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.

For a Start of Care, OASIS Guidance states that the assessing clinician has 5 days to continue to gather needed information to complete the Comprehensive Assessment. When additional time is needed to gather information during this 5-day window, the clinician is to note the last date that information was received to complete the assessment in M0090, Date Assessment Completed.

NOTE: the 5-day assessment window does not apply to other types of assessments. The 5-day window is also not just to complete the documentation of information already received at the SOC visit; the window is to get additional clarification from the provider, the family, or the care team such as the PT who is evaluating within the 5-day window, for example.

OASIS Assessments must be submitted and accepted to iQIES within 30 days of the recorded M0090 date.

The window for the new cycle selection for Ohio, North Carolina & Florida opened on April 1 and will close on April 14, 2025. Oklahoma's ended in March, Illinois & Texas are in July.

The options to choose from are #1 Pre-Claim Review, #2 Post Payment Review. If you were 90% successful with affirmations or approval under one of those two options, review in the subsequent selection period you may select: #1 Pre-Claim Review, #3 Selective Post Payment Review or #4 Spot Check Review.

Your question was specifically about Spot Check, which includes that 5% of your claims will be chosen for ADR REVIEW and this is PRE-PAYMENT.....meaning as you bill the claim they will be selected for ADR review and the chart will have to be submitted for medical review and that can take 60+ days to get the results and if approved you will then be paid. If you have an agency that bills 1,000 claims per month this means that you will have 6,000 in 6 months and 300 of them will be pulled for medical review. You are not only looking at delayed payment of 300 claims, but you are facing the possibility of denials that would require a lengthy appeal process and possibly being referred to additional medical reviews such as UPIC if the denials are significant.

I also want to reiterate that that if you select #3 there is no clear answer as to the calculation of identifying a Statistically Valid Sample of charts, not to mention the fact that if you select this one you are stuck there until 2029.

In our experience, being under Pre-Claim review, while it might seem tedious, has become a way for agencies to ensure that, at least initially, the certification passes medical review scrutiny and does NOT subject the entire chart to medical review nor does it delay cash flow.

Thank you for your questions regarding OASIS items and their use. Each item used in the OASIS data set is used in some capacity, but they are not all used for the same purpose. This makes it difficult to select only those used for reimbursement or outcomes measures.

For example, The M1800 items plus M1033 are used to calculate the functional domain in PDGM payment, which impacts your Medicare payments. However, the GG Items (GG0130 and GG0170) are used to determine the patient’s functional status for the Discharge Function Score in Home Health Value Based Purchasing.

M1021, Primary Diagnosis and M1023, Secondary diagnoses, are used for risk adjusting the Potentially Preventable Hospitalization measure for HHVBP (as well as M1021 and the M1700 items).

For a list of all the OASIS Items used in Home Health Quality Reporting program, this link to HHQRP Outcomes Measures will open a table with all the measures and the items used to calculate them.

This link opens a table with all the process measures used in HHVBP; some of these are also used in reports your surveyor pulls prior to on-site survey, such as the Potentially Avoidable Events reports.

Because of the comprehensive nature of the OASIS and its use, we strongly encourage agencies to review ALL the OASIS items and provide education to staff on the OASIS data set regularly. Should you need assistance with either, please let us know - we can help!

The OASIS E-1 Guidance Manual states that:

“Agencies may have the comprehensive assessment including OASIS, if applicable, completed by one clinician. If collaboration with other health care personnel and/or agency staff is utilized, the agency is responsible for establishing policies and practices related to collaborative efforts, including how assessment information from multiple clinicians will be documented within the clinical record, ensuring compliance with applicable requirements, and accepted standards of practice.”

The manual also states that “Any differences between OASIS coding should be discussed jointly by the assessing clinician and auditor to determine the reasons for the differences and to ensure that assessing clinicians fully understand the OASIS items and related guidance.”

Given this guidance, best practice would reflect that a discussion between the reviewer and the assessing clinician occurred, whether verbally or in writing, and that the clinician who is responsible for the comprehensive assessment agrees with the changes made. Agency policy would dictate how this is documented; some agencies document on a care coordination note with the assessing clinician re-signing and “locking” the comprehensive assessment after review to reflect this agreement and to affix the clinician signature to the legal document in the software platform.

Yes, if Medicare is listed as a pay source for home health, the data is used in Home Health Quality Reporting Program OASIS-based measures.

The Home Health Quality Reporting Program Quality Measures User’s Manual, Version 3.0 states:

“The OASIS-based quality measures in the Home Health Quality Reporting Program will continue to report only data for Medicare fee-for-service, Medicare Advantage (Medicare managed care), Medicaid, and Medicaid managed care.”

It also states in Chapter 3 of this manual that quality episodes [for use in HHQRP] are not created for patients who meet OASIS measure exclusions or who do not have Medicare Traditional fee-for-service, Medicare HMO/Managed Care/Advantage plans, Medicaid Traditional or Medicaid HMO/Managed Care plans, or are receiving only personal care, homemaker, or chore services.

The HHVBP adjustment should be applied prior to sequestration. There are two resources for your review and use regarding the VBP adjustment and sequestration. Question 5008 of the HHVBP FAQs states: Through the expanded HHVBP Model, CMS will adjust each HH PPS final claim payment amount to a home health agency (HHA) with a “through date” in the HHVBP payment year by an amount up to or down to the maximum applicable percent. Applying the sequestration adjustment is the final step in processing a claim.

• Home Health Value Based Purchasing Newsletter, March 2025. - See Page 4 of 6.
• Home Health Value based Purchasing Frequently Asked Questions, CMS, March 2025. - See Page 8 of 70, Question 5008.

Medically necessary skilled care is defined in section 40 of the Medicare Benefit Policy Manual, Home Health Chapter 7. This layer of coverage is in addition to beneficiary eligibility criteria covered in sections 20 and 30 of this manual. Additionally, CGS, your Home Health Medicare Administrative Contractor (MAC) provides information on coverage on their website. Keep in mind that some Medicare Advantage plans cover things that Traditional Medicare does not. You will need to check with the specific MA plan to determine.

Whether or not Medicaid covers long-term medication management is dependent on the individual Medicaid insurance policy’s coverage guidelines. Please refer to the Medicaid payer’s insurance contract and/or coverage criteria for information as to whether long-term medication management is a covered billable service.

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

The hospice physician that provides verbal CTI is not required to be the same hospice physician who complete the written CTI narrative.

The regulation that supports this is in the State Operations Manual appendix A page 275. It is a general Medicare reference: SOM Appendix A (cms.gov) Interpretive Guidelines §482.24(c)(2)

In some instances, the ordering practitioner may not be able to authenticate his or her order, including a verbal order (e.g., the ordering practitioner gives a verbal order which is written and transcribed, and then is “off duty” for the weekend or an extended period of time). In such cases it is acceptable for another practitioner who is responsible for the patient’s care to authenticate the order, including a verbal order, of the ordering practitioner as long as it is permitted under State law, hospital policies and medical staff bylaws, rules, and regulations. Hospitals may choose in their policies to restrict which practitioners it would authorize to authenticate another practitioner’s orders. For example, a hospital could choose to restrict authentication of orders for pediatric patients to practitioners who are privileged to provide pediatric care. (77 FR 29053, May 16, 2012).

Click here to view State Operations Manual - Appendix M

The submission of HQRP CY data will impact the corresponding FY APU. The submission of Q4 2025 data will count for the FY 2027 APU calculations. HQRP compliance is based on a full CY of data submissions (HIS/HOPE + CAHPS). The graphic in the HOPE Guidance Manual is just an example to show that submission for the first full year of HOPE data (CY2026) will count toward the FY 2028 APU.

There is concern that there may be issues with the transition from QIES to iQIES for HOPE transmission as both go into effect on 10/01/2025. Having said that there are requests to possibly not utilize the 1st quarter of HOPE data as it is implemented. As of today, May 9, 2025, there will be a direct impact on 2027 APU for HOPE data starting 10/01/2025.

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

Face to Face telehealth flexibilities were extended through September 30, 2025 as part of the law that delayed the government shutdown for FY 2025. The law, Full-Year Continuing Appropriations and Extensions Act, 2025 is found here, and specifically Section 2207 is where you will find the Telehealth Flexibilities extension.

SEC. 2207. EXTENSION OF CERTAIN TELEHEALTH FLEXIBILITIES.
(a) Removing Geographic Requirements and Expanding Originating Sites for Telehealth Services.--Section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended--

(1) in paragraph (2)(B)(iii), by striking ``ending March 31,
2025'' and inserting ``ending September 30, 2025''; and
(2) in paragraph (4)(C)(iii), by striking ``ending on March
31, 2025'' and inserting ``ending on September 30, 2025''.