New 30-day periods under PDGM

How will Medicare's shorter timeframes affect the F2F encounter and OASIS-D?

Medicare’s switch from standard 60-day to 30-day periods in 2020 is expected to shake up billing processes at the nation’s home care agencies, creating a need for expedited signatures and information collection.

But new 30-day timeframes under the Patient-Driven Groupings Model (PDGM) payment model won’t affect requirements such as the face-to-face encounter or OASIS-D, according to Home Health Solutions Owner and President J’non Griffin.

“CMS will maintain the existing 60-day timing for comprehensive assessments, certifications and recertifications, and Plans of Care,” J’non said.

Under the new payment model, the initial certification of patient eligibility, Plan of Care, and comprehensive assessment will be valid for two 30-day periods of care. Each recertification, care plan update, and comprehensive assessment update will also be valid for two 30-day periods of care.

Here's a more detailed look at how PDGM will affect the F2F and OASIS-D.

F2F Encounter under PDGM

Since Medicare first made specific documentation of the face-to-face encounter between patient and physician a requirement in 2011, home care providers have struggled to get the documentation correct. Inadequate face-to-face documentation still accounts for almost a third of claim denials, according to fourth quarter statistics from Medicare administrator Palmetto GBA.

Is it any wonder agencies have questions about how Medicare’s new 30-day period will impact the F2F requirement?

There's reassuring news, according to J'non. “PDGM won't affect the F2F at all," she said. "The purpose of the F2F is to achieve greater physician accountability in certifying a patient’s home health eligibility and in establishing the patient’s Plan of Care. Neither of things will change under PDGM, so the switch from a 60-day to a 30-day period will not affect F2F requirements."

The F2F encounter will still be required for certification, and the certification will now cover two 30-day periods. The F2F will cover all episodes that follow the initial episode. For example, if there are two recertification episodes after the initial episode, the F2F will stand for all six 30-day billing periods over the three episodes of care. All F2F requirements set forth at §424.22(a)(1)(v) will still need to be met, J’non said.

(Need help with your F2F documentation? Check out "The Dirty Dozen," our $24.99 digital guide highlighting 12 of the most common F2F errors agencies make.)

OASIS-D under PDGM Under PDGM, the patient’s impairment level will play a key role in determining reimbursement. Functional status determined by certain OASIS-D responses is one of the new payment methodology variables which also include a primary diagnosis-driven clinical grouping, admission source and whether the episode of care is the patient’s first 30-day period or a subsequent period.

(Read our blog post about why M items will matter more under PDGM.) Although new 30-day periods will hinge in part on OASIS-D answers, shorter timeframes under PDGM will not impact when OASIS-D is completed, or how often.

“OASIS-D timepoints will remain unchanged under PDGM,” J’non said. “Agencies will still need to complete the OASIS at Start of Care, Follow-up and Discharge or Transfer. The SOC OASIS will be used to determine the patient’s functional status for the first 30-day period of care. If there is no reason to update the assessment, responses to the SOC OASIS will also apply to the second 30-day period of care. Different versions of OASIS-D such as the ROC OASIS or the Follow-Up OASIS may be used to determine the patient’s functional status for additional 30-day periods, such as when there was an acute care hospitalization or significant change in condition."

Here is a look at how OASIS-D responses at various timepoints of care will be used to determine the patient’s functional status under PDGM:

SOC OASIS under PDGM Responses from the SOC OASIS-D will be used to determine the patient’s impairment level for both the first and second 30-day periods under PDGM. The first two 30-day periods are essentially no different from the current 60-day episode of care covered under the SOC OASIS-D.

ROC OASIS under PDGM A hospital admission and resumption of home care during the first 30-day period of home care would change how the patient’s functional status is determined for the second 30-day period.

If the patient was transferred from home health and admitted to the hospital for 24 hours or more, then returned to home health, the home care agency will need to complete a Resumption of Care OASIS-D within 48 hours. In that case, responses to the Resumption of Care OASIS-D would be used to determine the patient’s functional impairment level for the second 30-day period of care.

Follow-up OASIS under PDGM Responses to the Follow-Up OASIS which is completed near the time of recertification will be used for the third and fourth 30-day periods of care. Follow-Up may be used for significant changes occurring 14 days prior to the second 30-day episode. (The Follow-Up OASIS and the Recertification OASIS are the same.) Note that the third 30-day period will start a new 60-day episode.

How is your agency preparing for PDGM? If you're feeling overwhelmed by the complexity of the new payment model and unsure where to begin, we'd like to help. Contact Home Health Solutions today to get started!