Page 16 - Rehab Orientation Manual 4 04 19-updated_Neat

MEDICARE REIMBURSEMENT

Medicare has covered home care services since 1963.

OASIS – Outcome Assessment Information Set
1. A standardized set of questions which all certified home care agencies must use
2. It is a tool to measure outcomes and determines payment of home care services (PPS)

PPS – Prospective Payment System
1. This system is a fixed sum payment.
2. The payment for all home care services is based on a fixed rate per 60-day episode of care.
Re-certification constitutes a new episode of care.
3. The OASIS assessment provides a HHRG score, which determines the amount of payment
for the episode of care.
a. Individual characteristics are divided into clinically meaningful domains.

HHRG – Home Health Resource Group
1. Responses to specific OASIS questions are organized into 3 domains which produce the
HHRG score:
b. Clinical Severity:
i. Affected primarily by home care diagnosis and wound items
c. Functional Status:
i. Affected by patient’s level of assist for:
1. Bathing
2. Dressing
3. Toileting
4. Ambulation
5. Transfers
d. Service Utilization:
st
i. Episode Timing- what episode of care are they in i.e. 1 , 2 , 3 etc.
rd
nd
ii. Therapy need – the anticipated total number of PT, OT, SLP visits needed
2. Each question has a point value based on the severity.
3. Scores are totaled within each of the 3 respective domains. Clinical and Functional domains
are scored from 1-3 and the Service domain is scored from 1-5 (1 being the least severe to 5
being the most severe).
4. The combination of the 3 domains create a Home Health Resource Group (HHRG) score
i.e. C2F3S3.

PPS has payment variations
1. LUPA: Low Utilization Payment Adjustment- Four visits or less are paid on a per visit basis.
2. PEP: Partial Episode Payment- patient is admitted to Agency A, then elects to transfer to
Agency B. Agency A receives a proportional payment based on length of stay.

Relationship between OASIS information and the Plan of Care (POC)
1. OASIS and POC must match exactly
2. Accuracy is critical - prepare ahead of time; know what to assess
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