TRICARE Manuals - Display Chap 12 Sect 4 (Change 83, Aug 20, 2024) (2024)

3.3.1.1ClinicalSeverity Domain

The clinicalseverity domain captures significant indicators of clinical needfor several OASIS items. These include patient history, sensory,integument, respiratory, elimination, and neuro/emotional/behavioralstatus. It includes OASIS items pertaining to the following clinicalconditions and risk factors: diagnoses involving orthopedic, neurological,or diabetic conditions; therapies used at home (i.e., intravenoustherapy or infusion therapy, parenteral and enteral nutrition);vision; pain frequency; pressure ulcers, stasis ulcers, burns, traumaand surgical wounds; dyspnea; urinary and bowel incontinence; bowelostomy; and cognitive/behavioral problems, such as impaired decisionmaking and hallucinations. The clinical severity domain has fourseverity levels (0-3) and takes into account the beneficiary’s primarydiagnosis and prevalent medical conditions.

3.3.1.2Functional Dimension

The functional status domainis comprised of six Activities of Daily Living (ADLs) from the ADLsections of the OASIS assessment instrument. These include upperand lower body dressing, bathing, toileting, transferring, and locomotion,and consists of five severity levels (0-4).

3.3.1.3Services Utilization Domain

The services utilization dimensionhas four severity levels (0-3) and includes two types of data elements.First is the patient’s use of inpatient services (both inpatientand Skilled Nursing Facility (SNF)/rehabilitation stays) in the14 days preceding admission to home care. This information is obtainedfrom the patient history section of the OASIS. The second data elementin the service utilization dimension measures home health therapyhours (physical, occupational, or speech/language) totaling eighthours (approximately 10 therapy visits) or more during the 60-dayEOC. The threshold of eight hours targets additional payments forhome health therapy to patients with a clear need for therapy.

3.3.1.4Other Variables Affecting Case-MixAdjustment

3.3.1.4.1Diagnosis. Since home healthdiagnosis is generally used informally to characterize home healthpatients and the types of services they require, it is an importantvariable in the case-mix adjustment process. Since OASIS completionrules require submission of only the first three digits of the InternationalClassification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM) diagnosis code, the analysis used these categories. Sinceindividual analysis of the 900+ codes was not practical, the diagnosiscodes were grouped into Diagnostic Groups (DGs). These were basedon the Quality Indicator Groups (QUIGs) that had been developedfor use in monitoring HHC and outcomes with OASIS. Three of theDGs were found to be statistically significant predictors of homehealth resource use - Orthopedic, Neurologic, and Diabetic. A fourthcategory, Burn/Trauma, is not based on the QUIGs, but was subsequentlyadded to the model to capture patients with high needs for woundcare who are not otherwise captured by existing OASIS items. A listingof the diagnoses codes included in each DG as a primary or secondarydiagnosis is located on the CMS website at http://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/casemixgroupersoftware.html.For services provided before the mandated date, as directed by Healthand Human Services (HHS), for International Classification of Diseases,10th Revision (ICD-10) implementation, use diagnosis codes as containedin the ICD-9-CM. For services provided on or after the mandateddate, as directed by HHS, for ICD-10 implementation, use diagnosiscodes as contained in the ICD-10-CM.

3.3.1.4.2Secondary Diagnoses. The firstsecondary diagnosis is considered in some cases when the diagnosisof interest for case-mix purposes is a code representing manifestationof an underlying condition which is entered as the primary diagnosis.

3.3.1.4.3Availability of Caregiver.The availability of a caregiver was excluded from the case-mix adjustmentmodel since it was found to add little predictive insight giventhe variables that were already included.

3.3.1.4.4Service Utilization Variables.It was found that patients who had a rehab or SNF discharge, aswell as a hospital discharge, in the 14 days before home healthadmission generally had lower resource use than patients who hadbeen in a rehab or SNF only. It was felt that those who could movefrom a hospital to rehab/SNF to home care in 14 days were makinggood progress, while those who come to home care from a longer rehabor SNF stay likely had more chronic problems, or were progressingmore slowly. Thus, lack of a recent hospital discharge (blank itemM0175, line 1 on the OASIS) would be a definite predictor of resourceutilization.

3.3.2.1OASISItem Response Values

The OASIScontains 90 data items. OASIS items responses involve unique statementsthat require an objective assessment, and the number of possibleresponses varies by item.

3.3.2.1.1Each of the possible responseshave point values assigned to them that reflect their relationshipto home health resource utilization.

3.3.2.1.2In most of the items, severalresponses are grouped and assigned one value. For example, for itemM0670 (Bathing), response options 2, 3, 4, or 5 (ranging from “ableto bathe in shower or tub with assistance of another person” to“totally bathed by another person”) are all given a point valueof 8. If the patient had been rated as independent in bathing, however,with response 0, no value is added to the score.

3.3.2.2Point Scoring

The point values for the OASISitems within each of the three domains are summed to determine a patient’spoint score in each domain (clinical, functional and service utilization.)For example, if the response for each of the items listed in theFunctional Domain is a 2, then the score for the domain would becalculated as follows in Figure 12.4-1.

3.3.2.3SeverityLevels

Withineach domain, the total score is assigned to a severity level. Forexample, a summed score of 27 in the Functional Domain, as shownabove, would place a patient in the “high” (F3) functional severity level.There are four clinical severity levels, five functional severitylevels, and four service utilization severity levels. The rangeof scoring differs for each domain, so that a score of 25 in theClinical Domain would correspond to a moderate (C2) clinical severitylevel, but a score of 25 in the Functional Domain would place thepatient in the high functional severity level. A patient with ascore of 43 for the Clinical Domain would be placed in the highclinical (C3) severity level, while a patient with a total scoreof six in the Service Domain would be placed in the moderate (S2)severity level for that domain.

3.3.2.4GridSystem of OASIS Items, Values and Scoring

The following figures (Figure 12.4-2 - Figure 12.4-4)list the OASIS items used in the case-mix model, along with correspondingdescriptions, values and scoring:

3.3.6.1Composition of HIPPS Codesfor HHA PPS

3.3.6.5Examples of HIPPS Codes:

3.5.1.1For HH PPS episodes beginningon or after January 1, 2008, the distinct five position alphanumerichome health HIPPS is created as follows:

3.5.1.2Examples of HIPPS coding structurebased on Figure 12.4-6:

3.5.2.1Case-mix adjustment variablesand scores used in constructing HIPPS codes (i.e., point scoringused in Figure 12.4-6 for determining the appropriateHIPPS code for payment).

3.5.2.3The point scores for NRS levels(fifth position of the HIPPS code) are derived from the six severitygroups in Figure 12.4-10. These severity levels moreaccurately reflect the large variation in NRS used across all patienttypes.

3.5.2.3.2The supply payment amountsderived from the above severity level matrix (Figure 12.4-10) will be includedin the total payment returned by the HH Pricer. It will not be reflectedseparately on the claim. Supply amounts will not be calculated onLUPA claims.

3.5.2.3.4NRS provided during an EOCare subject to consolidated billing. If the date of service forNRS falls within the dates of an EOC, payment for the NRS is denied.However, NRS claims may be submitted by suppliers on the professionalclaim format, which has both “from” and “to” dates on each item.Medicare has instructed suppliers to report the delivery date asthe “from” date, and the date by which the supplies will be usedin the “to” date. When this causes the “to” date on a supply lineitem subject to consolidated billing to overlap on EOC, the servicemay be denied incorrectly. Contractors shall ensure proper paymentof NRS provided prior to the beginning of an EOC (“from” date priorto the beginning of an EOC), even if the “to” date overlaps theEOC.

3.5.3.1Following is the new formatof the treatment authorization code for episodes beginning on orafter January 1, 2008:

3.5.3.1.1The Julian dates in positions3-4 and 7-8 are converted from three position numeric values totwo position alphabetic values using the code system in Addendum E.

3.5.3.2Figure 12.4-14 provides anexample of a treatment authorization code that is created by the groupersoftware using the format outlined in Figure 12.4-13.

The treatment authorizationcode that would appear on the claim would be, in this example: 07JK08AA41GBMDCDLG

3.5.3.3Episode adjustment processusing authorization code.

3.5.3.3.2The system shall read the homehealth episode history when a new episode is received and identifyany HIPPS codes that represent an incorrect position in the sequence.The sequence of episodes are determined without regard to changesin the HHA. The calculated 60-day episode end date will be usedto measure breaks between episodes in all cases except for episodessubject to PEP adjustments. In the case of PEP episodes, the dateof latest billing will be used.

3.5.3.4Adjustment of previously paidepisodes.

3.5.3.4.1The contractor claims processingsystems shall initiate automatic adjustments for previously paidepisodes when the receipt of earlier dated episodes change theirposition in a sequence of episodes. The system shall re-code andre-price the automatic adjustments.

3.5.3.4.2The system shall calculatea supply adjustment amount and add it to the otherwise re-pricedepisode amount.

3.5.3.5Determining the gap betweenepisodes (i.e., if the episodes are adjacent/contiguous.

3.5.3.5.1The 60-day period to determinea gap that will begin a new sequence of episodes will be countedin most instances from the calculated 60-day end date of the episode.The exception to this is for episodes that were subject to PEP adjustment.

3.5.3.5.2In PEP cases, the system shallcount 60 days from the date of the last billable home health visitprovided in the PEP episode.

3.5.3.5.4If episodes are received aftera particular claim is paid that change the sequence initially assignedto the paid episode (for example, by service dates falling earlierthan those of the paid episode, or by falling within a gap betweenpaid episodes), the system will initiate automatic adjustments tocorrect the payment of any necessary episodes as described above.

3.6.3.2Ifa Medicare-certified HHA is not available within the service area,the contractor may authorize care in a non-Medicare certified HHA(e.g., a HHA which has not sought Medicare certification/approvaldue to the specialized beneficiary categories it services - patientsreceiving maternity care and/or patients under the age 18) thatqualifies for corporate services provider status under the TRICAREProgram (refer to the TRICARE Policy Manual (TPM), Chapter 11, Section 12.1, for the specificqualifying criteria for granting corporate services provider statusunder the TRICARE Program.) The following payment provisions willapply to HHAs qualifying for coverage under the corporate servicesprovider class:

3.6.3.2.1Otherwise covered professionalservices provided by TRICARE authorized individual providers employedby or under contract with a freestanding corporate entity will bepaid under the CHAMPUS Maximum Allowable Charge (CMAC) reimbursem*ntsystem, subject to any restrictions and limitations as may be prescribedunder existing TRICARE policy.

3.6.3.2.2Payment will also be allowedfor supplies used by a TRICARE Program authorized individual provideremployed by or contracted with a corporate services provider inthe direct treatment of a TRICARE eligible beneficiary. Allowablesupplies will be reimbursed in accordance with the allowable chargemethodology as described in Chapter 5.

3.6.3.2.3Reimbursem*nt of covered professionalservices and supplies will be made directly to the TRICARE authorizedcorporate services provider under its own tax identification number.

3.6.3.2.4There are also regulatory andcontractual provisions currently in place that grant contractorsthe authority to establish alternative network reimbursem*nt systemsas long as they do not exceed what would have otherwise been allowedunder TRICARE payment methodologies.

3.8.1.2Figure 12.4-15 provides thecalculations involved in the establishment of the non-standardizedprospective payment amount per 60-day episode in FY 2001, alongwith adjustments for NRS, Part B therapies and OASIS implementationand ongoing costs.

3.8.1.3The adjusted non-standardizedprospective payment amount per 60-day episode for FY 2001 was adjustedas follows in Figure 12.4-16 for case-mix, budget neutralityand outliers in the establishment of a final standardized and budgetneutral payment amount per 60-day episode for FY 2001.

3.8.1.3.1The above 60-day episode paymentcalculations were derived using base-year costs and utilizationrates and subsequently adjusted by annual inflationary update factors,the last three iterations of which can be found in AddendumsC (CY 2019) and C (CY 2020).

3.8.1.5Annual Updating of HHA PPSRates and Wage Indexes.

In subsequentfiscal years, HHA PPS rates (i.e., both the national 60-day episodeamount and per-visit rates) will be increased by the applicablehome health market basket index change.

3.8.2.1PEP Adjustment

The PEP adjustment is usedto accommodate payment for EOCs less than 60 days resulting fromone of the following intervening events: 1) beneficiary electeda transfer prior to the end of the 60-day EOC; or 2) beneficiarydischarged after meeting all treatment goals in the original POCand subsequently readmitted to the same HHA before the end of the60-day EOC. The PEP adjustment is based on the span of days overwhich the beneficiary received treatment prior to the interveningevent; i.e., the days, including the start-of-care date/first billableservice date through and including the last billable service date,before the intervening event. The original POC must be terminatedwith no anticipated need for additional home health services. Anew 60-day EOC would have to be initiated upon return to a HHA, requiringa physician’s recertification of the POC, a new OASIS assessment,and authorization by the contractor. The PEP adjustment is calculatedby multiplying the proportion of the 60-day episode during whichthe beneficiary was receiving care prior to the intervening eventby the beneficiary’s assigned 60-day episode payment. The PEP adjustmentis only applicable for beneficiaries having more than four billablehome health visits. Transfers of beneficiaries between HHAs of commonownership are only applicable when the agencies are located in differentmetropolitan statistical areas. Also, PEP adjustments do not applyin situations where a patient dies during a 60-day EOC. Full episode paymentsare made in these particular cases. For example, a beneficiary assignedto HHRG C2F1S2 and receiving care in Denver, CO was discharged froma HHA on Day 28 of a 60-day EOC and subsequently returned to thesame HHA on Day 40. However, the first billable visit (i.e., a physicianordered visit under a new POC) did not occur until Day 42. The beneficiarymet the requirements for a PEP adjustment, in that the treatmentgoals of the original POC were accomplished and there was no anticipatedneed for home care during the balance of the 60-day episode. Sincethe last visit was furnished on Day 28 of the initial 60-day episode,the PEP adjustment would be equal to the assigned 60-day episodepayment times 28/60, representing the proportion of the 60 daysthat the patient was in treatment. Day 42 of the original episodebecomes Day 1 of the new certified 60-day episode. The followingsteps are used in calculating the PEP adjustment:

3.8.2.2SCIC Payment Adjustment

For Episodes Beginning On OrAfter January 1, 2008. The refined HH PPS no longer contains a policyto allow for adjustments reflecting SCICs. Episodes paid under therefined HH PPS will be paid based on a single HIPPS code. Claimssubmitted with additional HIPPS codes reflecting SCICs will be returnedto the provider; i.e., claims for episodes beginning on or afterJanuary 1, 2008, that contain more than one revenue code 0023 line.

3.8.2.3LUPA

3.8.2.3.1For Episodes Beginning On OrAfter January 1, 2008

3.8.2.3.2LUPA may be subject to an additionalpayment adjustment. If the LUPA episode is the first episode ina sequence of adjacent episodes or is the only EOC the beneficiaryreceived and the Source of Referral and Admission or Visit Codeis not B (Transfer From AnotherHHA) or C (Readmission to Same HHA), an additionaladd-on payment will be made. A lump-sum established in regulationand updated annually will be added to these claims. The additionalamount for CY 2008 is $87.93.

3.8.2.4TherapyThreshold Adjustment

3.8.3.2The outlier payment amountis a proportion of the wage-adjusted estimated imputed costs beyondthe wage-adjusted threshold. The loss-sharing ratio is the proportionof additional costs paid as an outlier payment. The loss-sharingratio, along with the FDL amount, is used to constrain outlier coststo five percent of total episode payments. The estimated imputedcosts are derived from those home health visits actually orderedand received during the 60-day episode. The total visits per disciplineare multiplied by their national average per-visit amounts (referto Figure 12.4-4 forthe calculation of national average per-visit amounts) and are wage-adjusted.The wage-adjusted imputed costs for each discipline are summed toget the total estimated wage-adjusted imputed costs for the 60-dayEOCs. The outlier threshold is then subtracted from the total wage-adjustedimputed per visit costs for the 60-day episode to come up with theimputed costs in excess of the outlier threshold. The amount inexcess of the outlier threshold is multiplied by 80% (i.e., theloss share ratio) to obtain the outlier payment. The HHA receivesboth the 60-day episode and outlier payment. For example, a beneficiaryassigned to HHRG C2L2S2 [case-mix weight of 1.9532 and receivingHHA care in Missoula, MT (wage index of 0.9086)], has physicianorders for and received 54 skilled nursing visits, 48 home healthaide visits, and six physical therapy visits. The following stepsare used in calculating the outlier payment: