient to choose a NP or PA as their attending physician. However, if the attending/supervising physician for the NP/PA is not specifically chosen and is not named on the Hospice Election Statement, then that physician can’t perform as their attending and sign the POC and CTI.

If the patient chooses a NP or PA as their attending, then the hospice physician alone would complete and sign the written certification. NP/PAs cannot certify a patient for hospice care but can be involved in the patient’s plan of care.

Regulations: §418.102 Condition of participation: Medical director

NPs may function as the “Attending Physician” and may write orders within the scope of their state practice act.

PA’s functioning as the “Attending Physician,” PAs may write orders that are unrelated to the terminal illness, within the scope of their state practice act.

Neither NPs or PAs can function as the physician on the interdisciplinary team or certify terminal illness.

L515 (Rev. 210; Issued:02-03-23; Effective:02-03-23; Implementation:02-03-23)

§418.52(c)(4) Choose his or her attending physician;

Interpretive Guidelines §418.52(c)(4)

Patients have the right to choose their attending physician (generally a provider for whom the beneficiary has a relationship with and is not part of the current hospice staff) and to have this person involved in their medical care in collaboration with the hospice medical staff. An attending physician (if any) can also manage those aspects of his/her health care unrelated to the hospice services being provided.

The HCI or Hospice Care Index is calculated solely from data found on the Hospice Claims. The following is a list of the 10 Indicators:

• 1. Continuous Home Care (CHC) or General Inpatient (GIP) - % of CHC and GIP level of care days reflected on the Medicare claims during the reporting period. (Need to be greater than 0%)
• 2. Gaps in Nursing Visits - Number of Medicare Elections that had Gaps in Nursing Visits greater than 7 days within a 30-day period. (Need to be < 90%)
• 3. Early Live Discharges - % of Early Live Discharges within 7 days of admission compared to other hospice providers (Need to be < 90%)
• 4. Late Live Discharges - % of Late Live Discharges on or after 180 days from the hospice admission compared to other hospice providers (Need to be < 90%)
• 5. Burdensome Transitions (Type 1) - % of Live Discharges from Hospice Followed by Hospitalization and Subsequent Hospice Readmission (Need to be < 90%)
• 6. Burdensome Transitions (Type 2) - % of Live Discharges from Hospice Followed by Hospitalization with the Patient Dying in the Hospital (Need to be < 90%)
• 7. Per-beneficiary Medicare Spending compared to other hospice providers - Calculate by the total # of payments, Medicare paid to hospice providers divided by the total # of hospice beneficiaries served. (Need to be < 90%)
• 8. Nurse Care Minutes per Routine Home Care (RHC) Day - Average SN Care Minutes per RHC Day compared to other hospice providers (Need to be Greater than 10%)
• 9. Skilled Nursing Minutes on Weekends –SN Minutes on the Weekends (Saturday & Sunday) out of all SNV during RHC services days (Need to be Greater than 10%)
• 10. Visits Near Death - The number of Visits Near Death reflected on the Medicare claims compared to other hospice providers. The % of beneficiaries receiving at least one visit by a SN or social worker during the last three days of the patient’s life (Need to be Greater than 10%) - A visit on the date of death, the date prior to the date of death, or two days prior to the date of death).

For additional information: Hospice Care Index Technical Report

The patient has the right to name an Attending in the community that is a Nurse Practitioner or a Physician Assistant. Neither of these practitioners can CERTIFY the terminal illness of the patient. This means that your Medical Director or physician member of the Hospice IDG will be the only one to provide the verbal and written certification of the patient’s terminal illness.

Medicare Benefit Policy Manual – Chapter 9 – Section 20.1

The patient has the choice whether to select an attending physician or not at time of election. If the patient does not choose an attending physician; the hospice medical director or other hospice physician assumes responsibility for the patient and only that physician is required to certify the patient at time of initial certification (first 90 days episode).

All subsequent benefit periods - 2nd and subsequent only require certification by the hospice physician even if the patient has chosen an attending physician.

Please see the Medicare Benefit Policy Manual Chapter 9 Sections 10 & 20

Face to Face Encounters continue to be a nightmare for some hospices when patients are admitted under the incorrect benefit period. First, in the above scenario you will have no other option, but to discharge and readmit the patient in conjunction with a Face to Face being conducted. You will have to absorb the cost from treating the patient during the time they have been on service with you with no reimbursement,

Tips to avoid in the future:

1. 1) If there is any evidence that a hospice has been with the patient prior and there is NOT a discharge claim or Notice of Termination/Revocation in place, then you should contact the prior hospice to determine the exact situation and you should proceed with conducting a Face to Face in case it is determined that the patient will be in their 3rd benefit period with you.
2. 2) IF IN DOUBT DO A FACE TO FACE! – Reminder – currently the Telehealth Face to Face Encounter Allowance is set to expire March 31, 2025.

CMS Hospice Center

Yes - Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC. Providers may formally delegate the delivery of the notices to a designated agent such as a courier service; however, all of the requirements of valid notice delivery apply to designated agents.

The new forms were issued with an expiration date of 11/30/2027. Make sure to use the new forms as of 1/1/2025.

For additional information: Click here