Presentations abound on what is changing and staying the same with PDGM next year. This article about the changes will focus on strategies to deploy, either within a current EMR if it is capable, or outside of it, that can ensure ongoing financial success. It was authored by KanTime staff, with expert input from OperaCare.
There are EMRs and Clinical Process Optimization methodologies available that support sub-5-day RAP submissions. Some are configurable by payor to maximize 2021 compliance and revenue generation. We will speak to some of those methodologies that can be implemented with any EMR. We will also suggest processes your EMR should be planning to implement.
Interpretations of the 2021 PDGM final rule vary. It is important to point out the sources -- dated presentations, documents, and conversations -- on which our interpretations are base.
Medicare HHAs accredited in 2020 have been dealing with the zero pay RAP all year. Established agencies experienced a 50% RAP rate reduction in 2020, from 40 percent to 20 percent, to ease the transition into zero percent. CMS's intends this change, with the accompanying 5-day penalty, which we will get into in a moment, to accomplish the following:
Cash flow implications of the removal of anticipated payments will require a shift in funding operations for established HHAs. The need to adapt will be compounded by new timeliness requirements and the penalties imposed to encourage compliance with them. Ignoring this change and not optimizing operations to eliminate the possibility of incurring a payment penalty could well result in a financial failure as these penalties can indeed be significant. Currently published average RAP submission time is 12 to 14 days. If this is the average, that means many providers submit far later. CMS wants it to be no more than five days, not on average but as a ceiling. Let's look at the impact on revenue a late submission will have under the new rule.
30-day HHRG: $2,000.00
RAP (or NOA) submitted on 1/7/2021 (day 6*)
6 ÷ 30 x $2,000.00 = $400.00; $2,000.00 - $400 = $1,600.00
30 claims (per day? week? month?) extrapolates to $12,000 loss
*Days 1-5, no penalty; day 6 is not one day late but 6 days late.
Since the calculation considers the day of Admission, the day the assessment visit is performed, also called the "From date," as day zero, a one-day late scenario where the RAP is submitted on day six instead of day five results in a 20% reduction in payment. This is because the penalty is calculated from day one, not from day five, as one might assume.
Therefore, today's average provider, who submits RAPs in 14 days, will receive a nearly 50 percent payment reduction, for every episode. Some additional inclusions in this rule are:
A clarification made after some early PDGM webinars were published has led to some confusion about whether a submitted RAP must also be accepted to avoid penalty. Initial CMS documents, including the Code of Federal Regulations and MLN 11855, stated the RAP must be "submitted" only, specifically by 5:00 pm in the time zone of the regional MAC, to avoid a penalty.
However, Change Request 11855 states:
"A timely-filed RAP is submitted to the A/B MAC (HHH) and accepted by the MAC within five calendar days after the "From the date" of a HH period of care. While a timely-filed RAP is submitted to and accepted by the Medicare contractor/MAC within five calendar days after the From date, posting to the CWF may not occur within that same time frame. The date of posting to the CWF is not a reflection of whether the RAP is considered timely-filed."
Through multiple conversations with Palmetto GBA, the authors have determined that their expressed opinion is that the RAP must be "submitted and accepted" but not "approved and processed."
Fortunately, the two primary reasons for a RAP to be rejected or put in "T" status are an invalid HIPPS code and an invalid or duplicated secondary diagnosis. There is no longer a requirement for a secondary diagnosis on the RAP under the new rule, and the submitted HIPPS code no longer has to be the one determined by the OASIS data if the assessment is not yet completed.
The entered HIPPS code can be any valid HIPPS code, one that is often referred to as a "place holder." Although there are other far less common reasons for a RAP to be rejected, such as overlapping services, the likelihood of an adequately configured RAP being rejected has been dramatically reduced.
Acceptance information can most rapidly be determined when submitted through DDE, but the information will also return within the 277 advice files. If a third-party vendor is being used for submission, spend the due diligence upfront to determine what that notification timeline is and plan accordingly.
Recommendation: If a submitted RAP is not accepted, submit a new RAP with your corrections. This is much faster than waiting for the RAP to become correctable when in RTP. The new RAP will not be duplicated as the initial RAP will not have processed because it was not accepted.
Below is an illustration of the significant reductions in what is required to be completed and submitted before releasing a valid RAP in 2021.
|WHAT IS REQUIRED ||WHAT IS NOT REQUIRED |
|1) The appropriate physician's written or verbal order that sets out the services required for the initial visit has been received and documented, as required in regulation at 42 CFR 484.60(b) and 42 CFR 409.43(d)|
|2) The initial visit within the 60-day certification period must have been made and the individual admitted to home health care.|
|3) Primary diagnosis code, valid HIPPS|| |
Low Utilization Payment Adjustments have not changed beyond the above content changes for RAPs in general. The same stipulation applied in 2020, where RAPs are not required for LUPAs, continues in 2021. However, there are some new potential pitfalls to consider. If no RAP is submitted, and your agency then later provides utilization over the LUPA threshold, this would result in the need to submit a RAP, which would be late and subject to the penalty. If a RAP is submitted late for a LUPA, any visits performed before the submission will not be reimbursed.
The best practice will be to submit RAPs within the 5-day window on all periods of care. But if you are late submitting a RAP for a LUPA episode that is certain to remain a LUPA, it may be best not to submit the RAP at all. Knowledge is indeed power. As the agency provider, you will have to decide which penalty to risk in these situations.
What to do if the RAP is Submitted Late
There is a process included in the final rule for situations where a RAP is submitted late inclusive of acceptable "Exceptional Circumstances" that may drive a RAP to be submitted late and out of the agency's control cause the MAC to waive the penalty.
CMS has directed the MACs to look for documentation regarding the reason for a requested waiver of the late submission penalty in the remarks section of the final claim if a KX modifier is added to the HIPPS code reported on revenue code 0023 line of the final claim. The best EMRs will be configurable to add the KX modifier whenever a RAP is submitted late and require your staff to document the remarks information at the time of late RAP submission.
By configuring this methodology, if your EMR supports it, the justification for late submission will be available to be "automagically" added to the final claim. This will prevent your staff from re-investigating and determining proper reasoning at the time of final claims submission. Remember, if this information is missing or incomplete, the MAC will request more information, which, of course, will hold up your claim and may reduce payment. Some examples of possible remarks examples are:
Of course, there is no guarantee that all of these sample remarks will result in a waiver of the penalty, but if you do not ask, you do not get it. If you know the patient is potentially under another agency's RAP claim, add condition code 47 to the RAP to prompt the MAC to override the existing claim.
Submitting Both RAPs for your Episode
CMS encourages agency providers to bill both 30-day RAPs for a 60-day certification period upfront if there is sufficient evidence to expect the patient to require more than the initial period of 30-days of care. All long-term LUPA patients should fit this criterion. Here is the exact quote from the regulation:
"In instances where the plan of care dictates multiple 30-day periods of care will be required to treat the beneficiary effectively, HHAs will be allowed to submit RAPs for both the first and second 30-day periods of care (for a 60-day certification) at the same time to help further reduce provider administrative burden (84 FR 60549)."
When an agency submits RAPs for both the first and second billing periods inside a 60-day episode of care, the service date for all subsequent periods will be the first date of the prospective period. NOTE: "from date" – not the first billable visit date. We were also able to gain from Palmetto GBA on 11/19/20 that "all subsequent periods" is defined as any period after the first period and would include recertifications. Additionally, quoted from Palmetto GBA, since there is no longer any payment associated with the RAPs, they will no longer auto-cancel, and agencies are not required to cancel RAPs that were submitted but not used.
This has been interpreted to mean agencies can standardize submitting both RAPs every time without concern for remembering to cancel those that are not used. Your EMR should enable this option to be configured in your organization if you choose to follow this process.
HIPPS Code Match between RAP and Final Claim and Revenue Projection
The HIPPS code utilized for the RAP must still match the one used for the final claim. Although this is not a new requirement, the added complexity that allows any valid HIPPS code to be used as a place holder when the assessment and OASIS data set is not yet complete could cause challenges for your EMR and result in rejected final claims.
Additionally, if the submitted RAP is using a "place holder" valid HIPPS code that is different than that generated by the OASIS data in the assessment, how will your agency then predict revenue and calculate service utilization? Your EMR should handle this change for you by utilizing either the assessment HIPPS code for the RAP if it is locked prior to RAP submission or a valid placeholder HIPPS code if it is not.
Further, your EMR should always use only the assessment generated HIPPS code whenever that assessment is completed and locked to generate your revenue projections and facilitate accurate determination of service utilization.
Lastly, regardless of when the assessment is completed and locked, your EMR should always use only the HIPPS code utilized in the RAP as the final claim HIPPS code. Remember, CMS will calculate their own HIPPS code from the Common Working File (CWF) and your submitted OASIS and final claim.
To avoid all this confusion and potential lost revenue, best practice would be to complete the OASIS assessment prior to the 5-day deadline. An EMR aware of this would use the OASIS HIPPS code for the RAP.
The < 5-Day RAP
Consistent 5-day or less RAP submission can be accomplished but it requires collaboration between QA and field clinician at the time of assessment. It cannot be done using the more common approach of finalizing QA and corrections several days -- or weeks -- after the assessment visit. Many agencies utilizing the time of assessment collaboration process are reliably submitting their RAPs right now in 24-48 hours. It can be done, with the right tools and processes in place.
We firmly believe our significant efforts in direct outreach to Palmetto GBA and other trusted consultants, as well as long hours reading the regulations, have resulted in the best and most accurate guidance available at the time of this writing. We urge each of you to take the time to review and modify your processes as needed and ask the hard questions of your EMR to make sure you are ready for these changes. With a properly designed EMR and implementation of clinical/QA optimization, your agency should not only survive but thrive under PDGM 2021.
Medicare Claims Processing Manual, Chapter 10,
Change Request 11855
Medicare and Medicaid Programs; CY 2020 Home Health Prospective Payment System Rate Update, Final rule.
KanTime Healthcare Software is an American-based healthcare technology company that is the fastest-growing post-acute software provider in the nation, with over 500,000 patients, 120,000 users, $5.1B in processed claims, and 32M annual visits. KanTime provides cloud-based enterprise software to home health, hospice, pediatric, private duty, and consumer directed services agencies. KanTime software operates seamlessly on any point of care device, both online and offline. Additionally, KanTime offers robust business intelligence tools that allow upper-level management to drill down into various clinical, financial, and operational KPIs.
OperaCare creates quality assurance systems capable of producing 48-hour RAP submissions, backed by a 100% money-back guarantee.
©2020 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Home Care Technology: The Rowan Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org