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CMS Gutted More Case-Mix Categories for 2017

Posted on Friday, November 4, 2016 5:42 PM

According to the 2017 PPS final rule, come Jan. 1, case-mix value will no longer be offered for two diagnosis categories — gastrointestinal conditions that occur with neuro conditions, and stroke conditions that interact with OASIS dressing items — and one OASIS item, M1400 (Dyspnea).

Though payment impact will vary depending on an agency’s patient mix, home health agencies are likely to see an overall decrease in reimbursement as the result of these case-mix changes, says home health expert Judy Adams, president of Adams Home Care Consulting in Durham, N.C.

These case-mix changes are a result of CMS’ policy to annually recalibrate the case-mix weights so they “reflect, as accurately as possible, current home health resource use and changes in utilization patterns,” the rule states.
CMS created its 2017 case-mix changes based on the CY2015 home health claims data.

Home health agencies express their concern

“The reduced scoring in the clinical and functional dimensions will significantly adversely impact” agencies’ ability to care for certain types of patients, commenters say in the rule.

However, the industry may not be accurately scoring these items to help show CMS that these patients require increased resources, says Brandi Whitemyer, an independent home health and hospice consultant in Canton, Ohio.

It likely comes down to the fact that the industry has failed to score these patients as acutely as it should have, resulting in data that shows these patients don’t require a lot of home health resources, Whitemyer says.

“We know that dyspnea is underreported,” says Ann Rambusch, president of Rambusch3 Consulting in Georgetown, Texas. Data gets skewed when patients aren’t properly assessed for dyspnea, which includes having them get up and move around as opposed to simply asking them if they’re short of breath, she says.

Home health clinicians often paint too rosy a picture of patients’ health status, which can result not only in an inaccurate view of their true acuity and resource use, but also has a negative impact on agencies’ outcomes scores, Rambusch says.

CMS’ plans

CMS intends to release an updated technical report that provides additional research conducted on the Home Health Groupings Model (HHGM). Agencies will have the opportunity to comment on the new report once it’s released.

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For the full article, please see the November 7, 2016 Home Health Line Edition.

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