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n this issue, we will discuss recent changes by the Centers for Medicare & Medicaid Services (CMS) to requirements for locking Outcome and Assessment Information Set (OASIS) data, highlight the planned 2007 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code changes, and note the CMS announcement in the Federal Register of August 3, 2006 of the proposed increase in payment rates to home healthcare agencies for 2007 and the requirements that must be met to receive the full increase.
       Since 2000, CMS has required home healthcare agencies to encode and lock OASIS data sets within 7 days of their completion, which was usually at the start of care (SOC) date. This lock time was monitored by the state regulators and considered when planning a survey of a home healthcare agency. If lock times were not within the 7 days, agencies would typically be cited for a deficiency during the survey. Effective June 21, 2006, CMS removed the time requirement for transmitting OASIS data sets to the state within 7 days of completion. It now requires transmission to the state within to 30 days of completion. This relaxed requirement reduces the risk of survey deficiencies, but wise home healthcare agencies will still try to lock and transmit OASIS data quickly because it triggers the request for anticipated payment (RAP) release of funds from CMS and prevents any other home healthcare agency from erroneously billing for services within the same time frame.
       Next, let us turn our attention to the 2007 ICD-9-CM diagnostic code changes that will take effect on October 1, 2006. As you may recall, M0230 (Primary Diagnosis) and M0240 (Other Diagnosis) can impact the home healthcare prospect payment received if the diagnosis is orthopedic, diabetic, or neurological. Now there are changes planned for the fall that impact these codes. Under the new 2007 ICD-9-CM coding guidelines, the neurological diagnoses associated with encephalitis must include a fifth digit (eg, 323.xx) in order to be used as a diagnosis. Attention to surgical dressings (ie, V53.80—V53.83) also changed and will require a fourth digit, depending on whether the visits are to change surgical or nonsurgical dressings or to remove staples. New codes for both acute and chronic pain (338.11—338.4) have also been added. It should be noted that implementation of the 2007 ICD-9-CM coding changes on October 1 will not include a grace period. Wise home healthcare agencies are consulting their coding experts now for updates in preparation for the change this fall.
       Our final topic is CMS’s recent proposal to increase Medicare payment rates to home healthcare agencies. On August 3, CMS formally issued a proposed rule that would increase Medicare payment rates to home health agencies by 3.1% in calendar year 2007. The announcement was published in the Federal Register (volume 71, number 149) and, if enacted, will provide an estimated $460 million in additional payments to home healthcare agencies next year.
       This rule implements changes mandated by the Deficit Reduction Act of 2005, which called for a voluntary quality data-reporting process for home healthcare agencies with reduced payments for those that do not submit the data. Under the proposed rule, home healthcare agencies that report the required OASIS-based quality measures will receive a 3.1% increase for 2007. Agencies that do not submit this data will receive only 1.1% of additional payment, which is the full amount minus 2%. The actual percentage of increase will vary slightly depending on geography. Rural home healthcare agencies will receive increases of approximately 3.3%, while some urban agency increases will receive closer to 2.9%. These steps reinforce the stated goal of CMS to shift at least part of the payment toward care that has proven effective in impacting quantifiable patient outcomes.
       This recent announcement is the next step in the implementation of a home health quality initiative by CMS that began with the OASIS requirement in 2000 as a condition for participating in the Medicare program for certified home healthcare agencies. In 2003, CMS began analyzing OASIS data and creating reports comparing agencies in each community. These reports, called Home Health Compare, were made available to the public on the CMS web site, www.medicare.gov, and represented a subset of the OASIS-based quality measures (QMs). They compare how well agencies assist patients in maintaining and/or regaining the functional ability shown to affect the patient’s chances of remaining in his or her home after discharge from the home healthcare agency. Most of the indicators measure how well a person can perform activities of daily living (ADLs), while other indicators note physical status. Two indicators note any hospitalizations or use of emergency care. In 2005, these publically reported indicators were revised based on the recommendations of a panel of experts convened by the private, nonprofit organization known as the National Quality Forum. Its recommendations are reflected in the current, OASIS-based Home Health Compare.
       So what is next? CMS has stated that OASIS will remain in use and continue to be refined, but an increasing percentage of the home healthcare payment will go to home healthcare agencies that are delivering care proven to be effective. CMS is also planning to standardize assessment and quality indicators (QIs) across post-acute care settings, integrate process measures into the mix, and embrace new technologies to support to development of a electronic health record (EHR) for each patient.

Questions and Answers

       Question: A patient is admitted with an open stage 2 pressure ulcer on the right trochanter requiring skilled dressing change and a healed stage 3 pressure ulcer on the coccyx. How do I answer M0460 and M0464?
       Answer: M0460 is asking about the stage of the most problematic pressure ulcer, with M0464 asking about its status. In this case, the stage 3 pressure ulcer is healed, thus the stage 2 for which treatment is being provided is the most problematic one. In this situation, M0460 and M0464 will be answered based on the condition of the stage 2 pressure ulcer located on the right trochanter.
       Question: Related to M0090: If a home healthcare agency’s policy requires personnel knowledgeable of ICD-9-CM coding to complete the diagnosis after the clinician has submitted the assessment, should M0090 be the date that the clinician completed gathering the assessment information or the date the ICD-9-CM code was assigned?
       Answer: The date at M0090 (Date Assessment Completed) should reflect the actual date the assessment is completed by the qualified clinician. The home health agency has the overall responsibility for providing services, assigning ICD-9-CM codes, and billing. CMS expects that each agency will develop its own policies and procedures and implement them throughout the agency in a manner that allows for correction or clarification of records to meet professional standards. It is appropriate for the clinician to enter the medical diagnosis on the comprehensive assessment. The home health agency can assign a qualified coder to determine the correct code based on the written diagnosis. If agency policy allows the assessment to be performed over more than one visit, the date of the last visit (when the assessment is finished) is the appropriate date to record.