change is here: a new era for medicare home health pps€¦ · medicare claims oasis assessments...

Change is Here: A New Era for Medicare

Home Health PPS

September 20, 2007

Presented for Missouri Alliance for Home Care

Presented by Mark P. Sharp, CPA [email protected]

BKD Health Care Group 901 E. St. Louis Street

P.O. Box 1190 Springfield, MO 65801-1190

417 865-8701 Fax 417 865-0682

www.bkd.com

Beyond Your NumbersCPAs & Advisors

Change is Here: A New Era for Medicare Home Health PPS

Presented by

Mark P. Sharp, CPAPartnerBKD Health Care GroupSpringfield, Missouri

Beyond Your Numbers

Presentation Overview

Why prospective payment system (PPS) refinementsWhat are the PPS refinementsHow to plan for the PPS refinements

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Beyond Your Numbers

Resources

PowerPoint handoutSummary of the PPS refinements (exhibit 1)Key tables from Federal Register (exhibit 2)Missouri PPS rates by HHRG, NRS & LUPA (exhibit 3)

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Beyond Your Numbers

Background

Purpose of PPSResearch of PPS effectiveness

Abt Associates, Inc.PPS designed for 34% accuracyAchieved 21% accuracy

Refinements deemed necessary

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Beyond Your Numbers

Refinement Research

Abt Associates, Inc.Medicare claimsOASIS assessmentsMedicare cost reports

Significant changes from proposed to finalProposed rule based on 2003 dataFinal rule based on 2005 data

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Beyond Your Numbers

Research Findings

“Later” episodes (3rd+) Require more resourcesRelationship of case-mix variables differed

Dual eligibility & caregiver status not good predictors of resource utilizationAdministrative difficulties & lack of predictive value of M0175

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Beyond Your Numbers

Research Findings

Therapy thresholdResponsible for a marked shift in therapy servicesTherapy resources cannot be effectively predicted on any indicators other than utilizationPayment gradations would be effectiveUsing visits just as accurate as minutes

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Beyond Your Numbers

Research Findings

More predictive indicatorsExpanded primary & secondary diagnosesInteractions of diagnosesManifestation codesAdditional clinical conditions & co-morbidities

With refinements, estimate 45% accuracy

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Beyond Your Numbers

Refinement Time Line

Proposed rule released April 27, 2007Final rule issued on August 22, 2007Published in August 29, 2007, Federal RegisterEffective for episodes ending on or after January 1, 2008

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Beyond Your Numbers

Refinement Elements

New case-mix modelNew base ratesUnbundling of non-routine medical supply paymentsChanges to payment adjustments

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Beyond Your Numbers

New Case-Mix Model

Four equation model#1 - Early episodes (1st & 2nd) with fewer than 14 therapy visits#2 - Early episodes (1st & 2nd) with 14 or more therapy visits#3 - Later episodes (3rd+) with fewer than 14 therapy visits#4 - Later episodes (3rd+) with 14 or more therapy visits

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Beyond Your Numbers

Early vs Later Episodes

Every episode countsOwn agencyOther agencyPEPLUPA

The end of all episodes (except a PEP) is day 60Must be a break in service in excess of 60 days to bounce back to an early episode

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Beyond Your Numbers

New Case-Mix Scoring

Four equation modelSample: Primary diagnosis = diabetes

• Different points for each equation• See Table 2a for logic

81125Points for Diabetes as primary diagnosis

4321Equation #14+0-1314+0-13Therapy Visits

3rd+1st or 2ndEpisode Number

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Beyond Your Numbers


Different points for each equation based on data relationshipsSample: Primary diagnosis = dysphagia, & M0250 = 3 (enteral therapy at home)

0060Primary diagnosis = dysphagia & M0250 = 3

4321Equation Number14+0-1314+0-13Therapy Visits

3rd+1st or 2ndEpisode Number

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Beyond Your Numbers


Utilizes 22 OASIS itemsRetain three domains/dimensions

ClinicalFunctionalService utilization

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Beyond Your Numbers

Clinical Dimension

M0230/ M0240/ M0246 – DiagnosesM0250 – Therapy at homeM0390 – VisionM0420 – PainM0450 & M0460 – Pressure ulcersM0476 – Stasis ulcersM0488 – Surgical woundsM0490 – Dyspnea

M0540 – Bowel incontinenceM0550 – OstomyM0650 & M0660 – Dressing (new)M0670 – Bathing (new)M0680 – Toileting (new)M0690 – Transferring (new)M0700 – Ambulation (new)M0800 – Injectable drugs (new)

Consists of

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Beyond Your Numbers

Clinical Dimension

EliminatedM0245 – Payment diagnosesM0440 – Skin lesions/open wounds

M0530 – Urinary incontinenceM0610 – Behaviors

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Beyond Your Numbers

Clinical Dimension

Blindness and low visionBlood disordersCancer & selected benign neoplasmsDiabetesDysphagiaGait abnormalityGastrointestinal disordersHeart diseaseHypertension

Neuro – brain and paralysis, peripheral, stroke & MSOrtho – leg & other disordersPsych – affective/other psychoses, degenerative & other PulmonarySkin – traumatic wounds, burns, post-op, ulcers & otherTracheostomy careUrostomy/Cystostomy care

Expanded diagnoses (table 2b)

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Beyond Your Numbers

Functional Dimension

Components unchangedM0650 or M0660 – DressingM0670 – BathingM0680 – ToiletingM0690 – TransferringM0700 – Ambulation

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Beyond Your Numbers

Service Utilization Dimension

M0175 eliminated from case-mix considerationThree therapy thresholds

6, 14 & 20 visitsGraduated payment increases

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Beyond Your Numbers

Case-Mix Scoring

Variation in scoring across four equationsClinical dimension

• Combinations of co-existing diagnoses• Combination of diagnoses & clinical or functional

OASIS itemsFunctional dimension

• Functional OASIS items onlyService utilization dimension

• Therapy utilization only

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Beyond Your Numbers

Case-Mix Grouping

11 to 1311 to 13S5

1010S418 to 197 to 918 to 197 to 9S3

16 to 17616 to 176S2

20+14 to 150 to 514 to 150 to 5S1Service Utilization (number of therapy visits)

8+9+10+8+7+F378976F2

0 to 60 to 70 to 80 to 60 to 5F1Functional (sum of points)

15+17+6+15+9+C3

8 to 149 to 163 to 57 to 145 to 8C20 to 70 to 80 to 20 to 60 to 4C1Clinical (sum

of points)

(2 or 4)4321Equation

20+ therapy14-19 therapy0-13 therapy14-19 therapy0-13 therapyDimension

All Episodes3rd+ Episodes1st & 2nd Episodes

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Beyond Your Numbers

Case-mix Grouping

Results in 153 HHRGsCase-mix weights range from .05827 to 3.4872Billing/HIPPS codes yet to be released

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Beyond Your Numbers

Base Rates

2007 rate = $2,339.00New rates

Episodes beginning in 2007 & ending in 2008• $2,337.06

Episodes beginning in 2008• $2,270.32

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Beyond Your Numbers

Base Rates

Market basket adjustment3.0% increaseRebased to FY2003 dataAt risk for Congress eliminationCompare to

• Hospital = 3.3%• SNF = 3.3%

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Beyond Your Numbers

Base Rates

Case-mix “creep” adjustmentAdministrative adjustmentAssess increases due to

• Change in patient characteristics, or• Creep due to scoring improvements

Per CMS, mostly creep from 2000 to 20052.75% reduction in 2008, 2009 & 20102.71% reduction in 2011 (proposed)

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Beyond Your Numbers

Wage Index

Continue to use hospital wage indexPre-floorPre-classified

Labor portion subject to wage indexIncreased from 76.775 to 77.082

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Beyond Your Numbers

Episode Adjustments

Low-utilization payment adjustment (LUPA) episodes

Maintain four or fewer visitsIdentified increased costs for first visitAdd-on of $87.93

• For LUPA-only episodes (no subsequent episodes)• For initial episodes• Add-on is wage-index adjusted

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Beyond Your Numbers

Episode Adjustments

Significant change in condition (SCIC) adjustments eliminated

Difficult in applicationNegative financial impacts foundOnly 2.1% of episodesAdjustment to base rate for elimination

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Beyond Your Numbers

Episode Adjustments

Partial episode payment (PEP) adjustments retainedOutlier episodes retained

Revised standards• Fixed dollar loss ratio increased to 0.89 from 0.67• 80% loss sharing

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Beyond Your Numbers

Non-Routine Supplies

Patient characteristics determine additional payment (tables 10a and 10b)

42 skin conditions• 19 primary & other diagnoses categories• Pressure ulcers, stasis ulcers & surgical wounds

7 other clinical factors• Ostomies, IV/infusion, urinary catheters & bowell

incontinence

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Beyond Your Numbers

Non-Routine Supplies

NRS payment amount added to case-mix & wage-index adjusted rate

Reduction in base episode rates

Six severity levelsNo supply payment for LUPA episodes

320.3749-985

139.8415-273

551.0099+6

207.7628-484

51.001-142

$ 14.1201PaymentPoints

Severity Level

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Beyond Your Numbers

Sample Rate Computation

Standard rate $2,270.32Case-mix index (C2F1S3 – early episode with 0-13 therapy) 1.2107Case-mix adjusted $2,748.68 Case-mix adjusted $2,748.68Labor portion .77082 $2,118.74Wage index (KC, Mo) 0.9504 Labor portion $2,013.65

(table 5)

(addendum A or B)

Continued…

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Beyond Your Numbers

Sample Rate Computation

Labor portion $2,013.65 Case-mix adjusted $2,748.68Non-labor portion .22918 629.94 Non-routine supplies (level 2) 51.00 Case-mix, wage-index adjusted & supply inclusive PPS rate $2,694.59

(table 9)

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Beyond Your Numbers

OASIS Changes

AddM0110 – Early or later episode

• CMS default = earlyM0246 – Case-mix diagnosesM0826 – Expected therapy visits

• Will adjust therapy up or down based on actual visits reported on final claim

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Beyond Your Numbers

OASIS Changes

DeleteM0245 – Payment diagnosesM0825 – Therapy threshold

Retain M0175But not used for case mix

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Beyond Your Numbers

Quality Improvement

2% reduction for failure to report OASISJuly 2006 through June 2007Compare to claims data

Add measures to Home Health CompareEmergent care for wound infectionsImprovement in status of surgical wounds

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Beyond Your Numbers

Financial Impact

Estimated net increase of $20 million$430M increase for market basket increase$410M decrease for case-mix creep adjustment

Winners?Non-profits, provider-based, North

Losers?Proprietary, freestanding, South

VERY agency-specific

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Beyond Your Numbers

Adapting to the Refinements

Be involved in the industryStudy new rules & regulationsEngage a knowledgeable advisory teamPerform impact assessmentsAssess current coding accuracy

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Beyond Your Numbers

Adapting to the Refinements

Solidify IT vendor interfaceEvaluate potential changes in care planning practicesBlend clinical & financial staff in planning operational changesConservative 2008 budget

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Beyond Your Numbers

How to Contact Me…

Mark Sharp, CPABKD Health Care Group

[email protected] 865-8701

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Beyond Your Numbers

Thank you!

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EXHIBIT 1

Summary of the PPS Refinements

Medicare Home Health ProgramPPS Refinements Summary of Key ChangesEffective January 1, 2008

Current PPS Rules New PPS Rules1

National 60- Day Episode Payment RatesPayment Rates

Episodes beginning in 2006 and ending Episodes beginning in 2007 and endingin 2007 in 2008

Urban Urban or 2,291.68$ 1

Rural Rural or 2,291.68$ 1

Episodes beginning and ending in 2007 Episodes beginning and ending in 2008

Urban Urban or 2,226.24$ 1

Rural Rural or 2,226.24$ 1

1 reduced payment rates for agenciesthat do not transmit OASIS datato the state

Wage Adjustment

Labor portion 76.775% Labor portion 77.082%Nonlabor portion 23.225% Nonlabor portion 22.918%

Episode Payment AdjustmentsLow Utilization Payment Adjustments (LUPA)

Per-visit payment paid on all episodes billed Per-visit payment paid on all episodes billedwith four or fewer visits with four or fewer visits

Additional $87.93 base amount paid for LUPA episodes when:

Episode is the only episode billed, orEpisode is the first episode in a series

2,339.00$ 2,455.95$

2,339.00$

2,337.06$ 2,337.06$

2,270.32$ 2,270.32$ 2,339.00$

BKD Health Care Group, All Rights Reserved 1 of 9



Episode Payment Adjustments (continued)Significant Change in Condition (SCIC)

SCIC adjustmend billed when patient Adjustment is elimintedexperiences an unexpected change incondition and other clinical and billing criteriaare met

Outliers

Fixed dollar loss ratio of 0.67 Fixed dollar loss ratio of 0.89

Case-Mix ModelPayment Categories

80 HHRGs and case-mix weights 153 HHRGs and case-mix weights

Case-Mix Scoring

Case-mix weights range from 0.5265 to Case-mix weights range from 0.5827 to2.8113 3.4872

Single equation model: Multiple equation model:

All episodes given equal weight Equation 1: regardless of whether the episode wasthe first or subsequent in a series of First or second episodes with 0 to 13episodes total therapy visits

Equation 2:

First or second episodes with 14 or moretotal therapy visits

Equation 3:

Third or later episodes with 0 to 13total therapy visits

Equation 4:

Third or later episodes with 14 or moretotal therapy visits




Case-Mix Model (continued)Episode Timing

No tracking or payment for episode sequence New OASIS item M0110 to track early (first oror timing second episodes) or late (third or later)

episodes which determines the equation thatwill be applied to the episode for paymentpurposes

Clinical Dimension

OASIS Questions OASIS Questions

15 questions with payment value: 20 questions with payment value:

M0230/M0245 M0476 M0230/M0240/M0246 M0540M0240a M0488 M0250 M0550M0250 M0490 M0390 M0650M0390 M0530 M0420 M0660M0420 M0540 M0450 M0670M0440 M0550 M0460 M0680M0450 M0610 M0476 M0690M0460 M0488 M0700

M0490 M0800

Dimension Codes Dimension Codes

C0 = A 0 to 7 points (minimum) Equation 1 (HHRG Group 1)C1 = B 8 to 19 points (low)C2 = C 20 to 40 points (moderate) C1 = A2 0 to 4 clinical pointsC3 = D 41 or more points (high) C2 = B2 5 to 8 clinical points

C3 = C2 9 or more clinical points




Case-Mix Model (continued)Clinical Dimension (continued)

Equation 2 (HHRG Group 2)

C1 = A2 0 to 6 clinical pointsC2 = B2 7 to 14 clinical pointsC3 = C2 15 or more clinical points





Equations 2 & 4 (HHRG Group 5)


Functional Dimension


6 questions with payment value: 6 questions with payment value:

M0650 M0680 M0650 M0680M0660 M0690 M0660 M0690M0670 M0700 M0670 M0700




Case-Mix Model (continued)Functional Dimension (continued)


F0 = E 0 to 2 points (minimum) Equation 1 (HHRG Group 1)F1 = F 3 to 15 points (low)F2 = G 16 to 23 points (moderate) F1 = F2 0 to 5 functional pointsF3 = H 24 to 29 points (high) F2 = G2 6 functional pointsF4 = I 30 or more points (maximum) F3 = H2 7 or more functional points


F1 = F2 0 to 6 functional pointsF2 = G2 7 functional pointsF3 = H2 8 or more functional points










Case-Mix Model (continued)Service Utilization Dimension


2 questions with payment value: 1 question with payment value

M0175 M0825 M0826


Single therapy threshold of 10 total therapy Multiple therapy thresholds at 6, 14 and visits 20 visits (M0826)

S0 = J 0 to 2 points (minimum) and Equation 1 (HHRG Group 1)less than 10 total therapy visits

S1 = K 3 points (low) and less than S1 = K2 0 to 5 total therapy visits10 total therapy visits S2 = L2 6 total therapy visits

S2 = L 4 to 6 points (moderate) and S3 = M2 7 to 9 total therapy visits10 or more total therapy visits S4 = N2 10 total therapy visits

S3 = M 7 points (high) and 10 or more S5 = P2 11 to 13 total therapy visitstotal therapy visits


S1 = K2 14 to 15 total therapy visitsS2 = L2 16 to 17 total therapy visitsS3 = M2 18 to 19 total therapy visits


S1 = K2 0 to 5 total therapy visitsS2 = L2 6 total therapy visitsS3 = M2 7 to 9 total therapy visitsS4 = N2 10 total therapy visitsS5 = P2 11 to 13 total therapy visits




Case-Mix Model (continued)Service Utilization Dimension (continued)


S1 = K2 14 to 15 total therapy visitsS2 = L2 16 to 17 total therapy visitsS3 = M2 18 to 19 total therapy visits


S1 = K2 20 or more total therapy visits

Nonroutine Medical Supplies

Nonroutine medical supplies factored into Additional episode payment made accordingnational standard rates but no extra payment to six patient severity levels:in addition to standard episode payment Additional

Severity StandardLevel HIPPS2 Points Payment

1 S 0 14.12$ 2 T 1 to 14 51.00$ 3 U 15 to 27 139.84$ 4 V 28 to 48 207.76$ 5 W 49 to 98 320.37$ 6 ? 99 or more 551.00$

Billing Codes2

HIPPS Codes

Five character alpha-numeric code, i.e., HAEJ1 Five character alpha-numeric code, i.e., 1AFKS

Position 1 H Home health Position 1 1 - 5 HHRG groupPosition 2 A - D Clinical domain score Position 2 A - C Clinical domain scorePosition 3 E - I Functional domain score Position 3 F - H Functional domain scorePosition 4 J - M Service utilization Position 4 K - N, P Service utilization

domain score domain scorePosition 5 1 - 8 Validity score Position 5 S - W Nonroutine supplies

severity level




Billing Codes2 (continued)OASIS Matching Key

18 character numeric code, i.e., 18 character alpha-numeric code, i.e.,200701012007010000 07JK08AA41GBMDCDLG

Positions 1 - 8 M0030: Start of care Positions 1 - 2 M0030: Start of caredate year (2 digit code)

Positions 9 - 16 M0090: Assessment Positions 3 - 4 M0030: Start of caredate month and day (2

Positions 17 - 18 M0100: Reason for character alpha code)assessment Positions 5 - 6 M0090: Assessment

year (2 digit code)Positions 7 - 8 M0090: Assessment

month and day (2character alpha code)

Position 9 M00100: Reason forassessment (1 digitcode)

Position 10 M0110: Episode timing(1 digit code)

Position 11 Clinical domain pointsunder equation 1 (alphacode)

Position 12 Functional domainpoints under equation 1(alpha code)








Billing Codes2 (continued)OASIS Matching Key (continued)



Publicly Reported Outcomes

10 publicly reported outcome measures 12 publicly reported outcome measurestracked using OASIS data and posted on tracked using OASIS data and posted onthe CMS home health compare website the CMS home health compare website

2 new measures include:

Emergent care for wound infections, deteriorating wound status, and

Improvement in status of surgical wound

BKD Health Care Group provides financial, billing, clinical and operational consulting services for home health and hospice agencies throughout the nation. Contact Mark Sharp at 417 865-8701 or [email protected] with questions regarding this information or browse the BKD website to learn more about our services.

1All new rules are effective January 1, 2008, and are based on the proposed rules in the Federal Register, dated May 4, 2007, and the final rules published in the Centers for Medicare and Medicaid Services (CMS) document CMS-1541-FC.

2All new HIPPS codes and other billing code information is based on proposed data and has not yet been finalized by CMS.


EXHIBIT 2

Key Tables from the Federal Register

49782 Federal Register / Vol. 72, No. 167 / Wednesday, August 29, 2007 / Rules and Regulations

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TABLE 10A.—NRS CASE-MIX ADJUSTMENT VARIABLES AND SCORES

Item Description Score

SELECTED SKIN CONDITIONS

1 ....................................... Primary diagnosis = Anal fissure, fistula and abscess ................................................................................. 15 2 ....................................... Other diagnosis = Anal fissure, fistula and abscess ..................................................................................... 13 3 ....................................... Primary diagnosis = Cellulitis and abscess ................................................................................................... 14 4 ....................................... Other diagnosis = Cellulitis and abscess ...................................................................................................... 8 5 ....................................... Primary or other diagnosis = Diabetic ulcers ................................................................................................ 20 6 ....................................... Primary diagnosis = Gangrene ...................................................................................................................... 11 7 ....................................... Other diagnosis = Gangrene ......................................................................................................................... 8 8 ....................................... Primary diagnosis = Malignant neoplasms of skin ........................................................................................ 15 9 ....................................... Other diagnosis = Malignant neoplasms of skin ........................................................................................... 4 10 ..................................... Primary or Other diagnosis = Non-pressure and non-stasis ulcers .............................................................. 13 11 ..................................... Primary diagnosis = Other infections of skin and subcutaneous tissue ....................................................... 16 12 ..................................... Other diagnosis = Other infections of skin and subcutaneous tissue .......................................................... 7 13 ..................................... Primary diagnosis = Post-operative Complications ....................................................................................... 23 14 ..................................... Other diagnosis = Post-operative Complications .......................................................................................... 15 15 ..................................... Primary diagnosis = Traumatic Wounds and Burns ..................................................................................... 19 16 ..................................... Other diagnosis = Traumatic Wounds and Burns ......................................................................................... 8 17 ..................................... Primary or other diagnosis = V code, Cystostomy care ............................................................................... 16 18 ..................................... Primary or other diagnosis = V code, Tracheostomy care ........................................................................... 23 19 ..................................... Primary or other diagnosis = V code, Urostomy care ................................................................................... 24 20 ..................................... OASIS M0450 = 1 or 2 pressure ulcers, stage 1 ......................................................................................... 4 21 ..................................... OASIS M0450 = 3+ pressure ulcers, stage 1 ............................................................................................... 6 22 ..................................... OASIS M0450 = 1 pressure ulcer, stage 2 ................................................................................................... 14 23 ..................................... OASIS M0450 = 2 pressure ulcers, stage 2 ................................................................................................. 22 24 ..................................... OASIS M0450 = 3 pressure ulcers, stage 2 ................................................................................................. 29 25 ..................................... OASIS M0450 = 4+ pressure ulcers, stage 2 ............................................................................................... 35 26 ..................................... OASIS M0450 = 1 pressure ulcer, stage 3 ................................................................................................... 29 27 ..................................... OASIS M0450 = 2 pressure ulcers, stage 3 ................................................................................................. 41 28 ..................................... OASIS M0450 = 3 pressure ulcers, stage 3 ................................................................................................. 46 29 ..................................... OASIS M0450 = 4+ pressure ulcers, stage 3 ............................................................................................... 58 30 ..................................... OASIS M0450 = 1 pressure ulcer, stage 4 ................................................................................................... 48 31 ..................................... OASIS M0450 = 2 pressure ulcers, stage 4 ................................................................................................. 67 32 ..................................... OASIS M0450 = 3+ pressure ulcers, stage 4 ............................................................................................... 75 33 ..................................... OASIS M0450e = 1 (unobserved pressure ulcer(s)) .................................................................................... 17 34 ..................................... OASIS M0470 = 2 (2 stasis ulcers) .............................................................................................................. 6 35 ..................................... OASIS M0470 = 3 (3 stasis ulcers) .............................................................................................................. 12 36 ..................................... OASIS M0470 = 4 (4+ stasis ulcers) ............................................................................................................ 21 37 ..................................... OASIS M0474 = 1 (unobservable stasis ulcers) ........................................................................................... 9 38 ..................................... OASIS M0476 = 1 (status of most problematic stasis ulcer: fully granulating) ............................................ 6 39 ..................................... OASIS M0476 = 2 (status of most problematic stasis ulcer: early/partial granulation) ................................ 25 40 ..................................... OASIS M0476 = 3 (status of most problematic stasis ulcer: not healing) .................................................... 36 41 ..................................... OASIS M0488 = 2 (status of most problematic surgical wound: early/partial granulation) .......................... 4 42 ..................................... OASIS M0488 = 3 (status of most problematic surgical wound: not healing) .............................................. 14

OTHER CLINICAL FACTORS

43 ..................................... OASIS M0550 = 1 (ostomy not related to inpt stay/no regimen change) .................................................... 27 44 ..................................... OASIS M0550 = 2 (ostomy related to inpt stay/regimen change) ................................................................ 45 45 ..................................... Any ‘Selected Skin Conditions’ (rows 1–42 above) AND M0550 = 1 (ostomy not related to inpt stay/no

regimen change).14

46 ..................................... Any ‘Selected Skin Conditions’ (rows 1–42 above) AND M0550 = 2 (ostomy related to inpt stay/ regimen change).

11

47 ..................................... OASIS M0250 (Therapy at home) =1 (IV/Infusion) ....................................................................................... 5 48 ..................................... OASIS M0520 = 2 (patient requires urinary catheter) .................................................................................. 9 49 ..................................... OASIS M0540 = 4 or 5 (bowel incontinence, daily or >daily) ....................................................................... 10

Note: Points are additive, however points may not be given for the same line item in the table more than once. Points are not assigned for a secondary diagnosis if points are already assigned for a primary diagnosis

from the same diagnosis/condition group. See Table 12b for definitions of diagnosis/ condition groups.

Please see Medicare Home Health Diagnosis Coding guidance at http://

www.cms.hhs.gov/HomeHealthPPS/ 03_coding&billing.asp for definitions of primary and secondary diagnoses.

TABLE 10B.—ICD–9–CM DIAGNOSES INCLUDED IN THE DIAGNOSTIC CATEGORIES FOR THE NONROUTINE SUPPLIES (NRS) CASE-MIX ADJUSTMENT MODEL

Diagnostic Category ICD–9–CM Code* Manifestation Short Description of ICD–9–CM Code

Anal fissure, fistula and abscess .. 565 .................... ........................... ANAL FISSURE AND FISTULA.

VerDate Aug<31>2005 16:35 Aug 28, 2007 Jkt 211001 PO 00000 Frm 00093 Fmt 4701 Sfmt 4700 E:\FR\FM\29AUR2.SGM 29AUR2mst

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http://www.cms.hhs.gov/HomeHealthPPS/03_coding&billing.asp


TABLE 10B.—ICD–9–CM DIAGNOSES INCLUDED IN THE DIAGNOSTIC CATEGORIES FOR THE NONROUTINE SUPPLIES (NRS) CASE-MIX ADJUSTMENT MODEL—Continued


566 .................... ........................... ABSCESS OF ANAL AND RECTAL REGIONS. Cellulitis and abscess .................... 681.00 ............... ........................... FINGER—CELLULITIS AND ABSCESS, UNSPECIFIED.

681.01 ............... ........................... FELON. 681.10 ............... ........................... TOE—CELLULITIS AND ABSCESS, UNSPECIFIED. 681.9 ................. ........................... CELLULITIS AND ABSCESS OF UNSPECIFIED DIGIT. 682 .................... ........................... OTHER CELLULITIS AND ABSCESS.

Diabetic Ulcers .............................. 250.8x & 707.10–707.9.

........................... (PRIMARY OR FIRST OTHER DIAGNOSIS = 250.8x AND PRI-MARY OR FIRST OTHER DIAGNOSIS = 707.10- 707.9).

Gangrene ....................................... 440.24 ............... ........................... ATHERSCLER-ART EXTREM W/GANGRENE. 785.4 ................. M ...................... GANGRENE.

Malignant neoplasms of skin ......... 172 .................... ........................... MALIGNANT MELANOMA OF SKIN. 173 .................... ........................... OTHER MALIGNANT NEOPLASM OF SKIN.

Non-pressure and non-stasis ul-cers (other than diabetic).

440.23 ............... ........................... ATHEROSCLER-ART EXTREM W/ULCERATION.

447.2 ................. ........................... RUPTURE OF ARTERY. 447.8 ................. ........................... OTHER SPECIFIED DISORDERS OF ARTERIES AND

ARTERIOLES. 707.10 ............... ........................... ULCER OF LOWER LIMB, UNSPECIFIED. 707.11 ............... ........................... ULCER OF THIGH. 707.12 ............... ........................... ULCER OF CALF. 707.13 ............... ........................... ULCER OF ANKLE. 707.14 ............... ........................... ULCER OF HEEL AND MIDFOOT. 707.15 ............... ........................... ULCER OF OTHER PART OF FOOT. 707.19 ............... ........................... ULCER OF OTHER PART OF LOWER LIMB. 707.8 ................. ........................... CHRONIC ULCER OTHER SPECIFIED SITE. 707.9 ................. ........................... CHRONIC ULCER OF UNSPECIFIED SITE.

Other infections of skin and sub-cutaneous tissue.

680 .................... ........................... CARBUNCLE AND FURUNCLE.

683 .................... ........................... ACUTE LYMPHADENITIS. 685 .................... ........................... PILONIDAL CYST. 686 .................... ........................... OTH LOCAL INF SKIN&SUBCUT TISSUE.

Post-operative Complications ........ 998.11 ............... ........................... HEMORRHAGE COMPLICATING A PROCEDURE. 998.12 ............... ........................... HEMATOMA COMPLICATING A PROCEDURE. 998.13 ............... ........................... SEROMA COMPLICATING A PROCEDURE. 998.2 ................. ........................... ACC PUNCT/LACERATION DURING PROC NEC. 998.4 ................. ........................... FB ACC LEFT DURING PROC NEC. 998.6 ................. ........................... PERSISTENT POSTOPERATIVE FIST NEC. 998.83 ............... ........................... NON-HEALING SURGICAL WOUND NEC.

Traumatic wounds, burns and post-operative complications.

870 .................... ........................... OPEN WOUND OF OCULAR ADNEXA.

872 .................... ........................... OPEN WOUND OF EAR. 873 .................... ........................... OTHER OPEN WOUND OF HEAD. 874 .................... ........................... OPEN WOUND OF NECK. 875 .................... ........................... OPEN WOUND OF CHEST. 876 .................... ........................... OPEN WOUND OF BACK. 877 .................... ........................... OPEN WOUND OF BUTTOCK. 878 .................... ........................... OPEN WND GNT ORGN INCL TRAUMAT AMP. 879 .................... ........................... OPEN WOUND OTH&UNSPEC SITE NO LIMBS. 880 .................... ........................... OPEN WOUND OF SHOULDER&UPPER ARM. 881 .................... ........................... OPEN WOUND OF ELBOW, FOREARM&WRIST. 882 .................... ........................... OPEN WOUND HAND EXCEPT FINGER ALONE. 883 .................... ........................... OPEN WOUND OF FINGER. 884 .................... ........................... MX&UNSPEC OPEN WOUND UPPER LIMB. 885 .................... ........................... TRAUMATIC AMPUTATION OF THUMB. 886 .................... ........................... TRAUMATIC AMPUTATION OTHER FINGER. 887 .................... ........................... TRAUMATIC AMPUTATION OF ARM&HAND. 890 .................... ........................... OPEN WOUND OF HIP AND THIGH. 891 .................... ........................... OPEN WOUND OF KNEE, LEG, AND ANKLE. 892 .................... ........................... OPEN WOUND OF FOOT EXCEPT TOE ALONE. 893 .................... ........................... OPEN WOUND OF TOE. 894 .................... ........................... MX&UNSPEC OPEN WOUND LOWER LIMB. 895 .................... ........................... TRAUMATIC AMPUTATION OF TOE. 896 .................... ........................... TRAUMATIC AMPUTATION OF FOOT. 897 .................... ........................... TRAUMATIC AMPUTATION OF LEG. 941 except

941.0x and 941.1x.

........................... BURN OF FACE, HEAD, AND NECK.

942 except 942.0x and 942.1x.

........................... BURN OF TRUNK.


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TABLE 10B.—ICD–9–CM DIAGNOSES INCLUDED IN THE DIAGNOSTIC CATEGORIES FOR THE NONROUTINE SUPPLIES (NRS) CASE-MIX ADJUSTMENT MODEL—Continued


943 except 943.0x and 943.1x.

........................... BURN OF UPPER LIMB, EXCEPT WRIST AND HAND.

944 except 944.0x and 944.1x.

........................... BURN OF WRIST(S) AND HAND(S).

945 except 945.0x and 945.1x.

........................... BURN OF LOWER LIMB(S).

946.2 ................. ........................... BURNS OF MULTIPLE SPECIFIED SITES, BLISTERS, EPI-DERMAL LOSS [SECOND DEGREE].

946.3 ................. ........................... BURNS OF MULTIPLE SPECIFIED SITES, FULL-THICKNESS SKIN LOSS [THIRD DEGREE NOS].

946.4 ................. ........................... BURNS OF MULTIPLE SPECIFIED SITES, DEEP NECROSIS OF UNDERLYING TISSUES [DEEP THIRD DEGREE] WITHOUT MENTION OF LOSS OF A BODY PART.

946.5 ................. ........................... BURNS OF MULTIPLE SPECIFIED SITES, DEEP NECROSIS OF UNDERLYING TISSUES [DEEP THIRD DEGREE] WITH LOSS OF A BODY PART.

998.31 ............... ........................... DISRUPTION OF INTERNAL OPERATION WOUND. 998.32 ............... ........................... DISRUPTION OF EXTERNAL OPERATION WOUND. 998.51 ............... ........................... INFECTED POSTOPERATIVE SEROMA. 998.59 ............... ........................... OTHER POSTOPERATIVE INFECTION.

V-code, Cystostomy Care ............. V55.5 ................. ........................... CYSTOSTOMY—CARE. V-code, Tracheostomy Care ......... V55.0 ................. ........................... TRACHEOSTOMY—CARE. V-code, Urostomy Care ................. V55.6 ................. ........................... OTHER ARTIFICIAL OPENING OF URINARY TRACT-

NEPHROSTOMY, URETEROSTOMY, URETHROSTOMY.

To ensure that NRS costs are being reported, claims that do not report NRS costs, unless explicitly noted by the HHA that NRS was not provided, will be returned to the provider (RTP). For episodes in which NRS was provided, the provider will need to resubmit the claim with NRS reported. For episodes in which NRS was not provided, the HHA will need to explicitly note that fact on the claim. We will allow a grace period, which will be determined and communicated in instructions from CMS. This will improve data on NRS, in the home health setting, providing us with better data with which to analyze and evaluate payment to HHAs for NRS in the future. We will monitor the accuracy of the 6-severity group methodology for payment of NRS. We will continue to monitor the accuracy and completeness of the reporting of NRS costs. Finally, we will explore alternative methods for accounting for NRS costs and payments in the future.

D. The Outlier Policy

As noted in section II, of this final rule with comment period, outlier payments are made for episodes for which the estimated cost exceeds a threshold amount and are intended to address home health episodes that incur unusually high costs due to patient health care needs. Section 1895(b)(5) of the Act requires that the estimated total

outlier payments are no more than 5 percent of total estimated HH PPS payments. For a full description of our outlier policy, we refer to the CY 2008 HH PPS proposed rule (72 FR 25434– 25435).

The wage adjusted fixed dollar loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. The loss sharing ratio is 0.80. As noted in the proposed rule, when the HH PPS system was implemented, we chose a value of 0.80 for the loss-sharing ratio and an FDL ratio of 1.13. In the October 2004 final rule, we revised the FDL ratio to 0.70, based on analysis of CY 2003 HH PPS data. We believed this updated FDL ratio of 0.70 preserved a reasonable degree of cost sharing, allowed a greater number of episodes to qualify for outlier payments, and yet did not result in a projected target percentage of estimated outlier payments of more than 5 percent.

Our CY 2006 update to the HH PPS rates, which was based upon CY 2004 HH claims data, again revised the FDL ratio from 0.70 to 0.65 to allow even more home health episodes to qualify for outlier payments and to better meet the estimated 5 percent target of outlier payments as a percentage of total HH PPS payments. In our CY 2007 update, we again changed the FDL ratio from 0.65 to 0.67 to better meet the 5 percent

target of outlier payments to total HH PPS payments, and based the change on analysis of CY 2005 HH claims.

In the proposed rule (72 FR 25434), we stated that preliminary analysis showed that outlier payments, as a percentage of total HH PPS payments, have increased on a yearly basis. With outlier payments having increased in recent years, and given the unknown effects that the proposed refinements may have on outliers, we proposed to maintain the FDL ratio at 0.67. We believed that this would continue to meet the statutory requirement of having an outlier payment outlay that does not exceed 5 percent of total HH PPS payments, while still providing for an adequate number of episodes to qualify for outlier payments. We stated in the proposed rule that we would rely on the latest data and best analysis available at the time to estimate outlier payments and update the FDL ratio in the final rule if appropriate.

Comment: A commenter supported our proposed outlier policy but does not understand why it needs to be capped at 5 percent.

Response: The statute, at section 1895(b)(5) of the Act, limits estimated outlier payments to no more than 5 percent of the total estimated HH PPS payments during a given year.

Comment: Commenters stated that the fixed dollar loss (FDL) ratio should be


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EXHIBIT 3

Missouri PPS Rates by HHRG, NRS & LUPA

Medicare Home Health PPS Payment Rates

Effective for Episodes Beginning and Ending in January 2008

Service AreaCBSACode17860 Columbia, Missouri

Boone CountyHoward County

Rates by HHRG Code1

Equation 1: 1st and 2nd Episodes, 0 to 13 Therapy VisitsC1F1S1 0.5827 1,186.07$ C2F1S1 0.7335 1,493.02$ C3F1S1 0.9010 1,833.96$ C1F1S2 0.8507 1,731.57 C2F1S2 1.0015 2,038.52 C3F1S2 1.1691 2,379.67 C1F1S3 1.0599 2,157.39 C2F1S3 1.2107 2,464.34 C3F1S3 1.3783 2,805.49 C1F1S4 1.2744 2,594.00 C2F1S4 1.4252 2,900.95 C3F1S4 1.5927 3,241.89 C1F1S5 1.4506 2,952.65 C2F1S5 1.6014 3,259.60 C3F1S5 1.7690 3,600.74 C1F2S1 0.6713 1,366.41 C2F2S1 0.8221 1,673.36 C3F2S1 0.9896 2,014.30 C1F2S2 0.9393 1,911.92 C2F2S2 1.0901 2,218.86 C3F2S2 1.2577 2,560.01 C1F2S3 1.1485 2,337.74 C2F2S3 1.2993 2,644.68 C3F2S3 1.4669 2,985.83 C1F2S4 1.3630 2,774.34 C2F2S4 1.5138 3,081.29 C3F2S4 1.6813 3,422.23 C1F2S5 1.5392 3,132.99 C2F2S5 1.6900 3,439.94 C3F2S5 1.8576 3,781.09 C1F3S1 0.7550 1,536.78 C2F3S1 0.9058 1,843.73 C3F3S1 1.0733 2,184.67 C1F3S2 1.0230 2,082.28 C2F3S2 1.1738 2,389.23 C3F3S2 1.3414 2,730.38 C1F3S3 1.2322 2,508.10 C2F3S3 1.3830 2,815.05 C3F3S3 1.5506 3,156.20 C1F3S4 1.4467 2,944.71 C2F3S4 1.5975 3,251.66 C3F3S4 1.7650 3,592.60 C1F3S5 1.6229 3,303.36 C2F3S5 1.7737 3,610.31 C3F3S5 1.9413 3,951.46

Equation 2: 1st and 2nd Episodes, 14 to 19 Therapy Visits C1F1S1 1.6118 3,280.77$ C2F1S1 1.8626 3,791.26$ C3F1S1 2.1524 4,381.14$ C1F1S2 1.7675 3,597.69 C2F1S2 2.0183 4,108.19 C3F1S2 2.3081 4,698.07 C1F1S3 1.9046 3,876.75 C2F1S3 2.1554 4,387.25 C3F1S3 2.4451 4,976.93 C1F2S1 1.7281 3,517.49 C2F2S1 1.9789 4,027.99 C3F2S1 2.2686 4,617.66 C1F2S2 1.8837 3,834.21 C2F2S2 2.1345 4,344.71 C3F2S2 2.4243 4,934.59 C1F2S3 2.0208 4,113.28 C2F2S3 2.2716 4,623.77 C3F2S3 2.5613 5,213.45 C1F3S1 1.8010 3,665.88 C2F3S1 2.0518 4,176.38 C3F3S1 2.3415 4,766.05 C1F3S2 1.9566 3,982.60 C2F3S2 2.2074 4,493.09 C3F3S2 2.4972 5,082.97 C1F3S3 2.0937 4,261.66 C2F3S3 2.3445 4,772.16 C3F3S3 2.6342 5,361.83

Payment Amount

Payment Amount

HHRG Code

Case-Mix Weight

HHRG Code

Case-Mix Weight

Payment Amount

HHRG Code

Case-Mix Weight

By HHRG Code, NRS Level and LUPA Category

Page 1 of 27





Rates by HHRG Code1

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HHRG Code

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HHRG Code

Case-Mix Weight


Equation 3: 3rd+ Episodes, 0 to 13 Therapy Visits C1F1S1 0.6543 1,331.81$ C2F1S1 0.7124 1,450.07$ C3F1S1 0.9399 1,913.14$ C1F1S2 1.0041 2,043.81 C2F1S2 1.0622 2,162.08 C3F1S2 1.2897 2,625.14 C1F1S3 1.2065 2,455.79 C2F1S3 1.2646 2,574.05 C3F1S3 1.4922 3,037.33 C1F1S4 1.4277 2,906.04 C2F1S4 1.4858 3,024.30 C3F1S4 1.7134 3,487.57 C1F1S5 1.6024 3,261.64 C2F1S5 1.6605 3,379.90 C3F1S5 1.8880 3,842.97 C1F2S1 0.7882 1,604.36 C2F2S1 0.8463 1,722.62 C3F2S1 1.0738 2,185.69 C1F2S2 1.1380 2,316.36 C2F2S2 1.1962 2,434.83 C3F2S2 1.4237 2,897.90 C1F2S3 1.3405 2,728.55 C2F2S3 1.3986 2,846.81 C3F2S3 1.6261 3,309.88 C1F2S4 1.5167 3,087.20 C2F2S4 1.6198 3,297.05 C3F2S4 1.8473 3,760.12 C1F2S5 1.7364 3,534.39 C2F2S5 1.7945 3,652.65 C3F2S5 2.0220 4,115.72 C1F3S1 0.9151 1,862.66 C2F3S1 0.9732 1,980.92 C3F3S1 1.2007 2,443.99 C1F3S2 1.2649 2,574.66 C2F3S2 1.3230 2,692.93 C3F3S2 1.5506 3,156.20 C1F3S3 1.4674 2,986.85 C2F3S3 1.5255 3,105.11 C3F3S3 1.7530 3,568.18 C1F3S4 1.6886 3,437.09 C2F3S4 1.7467 3,555.35 C3F3S4 1.9742 4,018.42 C1F3S5 1.8632 3,792.49 C2F3S5 1.9213 3,910.75 C3F3S5 2.1489 4,374.02

Equation 4: 3rd+ Episodes, 14 to 19 Therapy Visits

C1F1S1 1.7530 3,568.18$ C2F1S1 2.0276 4,127.12$ C3F1S1 2.3479 4,779.08$ C1F1S2 1.8689 3,804.09 C2F1S2 2.1435 4,363.03 C3F1S2 2.4637 5,014.78 C1F1S3 2.0252 4,122.23 C2F1S3 2.2998 4,681.17 C3F1S3 2.6200 5,332.93 C1F2S1 1.8839 3,834.62 C2F2S1 2.1585 4,393.56 C3F2S1 2.4787 5,045.32 C1F2S2 1.9998 4,070.53 C2F2S2 2.2744 4,629.47 C3F2S2 2.5946 5,281.23 C1F2S3 2.1560 4,388.47 C2F2S3 2.4306 4,947.41 C3F2S3 2.7509 5,599.37 C1F3S1 2.0531 4,179.02 C2F3S1 2.3277 4,737.96 C3F3S1 2.6479 5,389.72 C1F3S2 2.1690 4,414.93 C2F3S2 2.4436 4,973.87 C3F3S2 2.7638 5,625.63 C1F3S3 2.3252 4,732.87 C2F3S3 2.5998 5,291.81 C3F3S3 2.9201 5,943.77

Case-Mix Rate

Case-Mix Weight

HHRG Code

Case-Mix Weight

Case-Mix Rate

Case-Mix Weight

HHRG Code

Case-Mix Rate

HHRG Code

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Rates by HHRG Code1

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Equations 2 and 4: All Episodes, 20+ Therapy Visits C1F1S1 2.5495 5,189.43$ C2F1S1 2.7632 5,624.41$ C3F1S1 3.0835 6,276.37$ C1F2S1 2.7390 5,575.15 C2F2S1 2.9527 6,010.13 C3F2S1 3.2730 6,662.09 C1F3S1 2.9532 6,011.15 C2F3S1 3.1669 6,446.13 C3F3S1 3.4872 7,098.09

Nonroutine Supply (NRS) LUPA Per-Visit Payment Rates1

Payment Rates1 Skilled nursing 94.06$ Physical therapy 102.84 Occupational therapy 103.53 Speech therapy 111.66 Medical social worker 150.77 Home health aide 42.60

LUPA Episode Add-On Payment Amount1

Initial and LUPA-only episodes 78.83$

1All rates are effective January 1, 2008, and are based on the Federal Register, dated May 4, 2007, and the Centers for Medicare and Medicaid Services document CMS-1541-FC.


14.12$ 51.00

139.84 207.76 320.37

RatePayment

6 551.00 5

34

12

SeverityLevel

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Service AreaCBSACode22220 Fayetteville-Springdale-Rogers, Arkansas-Missouri

Benton County, AR McDonald County, MOMadison County, ARWashington County, AR

Rates by HHRG Code1




Payment Amount

Payment Amount

HHRG Code

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HHRG Code

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Page 4 of 27





Rates by HHRG Code1


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HHRG Code

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Case-Mix Rate

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HHRG Code

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Rates by HHRG Code1


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Initial and LUPA-only episodes 79.40$ 5

34

12

SeverityLevel

6 551.00



14.12$ 51.00

139.84 207.76 320.37

RatePayment

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Service AreaCBSACode27620 Jefferson City, Missouri

Callaway County Osage CountyCole CountyMoniteau County

Rates by HHRG Code1




Payment Amount

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Rates by HHRG Code1


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HHRG Code

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HHRG Code

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Case-Mix Rate

HHRG Code

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Rates by HHRG Code1


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Payment Amount

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HHRG Code

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HHRG Code

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34

12

SeverityLevel

6 551.00



14.12$ 51.00

139.84 207.76 320.37

RatePayment

Page 9 of 27



Service AreaCBSACode27900 Joplin, Missouri

Jasper CountyNewton County

Rates by HHRG Code1



Payment Amount

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Rates by HHRG Code1

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Case-Mix Rate

Case-Mix Weight

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Case-Mix Rate

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14.12$ 51.00

139.84 207.76 320.37

RatePayment

6 551.00 5

34

12

SeverityLevel

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Service AreaCBSACode28140 Kansas City, Missouri-Kansas

Franklin County, KS Wyandotte County, KS Clinton County, MOJohnson County, KS Bates County, MO Jackson County, MOLeavenworth County, KS Caldwell County, MO Lafayette County, MOLinn County, KS Cass County, MO Platte County, MOMiami County, KS Clay County, MO Ray County, MO

Rates by HHRG Code1




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Rates by HHRG Code1


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34

12

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6 551.00



14.12$ 51.00

139.84 207.76 320.37

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Page 15 of 27



Service AreaCBSACode41140 St. Joseph, Missouri-Kansas

Doniphan County, KS Dekalb County, MOAndrew County, MOBuchanan County, MO

Rates by HHRG Code1

1st and 2nd Episodes, 0 to 13 Therapy VisitsC1F1S1 0.5827 1,196.67$ C2F1S1 0.7335 1,506.37$ C3F1S1 0.9010 1,850.36$ C1F1S2 0.8507 1,747.06 C2F1S2 1.0015 2,056.75 C3F1S2 1.1691 2,400.94 C1F1S3 1.0599 2,176.68 C2F1S3 1.2107 2,486.38 C3F1S3 1.3783 2,830.57 C1F1S4 1.2744 2,617.20 C2F1S4 1.4252 2,926.89 C3F1S4 1.5927 3,270.88 C1F1S5 1.4506 2,979.05 C2F1S5 1.6014 3,288.75 C3F1S5 1.7690 3,632.94 C1F2S1 0.6713 1,378.63 C2F2S1 0.8221 1,688.32 C3F2S1 0.9896 2,032.31 C1F2S2 0.9393 1,929.01 C2F2S2 1.0901 2,238.70 C3F2S2 1.2577 2,582.90 C1F2S3 1.1485 2,358.64 C2F2S3 1.2993 2,668.33 C3F2S3 1.4669 3,012.53 C1F2S4 1.3630 2,799.15 C2F2S4 1.5138 3,108.84 C3F2S4 1.6813 3,452.83 C1F2S5 1.5392 3,161.01 C2F2S5 1.6900 3,470.70 C3F2S5 1.8576 3,814.90 C1F3S1 0.7550 1,550.52 C2F3S1 0.9058 1,860.21 C3F3S1 1.0733 2,204.20 C1F3S2 1.0230 2,100.90 C2F3S2 1.1738 2,410.60 C3F3S2 1.3414 2,754.79 C1F3S3 1.2322 2,530.53 C2F3S3 1.3830 2,840.22 C3F3S3 1.5506 3,184.42 C1F3S4 1.4467 2,971.04 C2F3S4 1.5975 3,280.74 C3F3S4 1.7650 3,624.73 C1F3S5 1.6229 3,332.90 C2F3S5 1.7737 3,642.59 C3F3S5 1.9413 3,986.79

1st and 2nd Episodes, 14 to 19 Therapy Visits C1F1S1 1.6118 3,310.10$ C2F1S1 1.8626 3,825.16$ C3F1S1 2.1524 4,420.32$ C1F1S2 1.7675 3,629.86 C2F1S2 2.0183 4,144.92 C3F1S2 2.3081 4,740.07 C1F1S3 1.9046 3,911.42 C2F1S3 2.1554 4,426.48 C3F1S3 2.4451 5,021.43 C1F2S1 1.7281 3,548.95 C2F2S1 1.9789 4,064.01 C3F2S1 2.2686 4,658.95 C1F2S2 1.8837 3,868.50 C2F2S2 2.1345 4,383.56 C3F2S2 2.4243 4,978.71 C1F2S3 2.0208 4,150.05 C2F2S3 2.2716 4,665.11 C3F2S3 2.5613 5,260.06 C1F3S1 1.8010 3,698.66 C2F3S1 2.0518 4,213.72 C3F3S1 2.3415 4,808.67 C1F3S2 1.9566 4,018.21 C2F3S2 2.2074 4,533.27 C3F3S2 2.4972 5,128.42 C1F3S3 2.0937 4,299.77 C2F3S3 2.3445 4,814.83 C3F3S3 2.6342 5,409.77

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3rd+ Episodes, 0 to 13 Therapy Visits C1F1S1 0.6543 1,343.72$ C2F1S1 0.7124 1,463.03$ C3F1S1 0.9399 1,930.24$ C1F1S2 1.0041 2,062.09 C2F1S2 1.0622 2,181.41 C3F1S2 1.2897 2,648.62 C1F1S3 1.2065 2,477.75 C2F1S3 1.2646 2,597.07 C3F1S3 1.4922 3,064.48 C1F1S4 1.4277 2,932.02 C2F1S4 1.4858 3,051.34 C3F1S4 1.7134 3,518.76 C1F1S5 1.6024 3,290.80 C2F1S5 1.6605 3,410.12 C3F1S5 1.8880 3,877.33 C1F2S1 0.7882 1,618.70 C2F2S1 0.8463 1,738.02 C3F2S1 1.0738 2,205.23 C1F2S2 1.1380 2,337.08 C2F2S2 1.1962 2,456.60 C3F2S2 1.4237 2,923.81 C1F2S3 1.3405 2,752.94 C2F2S3 1.3986 2,872.26 C3F2S3 1.6261 3,339.47 C1F2S4 1.5167 3,114.80 C2F2S4 1.6198 3,326.53 C3F2S4 1.8473 3,793.74 C1F2S5 1.7364 3,565.99 C2F2S5 1.7945 3,685.31 C3F2S5 2.0220 4,152.52 C1F3S1 0.9151 1,879.31 C2F3S1 0.9732 1,998.63 C3F3S1 1.2007 2,465.84 C1F3S2 1.2649 2,597.69 C2F3S2 1.3230 2,717.00 C3F3S2 1.5506 3,184.42 C1F3S3 1.4674 3,013.55 C2F3S3 1.5255 3,132.87 C3F3S3 1.7530 3,600.08 C1F3S4 1.6886 3,467.83 C2F3S4 1.7467 3,587.14 C3F3S4 1.9742 4,054.35 C1F3S5 1.8632 3,826.40 C2F3S5 1.9213 3,945.71 C3F3S5 2.1489 4,413.13

3rd+ Episodes, 14 to 19 Therapy Visits


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All Episodes, 20+ Therapy Visits C1F1S1 2.5495 5,235.83$ C2F1S1 2.7632 5,674.70$ C3F1S1 3.0835 6,332.49$ C1F2S1 2.7390 5,625.00 C2F2S1 2.9527 6,063.87 C3F2S1 3.2730 6,721.66 C1F3S1 2.9532 6,064.90 C2F3S1 3.1669 6,503.76 C3F3S1 3.4872 7,161.55







14.12$ 51.00

139.84 207.76 320.37

RatePayment

6 551.00 5

34

12

SeverityLevel

Page 18 of 27



Service AreaCBSACode41180 St. Louis, Missouri-Illinois

Bond County, IL Monroe County, IL St. Charles County, MOCalhoun County, IL St. Clair County, IL St. Louis County, MOClinton County, IL Crawford County, MO Warren County, MOJersey County, IL Franklin County, MO Washington County, MOMacoupin County, IL Jefferson County, MO St. Louis City, MOMadison County, IL Lincoln County, MO

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Payment Amount

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HHRG Code

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HHRG Code

Case-Mix Weight









14.12$ 51.00

139.84 207.76 320.37

RatePayment

6 551.00 5

34

12

SeverityLevel

Page 21 of 27



Service AreaCBSACode44180 Springfield, MO

Christian County, MO Polk County, MODallas County, MO Webster County, MOGreene County, MO

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34

12

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6 551.00



14.12$ 51.00

139.84 207.76 320.37

RatePayment

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Service AreaCBSACode99926 Rural Missouri

Includes all counties not classified elsewhere as urban areas

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Rates by HHRG Code1


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34

12

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6 551.00



14.12$ 51.00

139.84 207.76 320.37

RatePayment

Page 27 of 27

change is here: a new era for medicare home health pps€¦ · medicare claims oasis assessments...

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