evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
10.2 - Adjustments to the 30 -Day Period Payment Rate  (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)   A.  Case -Mix Adjustment   A case -mix methodology adjusts the 30- day payment rate based on characteristics of the patient and his/her corresponding resource needs (e.g., diagnoses, functional impairment level, and other factors).  The 30-day period payment rate is adjusted by a case- mix methodology based on information from home health claims, other Medicare claims, and data elements from the Outcome and Assessment Information Set (OASIS).  The claims information and OASIS data elements are used to group 30-day periods of care into t heir case-mix groups.    The following case-mix variables are obtained from home health or other Medicare claims:   Admission Source -Institutional (i.e., acute hospital, inpatient rehabilitation facility, skilled nursing facility, long -term care hospital, inpatient psychiatric facility) or Community;   Timing -Early (the first 30 -day period of care) or Late (all subsequent 30- day periods of care, unless there is a gap of more than 60-days between the end of one period of care and the start of another),   Clinical Group -As determined by the principal diagnosis reported on home health claims; 30 -day periods are assigned to one of 12 clinical groups describing the primary reason for the home health encounter:  Clinical Groups  The Primary Reason for the Home Health Encounter is to Provide:  Musculoskeletal Rehabilitation Therapy (physical, occupational or speech) for a musculoskeletal condition  Neuro/Stroke Rehabilitation Therapy (physical, occupational or speech) for a neurological condition or stroke  Wounds  Post-Op Wound Aftercare and Skin/Non- Surgical Wound Care  Assessment, treatment & evaluation of a surgical wound(s); assessment, treatment & evaluation of non -surgical wounds, ulcers, burns, and other lesions  Behavioral Health Care  Assessment, treatment & evaluation of psychiatric and substance abuse conditions  Complex Nursing Interventions Assessment, treatment & evaluation of complex medical & surgical conditions including IV, TPN, enteral nutrition, ventilator, and ostomies  Medication Management, Teaching and Assessment (MMTA)        MMTA Surgical Aftercare  Assessment, evaluation, teaching, and medication management for surgical aftercare
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MMTA Surgical Aftercare  Assessment, evaluation, teaching, and medication management for surgical aftercare       MMTA  Cardiac/Circulatory  Assessment, evaluation, teaching, and medication management for cardiac or other circulatory related conditions       MMTA  Endocrine  Assessment, evaluation, teaching, and medication management for endocrine related conditions       MMTA  GI/GU  Assessment, evaluation, teaching, and medication management for gastrointestinal or genitourinary related conditions       MMTA  Infectious    Disease/Neoplasms/Blood -forming Diseases  Assessment, evaluation, teaching, and medication management for conditions related to infectious diseases, neoplasms, and blood-forming diseases       MMTA Respiratory  Assessment, evaluation, teaching, and medication management for respiratory related conditions       MMTA  Other  Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not classified in one of the previously listed groups     Comorbidity Adjustment -As determined by certain secondary diagnoses reported on home health claims; a 30-day period of care can receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment.  The following case mix variable is determined from responses to certain items on the OASIS assessment:    Functional Impairment Level -As determined by responses to certain OASIS items. A 30 -day period of care can be assigned a low, medium, or high functional impairment level.   Each 30 -day period is assigned into one of 432 case-mix groups based on the variables described above. Each groups case- mix weight reflects the predicted mean cost of the group relative to the overall average across all groups.   B.  Labor Adjustments   The labor portion of the 30- day period payment rate is adjusted to reflect the wage index based on the site of service of the beneficiary.  The beneficiary's location is the determining factor for the labor adjustment.  The HH PPS rates are adjusted by the pre -floor and pre-reclassified hospital wage index.  The hospital wage index is adjusted to account for the geographic reclassification of hospitals in accordance with 1886(d)(8)(B)  and 1886(d)(10)
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of the Social Security Act (the Act.)  According to the law, geographic reclassification only applies to hospitals.  Additionally, the hospital wage index has specific floors that are required by law.  Because these reclassifications and floors do not apply to HHAs, the home health rates are adjusted by the pre-floor and pre-reclassified hospital wage index.   NOTE:  The pre-floor and pre-reclassified hospital wage index varies slightly from the numbers published in the Medicare inpatient hospital PPS regulation that reflects the floor and reclassification adjustments.  The wage indices published in the home health final rule and subsequent annual updates reflect the most recent available pre- floor and pre-reclassified hospital wage index available at the time of publication.   10.3 - Continuous 60- Day Recertifications  (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)   While HH PPS payment is now made for each 30-day period, the home health PPS permits continuous 60-day recertifications for patients who continue to be eligible for the home health benefit.  Medicare does not limit the number of continuous 60-day recertifications for beneficiaries who continue to be eligible for the home health benefit. Each 60 -day certification can include two 30 -day payment periods.  Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60 -day certification. The recertification visit can be done during the prior certification period.  With some minor exceptions, the Medicare Conditions of Participation at 42 CFR 484.55(d)(1), require that the recertification assessment be done during the last 5 days of the previous certification period (for example, during the initial 60-day certification period, the recertification visit is required to be done on days 56- 60).  10.4 - Submission of the Notice of Admission (NOA)                               (Rev. 11447, Issued: 06-06-22, Effective: 01-01-22, Implementation: 05-26-22)
(Medicare Benefit Policy Manual)
10.4 - Submission of the Notice of Admission (NOA)                               (Rev. 11447, Issued: 06-06-22, Effective: 01-01-22, Implementation: 05-26-22)   Beginning January 1, 2022, HHAs will no longer submit Requests for Anticipated Payment (RAPs). Instead, for each admission to home health, the HHA notifies Medicare systems via submission of an NOA. The NOA is a one- time submission to establish that the beneficiary is under a home health period of care and trigger home health consolidated billing edits. The NOA covers contiguous 30-day periods of care until the individual is discharged from Medicare home health services. There is no upfront payment with the submission of the NOA.   The NOA must be submitted timely. All HHAs must submit an NOA to their Medicare contractor within 5 calendar days from the start of care date to establish that the beneficiary is under a Medicare home health period of care and also to trigger home health consolidated billing edits required under section 1842(b)(6)(F) of the Act.  For example, if the start of care date is January 1, 2022, the NOA would be considered timely -filed if it is submitted on or before January 6, 2022.  Example:   1/1/2022 = Day 0 (start of the first 30-  day period of care)  1/6/2022 = Day 5 (An NOA submitted on or before this date would be considered timely -filed.)  1/7/2022 and after = Day 6 and beyond (An NOA submitted on and after this date would be considered untimely and would trigger the penalty.)
(Medicare Benefit Policy Manual)
In instances where an NOA is not timely -filed, Medicare shall reduce the payment for a period of care, including outlier payments, by the number of days from the home health admission date until the date the NOA is submitted to, and accepted by, the A/B M AC (HHH), divided by 30. No LUPA per -visit payments shall be made for visits that occurred on days that fall within the period of care prior to the submission of the NOA. This reduction shall be a provider liability, and the provider shall not bill the beneficiary for it.  CMS may waive the consequences of failure to submit a timely -filed NOA if it is determined that a circumstance encountered by a home health agency is exceptional and qualifies for waiver of the consequence. An exceptional circumstance may be due to, but is not limited to the following:    Fires, floods, earthquakes, or similar unusual events that inflict extensive damage to the home health agencys ability to operate.   A CMS or Medicare contractor systems issue that is beyond the control of the home health agency.   A newly Medicare -certified home health agency that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor.    Other situations determined by CMS to be beyond the control of the home health agency.   If an HHA believes that there is a circumstance that may qualify for an exception, the HHA must fully document and furnish any requested documentation to their MAC for a determination of exception.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing for requirements regarding the notice of admission process.   10.5 - Requirements for Submission of the NOA                                      (Rev. 11447, Issued: 06- 06-22, Effective: 01 -01-22, Implementation: 05- 26-22)   For CY 2022, submission of the NOA can be made when the following criteria have been met:  (1) The appropriate physicians or allowed practitioners written or verbal order that sets out the services required for the initial visit has been received and documented as required at  484.60(b) and 409.43(d);
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(2) The initial visit within the 60 -day certification period must have been made and the individual admitted to home health care.  . 10.6 - Low Utilization Payment Adjustment (LUPA)  (Rev. 265, Issued: 01- 10-20, Effective: 01 -01-20, Implementation: 02- 11-20)  The LUPA threshold varies for a 30 -day period of care depending on the payment group to which it is assigned. For each payment group, the 10th percentile value of visits is used to create a payment group -specific LUPA threshold with a minimum threshold of at least 2 visits for each group. A 30- day period with visits less than the LUPA threshold for the payment group is paid the national per visit amount by discipline adjusted by the appropriate wage index based on the site of service of the beneficiary.  Such periods that do not meet the LUPA threshold for the payment group are paid the wage -adjusted per visit amount for each of the visits rendered instead of the full 30- day period payment amount.  The national per visit amounts by discipline (skilled nursing, home health aide, physical therapy, speech -language pathology, occupational therapy, and medical social services) are updated and published annually by the applicable market basket for each visit type.  To offset the full cost of longer, initial visits in some LUPA periods, 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
(Medicare Benefit Policy Manual)
 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
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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)
(Medicare Benefit Policy Manual)
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;
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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
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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.