Financial Management Aspects of OASIS-C2 mag

1

Financial & Management Aspects

of OASIS‐C2

Presented By:

Melinda A. Gaboury, COS‐C Healthcare Provider Solutions, Inc.

615‐399‐[email protected]

WHAT DOES OASIS‐C2 IMPACT?

• HHRG/HIPPS Code Reimbursement

• 2% Reimbursement Deduction if OASIS is NOT transmitted

• Reimbursement of Non‐Routine Supplies

• Denied claims if OASIS is NOT transmitted and accepted prior to billing the final claim (April 3, 2017)

• State Survey Edits

• Home Health Compare

• Quality of Patient Care Star Rating

• ADR/RA/ZPIC Reviews

• Value Based Purchasing

• Pre‐Claim Review

2

Case‐Mix Reform

–Expanded set of case‐mix variables

• 153 case mix groups

–Additional clinical conditions and co‐morbidities

–Primary and secondary diagnoses

–Manifestation codes

–Four equation model (or is it five?)

• Early versus late episode

• Three therapy thresholds with smoothing

Four Equation Model

• Four Equations

–Early episodes (1st or 2nd) with fewer than 14 therapy visits

–Early episodes (1st or 2nd) with 14 to 19 therapy visits

–Late episodes (3rd or later) with fewer than 14 therapy visits

–Late episodes (3rd or later) with 14 to 19 therapy visits

• Fifth Grouping Step

–Early and late episodes with 20 or more therapy visits

4

OASIS‐C2 Items

Clinical Domain

• M1021 and M1023 and M1025

• M1030 Therapies

• M1200 Vision

• M1242 Pain

• M1311 & M1324 Pressure ulcer

• M1334 Stasis ulcers

• M1342 Surgical wounds

• M1400 Dyspnea

• M1620 Bowel incontinence

• M1630 Ostomy

• M2030 Injectable drugs

Functional Status

• M1810 – Dressing Upper Body

• M1820 – Dressing Lower Body

• M1830 – Bathing

• M1840 ‐Toileting

• M1850 ‐Transferring

• M1860 ‐Ambulation

OASIS‐C2 ITEMS

5

2015‐17 Case Mix Adjustments

• See attachments regarding calculation of the HHRG

• No case mix points at all for Psychiatric Diagnoses

• No case mix points at all for Vision Problems

• No points for a diagnosis for Blindness or Low Vision

• No Points for Injectable Drugs

• No Points of Dyspnea

• Plumonary Diagnoses taken away and then put back in very limited circumstances

• Limited points for Diabetic Diagnoses

• Changes to the Functional Scoring

• Almost impossible to get a F3

• Payment based on patient characteristics

• Payment amount added to case‐mix and wage index adjusted rate

–Episode rate reduction

• NRS Case‐mix

–OASIS: ostomies, catheters, stasis ulcers, therapies at home

–Diagnosis: wounds, burns, post‐op complications

–Ex. Urinary catheter=17 points, ostomy up to 35

NON‐ROUTINE MEDICAL SUPPLIES

6

NON‐ROUTINE MEDICAL SUPPLIES

2017 HHRG

Conversion

C1 = A S1 = K C2 = B S2 = LC3 = C S3 = M

S4 = NF1 = F S5 = PF2 = GF3 = H

1st Digit = Equation

1= Early Episode 0‐13 Therapy

2= Early Episode 14‐19 Therapy

3= Late Episode 0‐13 Therapy

4= Late Episode 14‐19

5= 20+ Therapy

HIPPS 2017

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Medical Supplies:

1 = S

2 = T

3 = U

4 = V

5 = W

6 = X

HIPPS 2016

HHRG = C2F2S2 3rd

Episode, 6 therapy visits and Supply

Category 2

HIPPS Code 2016 = 3BGLT

CALCULATING THE PAYMENT

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Therapy

THERAPY NEED

• (M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech‐language pathology visits combined)? (Enter zero [“000”] if no therapy visits indicated.)• (__ __ __) Number of therapy visits indicated (total of

physical, occupational and speech‐language pathology combined).

• NA ‐Not Applicable: No case mix group defined by this assessment.

Episode Timing

• (M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an “early” episode or a “later” episode in the patient’s current sequence of adjacent Medicare home health payment episodes?

• 1 ‐ Early

• 2 ‐ Later

• UK ‐Unknown

• NA ‐Not Applicable: No Medicare case mix group to be defined by this assessment.

9

MLN Matters® Number: MM9585 Related Change Request (CR) #: CR 9585

Related CR Release Date: October 27, 2016 Effective Date: April 1, 2017

Related CR Transmittal #: R3629CP Implementation Date: April 3, 2017

• Submission of an OASIS assessment is a condition of payment for HH episodes of care. OASIS reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary. In most cases, this 30-day period will have elapsed by the time a 60-day episode of HH services is completed and the HHA submits the final claim for that episode to Medicare. If the OASIS assessment is not found in the QIES upon receipt of a final claim for an HH episode and the receipt date of the claim is more than 30 days after the assessment completion date, Medicare systems will deny the HH claim. (While the regulation requires the assessment to be submitted within 30 days, the initial implementation of this edit will allow 40 days.)

• In denying the claim, Medicare will supply the following remittance messages:

• Group Code of CO

• Claim Adjustment Reason Code 272

NO OASIS – NO PAYMENT

Outcome & ProcessMeasures Source VBP

Home Health Compare

Star Rating

Timely Initiation of Care Multiple

Improvement In Ambulation/Locomotion M1860 X

Improvement In Transferring M1850 X

Improvement In Bathing M1830 X

Improvement In Management of Oral Meds M2020 X

Improvement In Pain M1242 X

Improvement In Dyspnea M1400 X

60‐Day Acute Care Hospitalization Rate Claims X

60‐Day Emergency Department Use Claims X

Discharged to Community M2420 X

Prior ADL/IADL Functioning M1900

Influenza Immunization Received M1046 X

Pneumococcal Vaccine Ever Received M1051 X

Drug Education for all Meds M2015 X

Reason PneumococcalVaccine Not Received M1056

InfluenzaVaccine Data Collection Period M1041

Types and Sources of Assistance M2102

10

3‐8% payment for incentive payments

Not a withholding of funds like some have believed….set aside or allocated for distribution

Phase‐in to 8%

Payment Adjustment Timeline

5 performance years beginning in 2016

2016 Performance = 2018 payment adjustment (3%)





Updates to the rule can be issued at any time beginning with 2019!

One possibility is updating payments every 6 months versus annually!

VALUE BASED PURCHASING (VBP) PILOT

Value Based Purchasing (VBP) Pilot

Measures: 14 Outcome Measures, 3 Process Measures, & 3 New Measures - -- source - OASIS, Claims, HHCAHPS

Outcome Measures

1. Improvement in Ambulation‐Locomotion (OASIS – M1860)

2. Improvement in Bed Transferring (OASIS – M1850)

3. Improvement in Bathing (OASIS – M1830)

4. Improvement in Dyspnea (OASIS – M1400)

5. Discharged to community – (OASIS – M2420)

6. Acute care hospitalization (unplanned within 60 days) – (Claims)

7. Emergency Department use w/o hospitalization – (Claims)

8. Improvement in pain interfering with activity (OASIS – M1242)

9. Improvement in oral medication management (OASIS – M2020)

10. *Prior functioning ADL/IADL (OASIS – M1900)

11. Care of Patients (CAHPS)

12. Communication between providers and patients (CAHPS)

13. Specific care issues (CAHPS)

14. Overall rating of home health care (CAHPS)

15. Willingness to recommend the agency (CAHPS)

*Items REMOVED from VBP Pilot 2017

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VALUE BASED PURCHASING (VBP) PILOT

Process Measures

1. *Influenza vaccine data collection period (OASIS – M1041)

2. Influenza immunization received (OASIS – M1046)

3. Pneumococcal vaccine ever received (OASIS – M1051)

4. *Reason Pneumococcal vaccine not received (OASIS – M1056)

5. Drug education for all medications (OASIS – M2015)

6. *Care management: Types and sources of assistance (OASIS – M2102)

*Items REMOVED from VBP Pilot 2017

Quality of Patient Care Star Rating

• The quality of patient care star rating is a summary measure of agency performance based on how well a home health agency performs on 9 of the individual quality measures reported on Home Health Compare. These 9 measures include:

• Process of care measures – how often the agency:

• Initiated patient care in a timely manner

• Provided patient/caregiver drug education on all medications

• Ensured patients received flu vaccine for the current season

• Outcome of care measures – how often the patient:

• Got better at walking or moving around

• Got better at getting in and out of bed

• Got better at bathing themselves

• Was able to engage in activity with less pain

• Experienced less shortness of breath

• Required acute care hospitalization

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HHGM – Home Health Payment Groupings

What is HHGM? It is a potential refinement of the Home Health Resource Groups (HHRG) reimbursement methodology. It will eliminate therapy visits being utilized as a factor in determining the resource use (case‐mix weight) in home health.

The model is made up of 128 payment groups defined by 5 categories:

• Timing – new 30 day periods:

• first 30 days is “early”

• all other 30 day periods are “late”

• Referral Source – community or institutional

• Clinical Groupings – 6 groups based on primary diagnosis

• Functional Level – high, medium or low ‐ based on 8 OASIS items

• Comorbidity – “yes” or “no” ‐ based on secondary diagnosis

• Technical Report:

https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf

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Key Questions to Ask?

• Admission Nurses vs. Everyone Completing OASIS

• Do you have per visit or per hour or salary?

• How much effort is put into review of the

OASIS documentation?

• Are the coders fully educated?

• How often is OASIS education provided?

• Is someone dedicated to reviewing

outcomes?

• Is there a strategic plan to move you to

where you need to be?

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Thank You For Coming!

Melinda A. Gaboury, COS‐CHealthcare Provider Solutions, Inc.

810 Royal Parkway, Suite 200

Nashville, TN 37214

615‐399‐7499

www.healthcareprovidersolutions.com

CMS-1648-F 23

an episode’s clinical score. The points for the functional variables are added together to

determine an episode’s functional score.

TABLE 3: Case-Mix Adjustment Variables and Scores

Case-Mix Adjustment Variables and Scores

Episode number within sequence of adjacent episodes 1 or 2 1 or 2 3+ 3+

Therapy visits 0-13 14+ 0-13 14+

EQUATION: 1 2 3 4

CLINICAL DIMENSION

1 Primary or Other Diagnosis = Blindness/Low Vision . . . .

2 Primary or Other Diagnosis = Blood disorders . 2 . .

3 Primary or Other Diagnosis = Cancer, selected benign neoplasms . 5 . 5

4 Primary Diagnosis = Diabetes . 4 . 2

5 Other Diagnosis = Diabetes 1 . . .

6

Primary or Other Diagnosis = Dysphagia

AND Primary or Other Diagnosis = Neuro 3 – Stroke

2 18 2 12

7


AND M1030 (Therapy at home) = 3 (Enteral)

2 6 . 6

8 Primary or Other Diagnosis = Gastrointestinal disorders . . . .

9

Primary or Other Diagnosis = Gastrointestinal disorders

AND M1630 (ostomy)= 1 or 2

. 7 . .

10


AND Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis,

OR Neuro 2 - Peripheral neurological disorders, OR Neuro 3 - Stroke,

OR Neuro 4 - Multiple Sclerosis

. . . .

11 Primary or Other Diagnosis = Heart Disease OR Hypertension 1 2 . 2

12 Primary Diagnosis = Neuro 1 - Brain disorders and paralysis 2 12 7 12

13

Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis

AND

M1840 (Toilet transfer) = 2 or more

. 3 . 3

14


OR Neuro 2 - Peripheral neurological disorders

AND M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

2 3 1 3

15 Primary or Other Diagnosis = Neuro 3 - Stroke 3 12 2 5

16

Primary or Other Diagnosis = Neuro 3 - Stroke

AND

M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

. . . .

17


AND

M1860 (Ambulation) = 4 or more

. . . .

18

Primary or Other Diagnosis = Neuro 4 - Multiple Sclerosis AND AT

LEAST ONE OF THE FOLLOWING:

M1830 (Bathing) = 2 or more

OR


OR

3 7 6 11

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M1850 (Transferring) = 2 or more

OR


19

Primary or Other Diagnosis = Ortho 1 - Leg Disorders or Gait

Disorders

AND M1324 (most problematic pressure ulcer stage)= 1, 2, 3 or 4

8 1 7 .

20

Primary or Other Diagnosis = Ortho 1 - Leg OR Ortho 2 - Other

orthopedic disorders

AND M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

3 . 3 4

21 Primary or Other Diagnosis = Psych 1 – Affective and other

psychoses, depression . . . .

22 Primary or Other Diagnosis = Psych 2 - Degenerative and other

organic psychiatric disorders . . . .

23 Primary or Other Diagnosis = Pulmonary disorders . . . 1

24 Primary or Other Diagnosis = Pulmonary disorders AND

M1860 (Ambulation) = 1 or more . 1 . .

25 Primary Diagnosis = Skin 1 -Traumatic wounds, burns, and post-

operative complications 4 20 7 18

26 Other Diagnosis = Skin 1 - Traumatic wounds, burns, post-operative

complications 7 15 8 15

27

Primary or Other Diagnosis = Skin 1 -Traumatic wounds, burns, and

post-operative complications OR Skin 2 – Ulcers and other skin

conditions

AND

M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

3 . . .

28 Primary or Other Diagnosis = Skin 2 - Ulcers and other skin conditions 2 17 8 17

29 Primary or Other Diagnosis = Tracheostomy 4 17 4 17

30 Primary or Other Diagnosis = Urostomy/Cystostomy . 18 . 13

31 M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) . 17 6 17

32 M1030 (Therapy at home) = 3 (Enteral) . 16 . 9

33 M1200 (Vision) = 1 or more . . . .

34 M1242 (Pain)= 3 or 4 3 . 2 .

35 M1311 = Two or more pressure ulcers at stage 3 or 41 5 10 5 10

36 M1324 (Most problematic pressure ulcer stage)= 1 or 2 4 19 7 16


38 M1334 (Stasis ulcer status)= 2 4 15 8 15


40 M1342 (Surgical wound status)= 2 2 7 5 11

41 M1342 (Surgical wound status)= 3 . 6 4 9

42 M1400 (Dyspnea) = 2, 3, or 4 . . . .

43 M1620 (Bowel Incontinence) = 2 to 5 . 4 . 3

44 M1630 (Ostomy)= 1 or 2 4 12 2 8

45 M2030 (Injectable Drug Use) = 0, 1, 2, or 3 . . . .

FUNCTIONAL DIMENSION

46 M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3 1 . 1 .

47 M1830 (Bathing) = 2 or more 6 5 5 2

48 M1840 (Toilet transferring) = 2 or more 1 2 . .

1M1308 ‘Current Number of Unhealed Pressure Ulcers at Each Stage or Unstageable’ will be changed to M1311 ‘Current

Number of Unhealed Pressure Ulcers at Each Stage’ under the new OASIS C2 format, effective January 1, 2017.

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CMS-1648-F 23

an episode’s clinical score. The points for the functional variables are added together to

determine an episode’s functional score.

TABLE 3: Case-Mix Adjustment Variables and Scores


Episode number within sequence of adjacent episodes 1 or 2 1 or 2 3+ 3+

Therapy visits 0-13 14+ 0-13 14+

EQUATION: 1 2 3 4

CLINICAL DIMENSION

1 Primary or Other Diagnosis = Blindness/Low Vision . . . .

2 Primary or Other Diagnosis = Blood disorders . 2 . .

3 Primary or Other Diagnosis = Cancer, selected benign neoplasms . 5 . 5

4 Primary Diagnosis = Diabetes . 4 . 2

5 Other Diagnosis = Diabetes 1 . . .

6


AND Primary or Other Diagnosis = Neuro 3 – Stroke

2 18 2 12

7


AND M1030 (Therapy at home) = 3 (Enteral)

2 6 . 6

8 Primary or Other Diagnosis = Gastrointestinal disorders . . . .

9


AND M1630 (ostomy)= 1 or 2

. 7 . .

10


AND Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis,

OR Neuro 2 - Peripheral neurological disorders, OR Neuro 3 - Stroke,

OR Neuro 4 - Multiple Sclerosis

. . . .

11 Primary or Other Diagnosis = Heart Disease OR Hypertension 1 2 . 2

12 Primary Diagnosis = Neuro 1 - Brain disorders and paralysis 2 12 7 12

13


AND


. 3 . 3

14


OR Neuro 2 - Peripheral neurological disorders

AND M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

2 3 1 3

15 Primary or Other Diagnosis = Neuro 3 - Stroke 3 12 2 5

16


AND

M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

. . . .

17


AND


. . . .

18

Primary or Other Diagnosis = Neuro 4 - Multiple Sclerosis AND AT

LEAST ONE OF THE FOLLOWING:

M1830 (Bathing) = 2 or more

OR


OR

3 7 6 11

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M1850 (Transferring) = 2 or more

OR


19

Primary or Other Diagnosis = Ortho 1 - Leg Disorders or Gait

Disorders

AND M1324 (most problematic pressure ulcer stage)= 1, 2, 3 or 4

8 1 7 .

20

Primary or Other Diagnosis = Ortho 1 - Leg OR Ortho 2 - Other

orthopedic disorders

AND M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

3 . 3 4

21 Primary or Other Diagnosis = Psych 1 – Affective and other

psychoses, depression . . . .

22 Primary or Other Diagnosis = Psych 2 - Degenerative and other

organic psychiatric disorders . . . .

23 Primary or Other Diagnosis = Pulmonary disorders . . . 1

24 Primary or Other Diagnosis = Pulmonary disorders AND

M1860 (Ambulation) = 1 or more . 1 . .

25 Primary Diagnosis = Skin 1 -Traumatic wounds, burns, and post-

operative complications 4 20 7 18

26 Other Diagnosis = Skin 1 - Traumatic wounds, burns, post-operative

complications 7 15 8 15

27

Primary or Other Diagnosis = Skin 1 -Traumatic wounds, burns, and

post-operative complications OR Skin 2 – Ulcers and other skin

conditions

AND

M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

3 . . .

28 Primary or Other Diagnosis = Skin 2 - Ulcers and other skin conditions 2 17 8 17

29 Primary or Other Diagnosis = Tracheostomy 4 17 4 17

30 Primary or Other Diagnosis = Urostomy/Cystostomy . 18 . 13

31 M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) . 17 6 17

32 M1030 (Therapy at home) = 3 (Enteral) . 16 . 9

33 M1200 (Vision) = 1 or more . . . .

34 M1242 (Pain)= 3 or 4 3 . 2 .

35 M1311 = Two or more pressure ulcers at stage 3 or 41 5 10 5 10





40 M1342 (Surgical wound status)= 2 2 7 5 11

41 M1342 (Surgical wound status)= 3 . 6 4 9

42 M1400 (Dyspnea) = 2, 3, or 4 . . . .

43 M1620 (Bowel Incontinence) = 2 to 5 . 4 . 3

44 M1630 (Ostomy)= 1 or 2 4 12 2 8

45 M2030 (Injectable Drug Use) = 0, 1, 2, or 3 . . . .

FUNCTIONAL DIMENSION

46 M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3 1 . 1 .

47 M1830 (Bathing) = 2 or more 6 5 5 2

48 M1840 (Toilet transferring) = 2 or more 1 2 . .

1M1308 ‘Current Number of Unhealed Pressure Ulcers at Each Stage or Unstageable’ will be changed to M1311 ‘Current

Number of Unhealed Pressure Ulcers at Each Stage’ under the new OASIS C2 format, effective January 1, 2017.

34

CMS-1648-F 25


49 M1850 (Transferring) = 2 or more 3 1 2 .

50 M1860 (Ambulation) = 1, 2 or 3 7 . 4 .

51 M1860 (Ambulation) = 4 or more 8 9 6 8

Source: CY 2015 Medicare claims data for episodes ending on or before December 31, 2015 (as of June 30, 2016) for which we

had a linked OASIS assessment. LUPA episodes, outlier episodes, and episodes with SCIC or PEP adjustments were excluded.

Note(s): Points are additive; however, points may not be given for the same line item in the table more than once.

In updating the four-equation model for CY 2017, using complete 2015 data as of June 30, 2016

(the last update to the four-equation model for CY 2016 used 2014 data), there were few changes

to the point values for the variables in the four-equation model. These relatively minor changes

reflect the change in the relationship between the grouper variables and resource use between

2014 and 2015. The CY 2017 four-equation model resulted in 119 point-giving variables being

used in the model (as compared to the 124 point-giving variables for the 2016 recalibration). Of

those 119 variables, the CY 2017 four-equation model had 113 variables that were also present

in the CY 2016 four-equation model. Of those 113 variables, the points for 33 variables

increased in the CY 2017 four-equation model compared to CY 2016 and the points for 33

variables decreased in the CY 2017 4-equation model compared to CY 2016. There were 47

variables with the same point values between CY 2016 and CY 2017. There were 6 variables

that were added to the model in CY 2017 that weren’t in the model in CY 2016. Also, 11

variables were in the model in CY 2016 but dropped in CY 2017 due to the absence of additional

resources associated with these variables. In other words, these variables are not associated with

additional resources beyond what is captured by the other case-mix adjustment variables in the

regression model.

Step 2: Re-define the clinical and functional thresholds so they are reflective of the new

points associated with the CY 2017 four-equation model. After estimating the points for each of

the variables and summing the clinical and functional points for each episode, we look at the

distribution of the clinical score and functional score, breaking the episodes into different steps.

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CMS-1648-F 26

The categorizations for the steps are as follows:

● Step 1: First and second episodes, 0-13 therapy visits.

● Step 2.1: First and second episodes, 14-19 therapy visits.

● Step 2.2: Third episodes and beyond, 14-19 therapy visits.

● Step 3: Third episodes and beyond, 0-13 therapy visits.

● Step 4: Episodes with 20+ therapy visits

We then divide the distribution of the clinical score for episodes within a step such that a

third of episodes are classified as low clinical score, a third of episodes are classified as medium

clinical score, and a third of episodes are classified as high clinical score. The same approach is

then done looking at the functional score. It was not always possible to evenly divide the

episodes within each step into thirds due to many episodes being clustered around one particular

score.2 Also, we looked at the average resource use associated with each clinical and functional

score and used that to guide where we placed our thresholds. We tried to group scores with

similar average resource use within the same level (even if it meant that more or less than a third

of episodes were placed within a level). The new thresholds, based off of the CY 2017

four-equation model points are shown in Table 4.

TABLE 4: CY 2017 Clinical and Functional Thresholds

1st and 2nd Episodes 3rd+ Episodes All Episodes

0 to 13

therapy

visits

14 to 19

therapy

visits

0 to 13

therapy

visits

14 to 19

therapy

visits

20+ therapy

visits

Grouping Step: 1 2.1 3 2.2 4

Equation(s) used to

calculate points:

(see Table 3) 1 2 3 4 (2&4)

2 For Step 1, 49.2 percent of episodes were in the medium functional level (All with score 14). For Step 2.1, 70.7 percent of episodes were in the low functional level (Most with score 5 and 6).

For Step 2.2, 78.7 percent of episodes were in the medium functional level (Most with score 2).

For Step 3, 51.0 percent of episodes were in the medium functional level (Most with score 10). For Step 4, 51.2 percent of episodes were in the medium functional level (Most with score 5 and 6).

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CMS-1648-F 27

Dimension

Severity

Level

Clinical C1 0 to 1 0 to 1 0 to 1 0 to 1 0 to 3

C2 2 to 3 2 to 7 2 2 to 9 4 to 16

C3 4+ 8+ 3+ 10+ 17+

Functional F1 0 to 13 0 to 6 0 to 6 0 to 1 0 to 2

F2 14 7 to 13 7 to 10 2 to 9 3 to 6

F3 15+ 14+ 11+ 10+ 7+

Step 3: Once the clinical and functional thresholds are determined and each episode is

assigned a clinical and functional level, the payment regression is estimated with an episode’s

wage-weighted minutes of care as the dependent variable. Independent variables in the model

are indicators for the step of the episode as well as the clinical and functional levels within each

step of the episode. Like the four-equation model, the payment regression model is also

estimated with robust standard errors that are clustered at the beneficiary level. Table 5 shows

the regression coefficients for the variables in the payment regression model updated with CY

2015 data. The R-squared value for the payment regression model is 0.4929 (an increase from

0.4822 for the CY 2016 recalibration).

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CMS-1648-F 30

weights is equal to 1.0000.4 This last step creates the CY 2017 case-mix weights shown in Table

6.

TABLE 6: Final CY 2017 Case-Mix Payment Weights

Payment

Group Step (Episode and/or Therapy Visit Ranges)

Clinical and

Functional

Levels

(1 = Low;

2 = Medium;

3= High)

Final CY

2017

Case-Mix

Weights

10111 1st and 2nd Episodes, 0 to 5 Therapy Visits C1F1S1 0.5857

10112 1st and 2nd Episodes, 6 Therapy Visits C1F1S2 0.7168





































4When computing the average, we compute a weighted average, assigning a value of one to each normal episode and a value equal to the episode length divided by 60 for PEPs.

1

CMS-1648-F 31

Payment


Clinical and

Functional

Levels

(1 = Low;

2 = Medium;

3= High)

Final CY

2017

Case-Mix

Weights



































22111 3rd+ Episodes, 14 to 15 Therapy Visits C1F1S1 1.2523














2

CMS-1648-F 32

Payment


Clinical and

Functional

Levels

(1 = Low;

2 = Medium;

3= High)

Final CY

2017

Case-Mix

Weights















30112 3rd+ Episodes, 6 Therapy Visits C1F1S2 0.6333


































3

CMS-1648-F 33

Payment


Clinical and

Functional

Levels

(1 = Low;

2 = Medium;

3= High)

Final CY

2017

Case-Mix

Weights











40111 All Episodes, 20+ Therapy Visits C1F1S1 1.7552









To ensure the changes to the HH PPS case-mix weights are implemented in a budget

neutral manner, we apply a case-mix budget neutrality factor to the CY 2017 national,

standardized 60-day episode payment rate (see section III.C.3. of this final rule). The case-mix

budget neutrality factor is calculated as the ratio of total payments when the CY 2017 HH PPS

grouper and case-mix weights (developed using CY 2015 claims data) are applied to CY 2015

utilization (claims) data to total payments when the CY 2016 HH PPS grouper and case-mix

weights (developed using CY 2014 claims data) are applied to CY 2015 utilization data. Using

CY 2015 claims data as of June 30, 2016, we calculated the case-mix budget neutrality factor for

CY 2017 to be 1.0214.

The following is a summary of the comments and our responses to comments on the CY

2017 case-mix weights.

4

Medicare Home Health PPS Non‐Routine Supply Severity Calculation ‐ 2017

Description Score

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 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, burns and post‐operative complications 19

16 Other diagnosis = Traumatic wounds, burns and post‐operative complications 8

17 Primary or other diagnosis = Z code, Cystostomy care 16

18 Primary or other diagnosis = Z code, Tracheostomy care 23

19 Primary or other diagnosis = Z code, Urostomy care 24

20 OASIS M1322 = 1 or 2 pressure ulcers, stage 1 4

21 OASIS M1322 = 3+ pressure ulcers, stage 1 6

22 OASIS M1311 = 1 pressure ulcer, stage 2 14

23 OASIS M1311 = 2 pressure ulcers, stage 2 22










33 OASIS M1311e = 1 (unobserved pressure ulcer(s)) 17

34 OASIS M1332 = 2 (2 stasis ulcers) 6

35 OASIS M1332 = 3 (3 stasis ulcers) 12

36 OASIS M1332 = 4 (4+ stasis ulcers) 21

37 OASIS M1330 = 1 (unobservable stasis ulcers) 9

38 OASIS M1334 = 1 (status of most problematic stasis ulcer: fully granulating) 6

39 OASIS M1334 = 2 (status of most problematic stasis ulcer: early/partial granulation) 25

40 OASIS M1334 = 3 (status of most problematic stasis ulcer: not healing) 36

41 OASIS M1342 = 2 (status of most problematic surgical wound: early/partial granulation) 4

42 OASIS M1342 = 3 (status of most problematic surgical wound: not healing) 14

43 OASIS M1630 = 1(ostomy not related to inpt stay/no regimen change) 27

44 OASIS M1630 = 2 (ostomy related to inpt stay/regimen change) 45

45 Any `Selected Skin Conditions` (rows 1‐42 above) AND M1630 = 1 (ostomy not related to in 14

46 Any `Selected Skin Conditions` (rows 1‐42 above) AND M1630 = 2 (ostomy related to inpt s 11

47 OASIS M1030 (Therapy at home) = 1 (IV/Infusion) 5

48 OASIS M1610 = 2 (patient requires urinary catheter) 9

49 OASIS M1620 = 4 or 5 (bowel incontinence, daily or >daily) 10

Financial Management Aspects of OASIS-C2 mag

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