1. PPS Start-up

Medicare fee-for-service (FFS) patients on service prior to October 1:

For existing Medicare FFS (M0150=1) patients expected to have a continued need for service extending past October 1, HHAs must complete a follow-up (or SOC if patient is admitted during September) OASIS assessment using the new OASIS B-1 (8/2000) data set and encode it using the HAVEN 4.0 software (or other HAVEN-like vendor software) any time during the month of September. Follow-ups due in August may be delayed to September. The first certification period under PPS may span up to 90 days. This is a one-time only deviation (grace period) from the required time points for OASIS collection and reporting.

Follow-up assessments for all Medicare FFS (M0150=1) beneficiaries:
For beneficiaries with a continued need for services, a follow-up assessment using OASIS B-1 (8/2000) must be completed during the last 5 days of the first HHPPS start-up period, that is, during the period November 25 through November 29, 2000 inclusive. This applies to all Medicare PPS beneficiaries, regardless of the original SOC. Subsequent follow-up assessments would be completed for these patients during the last 5 days of the next 60-day period, and so forth until discharge.

1. PPS Start-up (cont'd.)

All new patients after October 1, 2000:
All applicable (skilled care) patients (not just Medicare patients) accepted for care on or after October 1 will be assessed according to the new established time points at 42 CFR 484.55, i.e., a patient whose start of care date is October 15 would be re-assessed for the need to continue services for another certification period during the last 5 days of the current 60-day certification period. In this example, the follow-up assessment would be conducted during the period 12/9/00 through 12/13/00.

2.  a)  First 60-day episode.
b)  New 60-day episode resulting from discharge with all goals met and return to same HHA during the 60-day episode. (PEP Adjustment)

Start of Care:
(M0100) RFA 1 and (M0825) select 0-No or 1-Yes

c) New 60-day episode resulting from transfer to HHA with no common ownership. (PEP Adjustment to original HHA)

PEP Adjustment does not apply if patient transfers to HHA with common ownership during a 60-day episode. Receiving HHA completes OASIS on behalf of transferring HHA. Transferring HHA serves as the billing agent for the receiving HHA. Transferring HHA may continue to serve as the billing agent for receiving HHA or conduct a discharge assessment at end of episode. Receiving HHA starts new episode with Start of Care (if original HHA discharges at end of episode) (M0100) RFA 1 and (M0825) select 0-No or 1-Yes

3. SCIC with intervening Hospital Stay during (but not at the end of ) current episode.

Resumption of Care:
(M0100) RFA 3 and (M0825) is 0-No or 1-Yes (or NA if no SCIC)

Patient was transferred to the hospital and returns during the current episode. HHA completes the Resumption of Care assessment (RFA 3) within 48 hours of the patient’s return, as required. The Resumption of Care assessment (RFA 3) also serves to determine the appropriate new case mix assignment for the SCIC adjustment.

Recommend that for Medicare PPS patients, complete transfer without discharge assessment at the time of transfer.

4. SCIC with intervening Hospital Stay and return home during the last 5 days of an episode (days 56-60).

Resumption of Care:
(M0100) RFA 3 and (M0825) is 0-No or 1-Yes and Follow-Up (M0100) RFA4 and (M0825) is 0-No or 1-Yes

Patient was transferred to the hospital and returns home during the last 5 days of the current episode (days 56-60). HHA completes the Resumption of Care assessment (RFA 3) within 48 hours of the patient’s return, as required. At (M0825) select 0-No or 1-Yes, based on therapy need for the current certification period.

The Follow-up comprehensive assessment (RFA 4) is required during the last five days of the certification period. For payment purposes, this assessment serves to determine the case mix assignment for the subsequent 60-day period. A new Plan of Care is required for the subsequent 60-day episode.

For non-Medicare PPS patients, only a Resumption of Care assessment is necessary if the two time periods overlap.

If no change in case-mix or HHA chooses not to claim a SCIC adjustment, only a ROC assessment is needed, as above. Remember that M0825 will be used to predict therapy need for the next 60 days and should be completed with this in mind.

4. SCIC with intervening Hospital Stay and return home during the last 5 days of an episode (days 56-60) (con’t.)

The Follow-up assessment (using RFA 4 and a 0 – No or 1 – Yes response to M0825) is required in addition to the Resumption of Care assessment if claiming a SCIC adjustment for the last few days of the current episode because the adjusted portion of the current episode and the new 60-day episode are subject to separate payment categories (HHRGs).

5. SCIC without intervening Hospital Stay.

Other Follow-Up Assessment:
(M0100) RFA 5 and (M0825) select 0-No or 1-Yes

6. Subsequent 60-day episode due to the need for continuous home health care after an initial 60 day episode.

Recertification (Follow-up):
(M0100) RFA 4 and (M0825) select 0-No or 1-Yes

7. Patient's inpatient stay extends beyond the end of the current certification period. (Patient returns to agency after day 60 of the previous certification period.)

Start of Care:
(M0100) RFA 1 and (M0825) select 0-No or 1-Yes

When patient returns home, new orders and plan of care are necessary.

At time of transfer to inpatient facility, HHA completes transfer. If transferred without discharging, HHA will need to complete agency discharge paperwork (not OASIS data) before doing a new SOC. HHA starts new episode and completes a new start of care assessment when patient returns home.