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.