3.1 Physician’s
Role in the Assessment Process
To qualify
for coverage of home health services, a beneficiary must be under
the care of a physician who establishes the Plan Of Care (POC).
The physician’s fundamental role in this process is to determine
the patient’s health care needs and advocate for the services required
to meet those needs. In order to perform this role efficiently,
the certifying physicians must utilize their intimate knowledge of
the patient’s medical condition. As such, physicians have the following
responsibilities:
3.1.1 Home Health Certification
The beneficiary’s physician is responsible
for signing the Home Health Certification [Centers for Medicare
and Medicaid Services (CMS) Form 485] upon the initiation of any
POC. Home health services are required when an individual is confined
to his/her home and needs skilled nursing care on an intermittent
basis, or physical or speech therapy. If an individual who has been
furnished home health services based on such a need -- and who no
longer requires such care or therapy -- continues to require occupation
therapy; a plan for furnishing such services has to be established
and periodically reviewed by the beneficiary’s physician. Upon the
completion of every 60-day episode, if the patient is receiving
continuous home care from the same Home Health Agency (HHA), the beneficiary’s
physician is responsible for Home Health recertification.
3.1.2 POC Certification
The beneficiary’s physician is responsible
for development of a POC-based on his/her intimate knowledge of
the medical condition of the home health patient.
3.1.2.1 The POC
developed in consultation with the agency staff covers:
• Diagnoses,
including mental status;
• Types of services
and equipment required;
• Frequency of visits;
• Prognosis;
• Rehabilitation
potential;
• Functional
limitations;
• Activities
permitted;
• Nutritional
requirements;
• Medications and
treatments;
• Safety
measures to protect against injury;
• Instructions for
timely discharge or referral; and
• Any other appropriate
items.
3.1.2.2 The physician’s
orders for services in the POC must specify the medical treatments
to be furnished, as well as the type of home health discipline that
will furnish the ordered services, and at what frequency the services
will be furnished.
3.1.2.3 Standardized
data collection (CMS Form 485) facilitates accurate coverage decisions,
helps to ensure correct payment for covered services and promotes
compliance with federal laws and regulations.
3.1.2.3.1 CMS Form
485 (the Home Health Certification and POC):
• Meets the regulatory
and national survey requirements for the physician’s POC certification
and recertification.
• Provides a convenient
way to submit a signed and dated POC.
• Refer to
Addendum D for items contained in CMS Form
485.
3.1.2.3.2 However,
HHAs may submit any document that is signed and dated by the physician that
contains all the required components of the POC.
3.1.2.4 The POC
must be signed and dated by the beneficiary’s physician before the
agency can submit a claim. Any changes in the plan must be signed
and dated by the beneficiary’s physician. If any services are furnished
based on the beneficiary’s physician’s oral orders, the orders must
be put in writing and signed and dated with the date of receipt
by the registered nurse or qualified therapist responsible for furnishing
or supervising the ordered services.
3.1.2.5 The signed
POC is maintained in the beneficiary’s medical record at the HHA,
with a copy of the signed POC available upon request when needed
for medical review (MR). Providers may submit the POC electronically
if acceptable to the contractor.
3.1.2.6 Upon completion
of every 60-day episode, if the patient is receiving continuous
Home Health Care (HHC) from the same HHA, the beneficiary’s physician
is responsible for re-certification of the POC.
3.2 Comprehensive
Assessment Requirement
As a condition for
participation under the TRICARE Program, HHAs must conduct a comprehensive
assessment that identifies the patient’s need for home care, and
that meets the patient’s medical, nursing, rehabilitative, social
and discharge planning needs. The HHAs must use the most current
standard core data set (i.e., the OASIS), when evaluating adult,
non-maternity patients. This requirement underscores the importance
of a systematic patient assessment in improving quality of care
and patient outcomes. The comprehensive assessment of the patient,
in which patient needs are identified, is a crucial step in the
establishment of a POC. In addition, a comprehensive assessment identifies
patient progress toward desired outcomes or goals of the care plan.
The importance of the assessment process has been further accentuated
by its critical role in calculating the appropriate prospective
payment amounts for HHC.
3.2.1 Applicability
3.2.1.1 The comprehensive
assessment and reporting regulations (i.e., OASIS collection, encoding, and
transmission requirements) apply to any HHA required to meet Medicare
conditions for participation and are applied to all patients of
that HHA unless otherwise specified. This includes Medicare, Medicaid,
Managed Care, and private pay patients serviced by the agencies.
It also includes Medicaid waiver and State plan patients to the
extent they do not fall into one of the three exception categories
listed below. The comprehensive assessment and reporting regulations
are required by the State to meet Medicare conditions of participation.
3.2.1.2 Medicare’s
requirement to conduct comprehensive assessments that include OASIS
data items applies to each patient of the agency receiving home
health services, except for the following:
• Patients under the
age of 18;
• Patients
receiving maternity services;
• Patients receiving
housekeeping or chore services only; and
• Patients receiving
personal care services only.
3.2.1.3 However,
the encoding and transmission requirements for non-Medicare and
non-Medicaid patients receiving skilled care are delayed until a
system to mask their identity is developed and implemented. Until
such a system is developed and implemented, HHAs must meet all other requirements
of the comprehensive assessment regulation, including conducting
start of care comprehensive assessments and updates at the required
time points on all non-Medicare and non-Medicaid patients receiving
skilled services using the required OASIS data items. This means
that only the requirements to encode and transmit OASIS data is
delayed. The collection of OASIS data as part of the comprehensive
assessment process, and updates at the required time points, are
required in order to ensure quality of care for all patients and
to encourage the use of OASIS as the basis for care planning.
3.2.1.4 Due to
the delay in State agency validation of transmitted OASIS data for
non-Medicare/non-Medicaid patients, HHAs will only be responsible
for the collection and encoding of OASIS data for TRICARE beneficiaries
receiving services under a HHA’s POC. Encoding will be required
to generate the appropriate Health Insurance Prospective Payment
System (HIPPS) code and claims-OASIS matching key output necessary
to process and pay the HHA claim. Post-payment validation will be
utilized to ensure that the HIPPS code generated by the Home Assessment
Validation Entry (HAVEN) Grouper software is reflective of the patient’s
true condition, and that the services were actually rendered. Validation
may be accomplished either manually through the use of The Home
Health Resource Group (HHRG) Worksheet and accompanying OASIS instruction
manual, or through the use of an automated accuracy protocol designed
to assist medical review of home health claims submitted by HHAs
who are being paid under the HHA Prospective Payment System (PPS).
The Regional Home Health Intermediary (RHHI) Outcomes and Assessment
Information Set Verification Protocol for Review of HHA Prospective Payment
Bills (ROVER) utilizes medical records to verify that information
contained in a HHA-completed OASIS is reflective of the patient’s
condition. Both methods will guide medical review staff through
the clinical records, allowing the reviewer to document whether
or not the case-mix OASIS items are validated by the information
contained in the records. A HIPPS code will also be computed based
on the reviewer’s responses and compared to the HIPPS code assigned
by the HHA. The reviewer can either accept the HIPPS billed by the
provider, or adjust the claim as necessary.
3.2.1.5 Abbreviated
assessments will be required for TRICARE eligible beneficiaries
who are under the age of eighteen or receiving maternity care from
Medicare certified HHAs (i.e., HHAs meeting all Medicare conditions
of participation [Sections 1861(o) and 1891 of the Social Security
Act and part 484 of the Medicare regulation (42 CFR 484)] in order
to receive payment under the HHA PPS. Refer to
Section 4, paragraph 3.4 for more details
regarding the abbreviated OASIS data requirements for reimbursement
of these beneficiary categories. The above patient categories will
not be exempt from OASIS data collection if under a POC established
by a physician.
3.2.1.6 A patient
who is under age 18 and turns 18 while under the care of an HHA
is to receive a full comprehensive assessment (including OASIS)
at the next appropriate time point.
3.2.2 Data Collection
3.2.2.1 Patient
assessment data may be collected through a combination of methods,
including interaction with patient/family, observation, and measurement.
When used in combination, these methods provide a full picture of
the patient’s health status. The following addenda provide the primary
components of a home care patient assessment, along with the standard
data sets used in assessing the patient’s condition for reimbursement
under the HHA PPS:
• Addendum E -
primary components of a home care patient assessment.
• Addendum F -
Outcome and Assessment Information Set (OASIS-B1).
• Addendum F -
OASIS items used for assessments of 60-day episodes.
3.2.2.2 Patient
assessment data is required at specific time points to keep them
current and useful in planning care. These time points include:
3.2.2.2.1 Initial Assessment
Visit
3.2.2.2.1.1 The initial visit is performed to determine
the immediate care and support needs of the patient. This visit
is conducted within 48 hours of referral, or within 48 hours of
a patient’s return home from an inpatient stay, or on the physician-ordered
start of care date.
3.2.2.2.1.2 The initial
assessment visit is intended to ensure that the patient’s most critical
needs for home care services are identified and met in a timely
fashion. This initial assessment determines eligibility for the
home health benefit under the TRICARE Program, including homebound
status.
3.2.2.2.1.3 The initial
assessment visit must be conducted by a registered nurse unless rehabilitation
therapy services are the only services ordered by the physician.
In this care, the initial assessment would be made by the appropriate
rehabilitation skilled professional.
3.2.2.2.1.4 A comprehensive
assessment is not required to be completed at this visit, although
the HHA may choose to do so. The comprehensive assessment may be
initiated at this visit and completed within the time frames discussed
below.
3.2.2.2.2 Completion of the Comprehensive
Assessment
3.2.2.2.2.1 The comprehensive assessment must be completed
in a timely manner, consistent with the patient’s immediate needs,
but no later than five calendar days after the start of care.
3.2.2.2.2.2 This requirement
does not preclude a HHA from completing the comprehensive assessment
during the initial visit. This provides operational flexibility
to the HHA while maintaining patient safety in ensuring that all
patient needs will be identified within a standard time period.
3.2.2.2.2.3 The comprehensive
assessment must include a review of all medication the patient is currently
using in order to identify any potential adverse effects of drug
reactions, including ineffective drug therapy, significant side
effects and drug interactions, duplicate drug therapy, and noncompliance with
drug therapy.
3.2.2.2.2.4 The comprehensive
assessment describes the patient’s current health status and identifies
needs that subsequently are addressed in the POC. Updates of this
assessment identify progress toward goals.
3.2.2.2.3 Update of
the Comprehensive Assessment
The comprehensive
assessment, which includes the OASIS data set items, must be updated
within:
• Five days immediately
preceding each recertification - day 56 through day 60 of each period);
• Forty-eight (48) hours
of transfer to an inpatient facility;
• Forty-eight (48) hours
of resumption of care after an inpatient stay of 24 hours or more
for any reason except diagnostic testing;
• Forty-eight (48) hours
of discharge (discharge for this requirement means discharge to
the community, transfer to another facility, or the death of the patient);
and
• Forty-eight
(48) hours of significant change in condition (i.e., a major decline
or improvement in a patient’s health status).
3.2.2.3 The comprehensive
assessment is expected to meet the patient’s medical nursing, rehabilitative,
social, and discharge planning needs. As such, it is an assessment
of needs that might be met by a variety of disciplines. It is not
expected that a single clinician conducting the assessment will perform
a nursing, physical therapy, speech-language pathology, occupational
therapy, and social work assessment. The assessing clinician must,
however, conduct a sufficiently broad assessment of environmental,
social support, functional, and health domains that effectively
identify the patient’s needs.
3.2.2.4 The OASIS
data set was not intended to constitute a complete comprehensive
assessment instrument. It can, however, be used as the foundation
for valid and reliable information for patient assessment, care
planning, service delivery, and improvement efforts. The agency
might want to begin with required OASIS items and add core assessment
items deemed necessary to meet clinical, regulatory, or accreditation
requirements. The core comprehensive assessment with OASIS items
could then be supplemented with additional discipline-specific assessment
items required to meet the special needs of the beneficiary.
3.2.2.5 The OASIS
data set must be incorporated into the HHA’s own assessment, exactly
as written. Integrating the OASIS items into the agency’s own assessment
system in the order presented in the OASIS form will facilitate
data entry of the items into data collection and reporting software.
3.2.3 Encoding
of OASIS Data
3.2.3.1 Once the assessment is completed and OASIS
data items collected by the qualified skilled professional (i.e.,
the nurse or therapist responsible for coordinating or completing
the assessment), data can be encoded directly by the skilled professional
or by a clerical staff member from a hard copy of a completed OASIS.
Non-clinical staff may not assess patients or complete assessment
items; however, clerical staff or data entry operators may enter
the OASIS data collected by the skilled professional into the computer.
HHAs must also comply with requirements safeguarding the confidentiality
of patient identifiable information. HHAs may take up to seven days
after collection to enter it into their computer systems.
3.2.3.2 To enter
the data, HHAs will operate the HAVEN software program and run the
OASIS data set through the CMS-specified edits. This process involves
using HAVEN or HAVEN-like software to review the data for accuracy
and consistency, making any necessary changes and finalizing the
data. HAVEN will accommodate data entry of OASIS items from all
required time points. Seven days are allowed to encode, edit and
lock OASIS data, as that is believed to be a reasonable amount of
time to expect agencies to complete this task while ensuring accuracy
of data.
3.2.3.3 The agency must enter the OASIS data and identify
any information that does not pass the specified edits; that is,
any missing, incorrect, or inconsistent data. Editing and locking
functions are automatically performed using the HAVEN software.
3.2.3.4 Once the
OASIS information is encoded, HHAs will “lock” the data; i.e., use
their software to review and edit it to create a file that will
be transmitted to the State agency or other entity approved to receive
this transmission. Since State agency validation of non-Medicare/non-Medicaid
OASIS files have been delayed, transmission of TRICARE locked files
will not be required at this time. HHAs will, however, still be
responsible for the collection and encoding of OASIS data. This
information will provide a mechanism for objectively measuring facility
performance and quality. It will also be used to support the HHA
PPS (i.e., generate the HIPPS code and claim-OASIS matching key
output required on the CMS 1450 UB-04 claim form for pricing).
3.2.3.5 Since encoded
OASIS data must accurately reflect the patient’s status at the time
the information is collected, HHAs must ensure that data items on
its own clinical record match the encoded data.
3.2.3.6 Please
see
Addendum F for information regarding the OASIS.
The HHA can access the web site and download the required OASIS
data set for each data collection time point; i.e., start of care, resumption
of care following an inpatient facility stay, follow-up, discharge
(not to an inpatient facility), transfer to inpatient facility (with
or without agency discharge), and death at home. See
Addendum J for
information regarding the HAVEN system.
3.2.4 Case Management
Responsibilities
It is recognized that while
an abbreviated OASIS assessment may facilitate payment under the
HHA PPS, it does not adequately reflect the management oversight
required to ensure quality of care for beneficiaries under the age
of 18 and obstetrical patients. As a result, the contractors will
have to continue to case manage these beneficiary categories through
the use of appropriate evaluation criteria as required under the
specific terms of their contract to ensure the quality and appropriateness of
home health services (e.g., the use of INTERQUAL criteria for managing
the appropriateness of home health services). Contractor involvement
will even be more critical in cases where home health services are
provided in non-Medicare HHAs (i.e., those HHAs for which Medicare
certification is not available due to the beneficiary categories
they serve). Refer to
Section 4, paragraph 3.6 for the hierarchical placement
and reimbursement of home health services for TRICARE eligible beneficiaries
under the age of 18 or receiving maternity care.