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/period, 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.
• For POC and physician certification/recertification
requirements, refer to the CMS Internet-Only Manuals Publication
# 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2
and 30.5.
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/period, 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
CMS website (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/index.html) 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
.
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.
3.2.4 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.