(Medicare Benefit Policy Manual)

the LUPA payment is increased by an add- on amount for LUPAs that occur as the only 30-day period or the initial 30- day period during a sequence of adjacent periods.  10.7 - Partial Payment Adjustment  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  A.  Partial Payment Adjustment Criteria   An HHA receives a national, standardized 30 -day payment of a predetermined rate for home health services unless CMS determines an intervening event warrants a new 30-day period for purposes of payment.   The partial payment adjustment is a proportion of the period payment and is based on the span of days including the start -of-care date (for example, the date of the first billable service) through and including the last billable service date under the original plan of care before the intervening event, defined as a    Beneficiary elected transfer, or   Discharge and return to home health that would warrant, for purposes of payment, a new OASIS assessment, certification of eligibility, and a new plan of care.   When a new 30 -day period begins due to an intervening event, the original 30- day period will be proportionally adjusted to reflect the length of time the beneficiary remained under the agencys care prior to the intervening event. The proportional payment is the partial payment adjustment.   B.  Methodology Used to Calculate Partial Payment Adjustment  The partial payment adjustment for the original 30- day period is calculated to reflect the length of time the beneficiary remained under the care of the original HHA based on the first billable visit date through and including the last billable visit date.   The partial payment adjustment will be calculated by using the span of days (first billable service date through and including the last billable service date) under the original plan of care as a proportion of the 30-day period. The proportion will then be multiplied by the original case-mix and wage index to produce the 30-day payment.  C.  Common Ownership Exception to Partial Payment Adjustment   The partial payment adjustment does not apply in situations of transfers among HHAs of common ownership.  Those situations would be considered services provided under arrangement on behalf of the originating HHA by the receiving HHA with the ownership interest until the end of the 30-day period.  The common ownership exception to the transfer partial payment adjustment does not apply if the beneficiary moved out of their Metropolitan Statistical Area (MSA) or non -MSA during the 30-day period before the transfer to the receiving HHA.  D.  Beneficiary Elected Transfer Verification   In order for a receiving HHA to accept a beneficiary elected transfer, the receiving HHA must document that the beneficiary has been informed that the initial HHA will no longer receive Medicare payment on behalf of the patient and will no longer provide M edicare covered services to the patient after the date of the patient's elected transfer in accordance with current patient rights requirements at 42 CFR 484.50(d).  The receiving HHA must also document in the record that it accessed the Medicare contractors inquiry system to determine whether or not the patient was under an established home health plan of care and it must contact the initial HHA on the effective d ate of transfer.  In the rare circumstance of a dispute between HHAs, the Medicare contractor is responsible for working with both HHAs to resolve the dispute. If the receiving HHA can provide documentation of its notice of patient rights on Medicare payment liability provided to the patient upon transfer and its contact of the initial HHA of the transfer date, then the initial HHA will be ineligible for payment for the period of overlap in addition to the appropriate partial payment adjustment.  If the receiving HHA cannot provide the appropriate documentation, the receiving HHA's RAP and/or final claim will be cancelled, and full period payment will be provided to the initial HHA.  For the receiving HHA to properly document that it contacted the initial HH A on the effective date of transfer it must maintain similar information as the initial HHA, including the same basic beneficiary information, personnel contacted, dates and times.  The initial HHA must also properly document that it was contacted and it a ccepted the transfer.  Where it disputes a transfer, the initial HHA must call its Medicare contractor to resolve the dispute.  The Medicare contractor is responsible for working with both HHAs to resolve the dispute.  10.8 - Outlier Payments (Rev. 265, Issued: 01- 10-20, Effective: 01 -01-20, Implementation: 02- 11-20)  When cases experience an unusually high level of services in a 30 -day period, Medicare systems will provide additional or "outlier" payments to the case -mix and wage -adjusted 30-day period payment.  Outlier payments can result from medically necessary high utilization in any or all- home health service disciplines.  CMS makes outlier payments when the cost of care exceeds a threshold dollar amount.  The outlier threshold for each case- mix group is the 30- day period payment amount for that group or the partia l payment adjustment amount for the 30- day period, plus a fixed dollar loss amount, which is the same for all case- mix groups.  The outlier payment is a proportion of the amount of imputed costs beyond the threshold.  CMS calculates the imputed cost for ea ch 30- day period by first taking the national per -visit payment amounts for each discipline and calculating per -unit payment amounts (1 unit = 15 minutes).  The per -unit amounts are then multiplied by the number of units in the discipline and computing the  total imputed cost for all disciplines (summed across the six disciplines of care).   If the imputed cost for the 30- day period is greater than the sum of the case -mix and wage- adjusted 30- day period payment plus the fixed dollar loss amount (the outlier threshold), a set percentage (the loss sharing ratio) of the difference between the imputed amount and outlier threshold will be paid to the HHA as a wage -adjusted outlier payment in addition to the 30- day period payment.   The amount of the outlier payment is determined as follows:   1. Calculate the case- mix and wage -adjusted 30- day period payment (including non-routine supplies (NRS));   2. Add the wage -adjusted fixed dollar loss amount.  The sum of steps 1 and 2 is the outlier threshold for the 30- day period;   3. Calculate the wage- adjusted imputed cost of the 30- day period by first multiplying the total number of units for each home health discipline by the national per unit amounts, and wage -adjusting those amounts.  Sum the per discipline wage -adjusted imputed amounts to yield the total wage -adjusted imputed cost for the 30- day period;   4. Subtract the total imputed cost for the 30- day period (total from Step 3) from the sum of the case -mix and wage -adjusted 30- day period payment and the wage -adjusted fixed dollar loss amount (sum of Steps 1 and 2 -  outlier threshold);   5. Multiply the difference by the loss sharing ratio; and  6. That total amount is the outlier payment for the 30 -day period.  Effective January 1, 2010, an outlier cap precludes any HHA from receiving more than 10 percent of their total home health payment in outliers.  10.9 - Discharge Issues                                                                               (Rev. 12382; Issued: 11- 28-23; Effective: 01 -01-24; Implementation:01- 02-24)  A. Hospice Election Mid -Period   If a patient elects hospice before the end of the 30 -day period and there was no partial payment adjustment  or LUPA adjustment, the HHA will receive a full 30 -day period payment. The 30- day period with visits less than the LUPA threshold for the payment group would be paid at the low utilization payment adjusted amount.  B. Patient's Death   The documented event of a patient's death would result in a full 30- day period payment, unless the death occurred in a low utilization payment adjusted 30- day period. Consistent with all episodes in which a patient receives four or fewer visits, if the pat ient's death occurred during a low utilization adjusted 30 -day payment period, the period would be paid at the low utilization payment adjusted amount. In the event of a patient's death during an adjusted 30- day period, the total adjusted period would constitute the full 30 - day period payment.   C. Patient is No Longer Eligible for Home Health (e.g., no longer homebound, no skilled need)   If the patient is discharged because he or she is no longer eligible for the Medicare home health benefit and has received visits meeting the LUPA threshold for the payment group, then the HHA would receive the full 30-day period payment. However, if the patient becomes subsequently eligible for the Medicare home health benefit during the same 30-  day period and transferred to another HHA or returned to the same HHA, then this would result in a partial payment adjustment.   D. Discharge Due to Patient Refusal of Services or is a Documented Safety Threat, Abuse Threat or is Noncompliant   If the patient is discharged because he or she refuses services or becomes a documented safety, abuse, or noncompliance discharge and has received visits meeting the LUPA threshold for the payment group, then the HHA would receive full period payment unles s the patient becomes subsequently eligible for the Medicare home health benefit during the same 30 -day period and transferred to another HHA or returned to the same HHA, then this would result in a partial payment adjustment.  E. Patient Enrolls in Managed Care Mid -Period   If a patient's enrollment in a Medicare Advantage (MA) plan becomes effective mid period, the 30- day period payment will be proportionally adjusted with a partial payment adjustment since the patient is receiving coverage under MA. Beginning with the effec tive date of enrollment, the MA plan will receive a capitation payment for covered services.   F. Submission of Final Claims Prior to the End of the 30- day Period  The claim may be submitted upon discharge before the end of the 30 -day period. However, subsequent adjustments to any payments based on the claim may be made due to an intervening event resulting in a partial payment adjustment or other adjustment.   G. Patient Discharge and Financial Responsibility for Part B Bundled Medical Supplies and Services   As discussed in detail under 10.11, below, the law governing the Medicare HH PPS requires the HHA to provide all bundled home health services (except DME) either directly or under arrangement while a patient is under an open home health plan of care during an open episode. Once the patient is discharged, the HHA is no longer responsible for providing home health services including the bundled Part B medical supplies and therapy services.   H. Discharge Issues Associated With Inpatient Admission Overlapping Into Subsequent 60 -Day Recertifications   1. If a patient is admitted to an inpatient facility and the inpatient stay overlaps into what would have been the subsequent 60- day recertification and there is no recertification assessment of the patient, then the new certification begins with the new s tart of care date after inpatient discharge.   2. If a patient is admitted to an inpatient facility and the inpatient stay overlaps into what would have been the subsequent 60- day recertification and there was a recertification assessment of the patient during days 56- 60 and the patient returns home fr om the inpatient stay on day 61, if the home health resource group (HHRG) remains the same then the 30- day period of care following the inpatient stay would be considered continuous and thus be considered a recertification. However, if the HHRG is different, this would result in a new start of care OASIS and thus be considered a new certification and begins with the new start of care date after inpatient discharge.   3. If a patient is admitted to an inpatient facility and the inpatient stay overlaps into what would have been the subsequent 60- day recertification and there was a recertification assessment of the patient during days 56- 60 and the patient returns home from the inpatient stay after day 61 (after the first day of the next 60- day recertification of care), then a new certification begins with the new start of care date after inpatient discharge.   10.10 - Consolidated Billing                                                                        (Rev. 12382; Issued: 11-28- 23; Effective: 01 -01-24; Implementation:01-02-24)  For individuals under a home health plan of care, payment for all services and supplies, with the exception of certain injectable osteoporosis drugs, DME, and furnishing NPWT using a disposable device is included in the HH PPS base payment rates. HHAs must provide the covered home health services (except DME) either directly or under  arrangement, and must bill for such covered home health services.  Payment must be made to the HHA.