The US Centers for Medicare and Medicaid Services (CMS) intends to go full steam ahead with its plans to shift to a new payment system for home health beginning in 2020. The plans are accompanied by other changes that include allowing maintenance therapy to be furnished by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), providing a payment "add on" for rural home health care, and adopting an APTA-supported "notice of admission" requirement to avoid duplicate billing. The new provisions, which include a 1.3% payment increase, are included in CMS’ proposed rule released on July 11.

The biggest shift has been more than a year in the making: a transition to a new payment system known as the Patient-Driven Groupings Model (PDGM). The PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. Instead, the system classifies 30-day care episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. APTA offers extensive information on the new system.

But that's not all in the proposed rule (.pdf). CMS also plans to allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the therapist assistant, the qualified therapist still would be responsible for the initial assessment; plan of care; maintenance program development and modifications; and reassessment every 30 days. CMS believes the change would bring home health in line with other care settings and give home health agencies (HHAs) more latitude in how they allocate resources.

The rule also would phase out the split payment approach that requires HHAs to submit a Request for Anticipated Payment (RAP) at the beginning of the initial episode for 60% of the anticipated final claim payment amount. A final bill for the remaining 40% is submitted at the end of the 60-day episode. RAP submissions are operationally significant, as they establish the beneficiary’s primary HHA by alerting the claims processing system that the beneficiary is under a home health plan of care and home health services are subject to consolidated billing, meaning Medicare makes payment for all home health items and services to the single HHA overseeing the plan of care.

Instead, CMS proposes requiring HHAs to submit a notice of admission to alert the claims processing arm of CMS that a beneficiary is under a home health episode of care. The new system is a direct result of APTA advocacy, which was fueled by members in private practice settings who shared data with the association to help APTA make its case. The change will be phased in next year and fully implemented in 2021.

APTA and its members successfully argued that the split percentage approach is fraught with logistical inefficiencies that often result in confusion for CMS and therapy providers in outpatient settings. The proposal to replace the RAP with the notice of admission, to be submitted within 5 days of the start of care, would be needed to establish the primary HHA so the claims processing system would be alerted to a home health period of care, helping to eliminate the possibility of any lag time between a beneficiary's admission in home health and the HHA's notice of the admission to CMS. This too-common delay trips up outpatient providers who begin treatment (and billing) before CMS knows that the beneficiary has transitioned to home health. CMS describes the change as "an important step in paying responsibly and appropriately for home health services," according to an agency fact sheet on the proposed rule.

As for payment, home health would see an overall 1.3% boost—about $250 million. The increase, initially targeted at 1.5% to comply with the Bipartisan Budget Act of 2018, was decreased by .2% to accommodate a rural add-on policy.

Among other elements of the proposed rule:

SPADE requirements are expanding. CMS is continuing its efforts to increase the range of standardized patient assessment data (SPADE) reported by HHAs. The use of SPADE in home health was instituted to bring HHAs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care settings. The proposed rule would follow through with the expansions, but it also includes requirements for reporting on cognitive function and mental status, comorbidities, and social determinants of health, among other categories. HHAs would be required to report these additional elements beginning in 2022 for admissions and discharges that occur between January 1 and June 30, 2021.

A pain measure would be discontinued. Partially in response to concerns about the potential for overprescription of opioids, CMS is proposing to remove the Improvement in Pain Interfering with Activity Measure (NQF #0177) from the Home Health Quality Reporting Program (HH QRP) beginning in 2022. Under this proposal, HHAs would no longer be required to submit OASIS Item M1242, "Frequency of Pain Interfering with Patient’s Activity or Movement" for quality reporting purposes beginning in 2021.

A pain-related question would be deleted from patient surveys. CMS proposes to remove a patient survey question that asks whether the patient and provider talked about pain in the past 2 months. The question, currently in the "Special Care Issues" composite measure, would be dropped beginning July 1, 2020. Similar to the pain measure being proposed for deletion, the survey question is being eliminated due to concerns about the ways it might influence unnecessary drug prescriptions. The changes are consistent with an earlier CMS decision to eliminate pain-related items from hospital patient surveys.

APTA continues to review the proposed rule and will provide comments to CMS by the September 9 deadline. In the coming weeks, APTA also will post a unique template letter on its Regulatory Take Action webpage for individuals to use to submit their own comments on the proposed rule.