CMS Manual System

1 CMS Manual System Department of Health & Human Services (DHHS) Pub 100-02 Medicare Benefit Policy Centers for Medicare & Medicaid Services (CMS) Transmittal 265 Date: January 10, 2020 Change Request 11577 SUBJECT: Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, maintenance Therapy, and Remote Patient Monitoring I. SUMMARY OF CHANGES: This Change Request (CR) updates the Medicare Benefit Policy Manual , (Publication 100-02), Chapter 7, to reflect policy changes finalized in the CY 2019 and 2020 Home Health Prospective Payment System (HH PPS) Final Rules with comment period (83 FR 56406 and 84 FR 60478). Specifically, these Manual updates reflect policies related to the implementation of the Patient-Driven Groupings Model, a change to a 30-day unit of payment, changes to split-percentage payments, changes to the provision of maintenance therapy, and the definition of remote patient monitoring.

2 EFFECTIVE DATE: January 1, 2020 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: February 11, 2020 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material . Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE R 7/Table of Contents R 7/10/Home Health Prospective Payment System (HH PPS) R 7 30-Day Period Payment Rate R 7 to the 30-Day Period Payment Rates R 7 60-Day Recertifications R 7 Percentage Payment Approach to the 30-Day Period Unit of Payment R 7 Signature Requirements for the Split Percentage Payments R 7 Utilization Payment Adjustment (LUPA) R 7 Payment Adjustment R 7 Payments R 7 Issues R 7 Billing R 7 of Ownership Relationship to Periods Under HH PPS R 7 Confined to the Home R 7 s Place of Residence R 7 of Orders R 7 of Signature R 7 of Oral (Verbal)

3 Orders R 7 of the Plan of Care-Qualifying Services R 7 of Qualifying Services and Other Medicare Covered Home Health Services R 7 Certification R 7 Recertification R 7 Principles Governing Reasonable and Necessary Skilled Nursing Care R 7 and Assessment of the Patient s Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient s Status R 7 and Evaluation of a Patient Care Plan R 7 R 7 Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy R 7 Supplies R/N/D CHAPTER / SECTION / SUBSECTION / TITLE R 7 Law, Routine and Nonroutine Medical Supplies, and the Patient s Plan of Care R 7 Pressure Wound Therapy Using a Disposable Device R 7 Visits Under the Hospital and Medical Plans R 7 Care Services N 7 Patient Monitoring R 7/110/Use of Telehealth in the Delivery of Home Health Services III.

4 FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

5 IV. ATTACHMENTS: Business Requirements Manual Instruction Attachment - Business Requirements Pub. 100-02 Transmittal: 265 Date: January 10, 2020 Change Request: 11577 SUBJECT: Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, maintenance Therapy, and Remote Patient Monitoring EFFECTIVE DATE: January 1, 2020 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: February 11, 2020 I. GENERAL INFORMATION A. Background: The regulations at 42 Code of Federal Regulations (CFR) set forth the basis of home health payment under a prospective payment System . Currently, HHAs are paid a prospective payment for a 60-day episode of care, adjusted for case-mix and area wage differences.

6 In accordance with section 51001 of the Bipartisan Budget Act of 2018, CMS finalized policy changes to the home health unit of payment and the case-mix adjustment methodology in the CY 2019 HH PPS final rule with comment period (83 FR 56406). As part of the HH PPS, home health agencies are paid a split percentage payment through the request for anticipated payment (RAP) at the start of each 60-day episode and the final claim at the end of each 60-day episode. In response to ongoing program integrity concerns, in the CY 2020 HH Prospective Payment System Final Rule with comment period (84 FR 60478), CMS finalized modifications to the split-percentage payment policies beginning in CY 2020.

7 While a therapist assistant is able to perform restorative therapy under the Medicare home health benefit, the regulations at (c)(2)(iii)(C) state that only a qualified therapist, and not an assistant, can perform maintenance therapy. In the CY 2020 HH Prospective Payment System Final Rule with comment period (84 FR 60478), CMS finalized changes regarding the provision of maintenance therapy services. Section 1895(e)(1)(A) of the Act prohibits payment for services furnished via a telecommunications System if such services substitute for in-person home health services ordered as part of a plan of care. However, the statute does not define the term telecommunications System as it relates to the provision of home health care.

8 In the CY 2019 HH Prospective Payment System (PPS) Final Rule with comment period (83 FR 56406), CMS defined remote patient monitoring and finalized associated changes regarding allowed administrative costs on Medicare cost reports. B. Policy: In the CY 2019 HH Prospective Payment System (PPS) Final Rule with comment period (83 FR 56406), CMS finalized a change in the unit of payment from 60-day episodes to 30-day periods for periods beginning on or after January 1, 2020. This 30-day payment amount is adjusted by a new case-mix adjustment methodology, the Patient-Driven Groupings Model (PDGM), also finalized in the CY 2019 HH PPS Final Rule. Payment under the PDGM is adjusted by patient characteristics and other information obtained from home health claims, other Medicare claims, and certain items from the Outcome and Assessment Information Item Set (OASIS).

9 Specifically, home health 30-day payments will be adjusted by the principal and secondary diagnoses, timing of the period of care, admission source, and level of functional impairment. In the CY 2020 HH Prospective Payment System (PPS) Final Rule with comment period (84 FR60478), CMS finalized a change to the split percentage payment approach, reducing the up-front payment amount to 20 percent in CY 2020 for all 30-day periods of care for home health agencies certified for participation in Medicare on or before December 31, 2018. HHAs will submit a Request for Anticipated Payment (RAP) at the beginning of each 30-day period and a final claim at the end of each 30-day period.

10 As finalized in the CY 2019 HH Prospective Payment System (PPS) Final Rule with Comment Period (83 FR 56406), newly-enrolled HHAs (that is, HHAs certified for participation in Medicare on and after January 1, 2019) will not receive split-percentage payments for 30-day periods beginning on or after January 1, 2020. Newly-enrolled HHAs will submit a no-pay RAP at the beginning of each 30-day period to establish the home health period of care and trigger consolidated billing edits in the Medicare claims processing System . Newly-enrolled HHAs will receive a full 30-day period payment rate (minus any adjustments) after submission of a final claim at the end-of each 30-day period.