RAP 2021 Confusion RAP 2021 Understanding

Understanding the Change

Objectives

• The participant will review the background of the 2021 regulatory changes and understand how this can impact their bottom line.

• The participant will review how technology can ensure a successful

transition for 2021.

• The participant will explore how to tighten operational process to prevent

RAP penalties in 2021.

Evolution of the RAP

As an operator, I have had to make so many changes!

Can we discuss those changes related to RAP and Revenue Cycle Management?

• Establish a home health episode in the

Common Working File (CWF)

• Billing period matches episode (60 days)

• RAP at the start of episode

• Initial episode 60/40 split payment

• Subsequent episodes 50/50 split payment

• RAP submission requirements

• OASIS completed

• Physician orders received

• Plan of care sent

• First visit completed

PPS and Revenue Cycle Management

• Establish a home health episode in the CWF

• 30-day periods of care and 60-day episode

• RAP/Final submitted for each period of care

• All periods of care see a 20/80 split payment

• Primary diagnosis can change in the second

period of care

• RAP submission requirements

– OASIS completed (first only)

– Physician orders received (first only)

– Plan of care sent (first only)

– First visit completed (both periods)

PDGM and Revenue Cycle Management

What is Next?

Can you tell me what is next and where I can go for resources?

I am confused about what 2021 means for me.

Changes 2021 and Beyond

• Establish period of care

• No split percentage payments

• Non-timely submission penalty• RAP accepted in the CWF to qualify

• Five days from start of care on initial

• Five days from start of second period of

care

• 1/30th reduction for each day late

• No LUPA payment before prior to RAP

• January 1, 2022, the RAP will be replaced

with a Notice of Admission (NOA)

The official instruction, CR 11855, issued to your MAC

regarding this change, is available at:https://www.cms.gov/files/document/r10369CP.pdf

If you have questions, your MACs may have more

information. Find their website at:https://www.cms.gov/Medicare/Medicare-

Contracting/FFSProvCustSvcGen/MAC-Website-List

https://www.cms.gov/files/document/MM11855.pdf

Start of Episode

End of Episode

RAP Revenue Cycle Management

• Cash flow considerations

• Revenue recognition

• Avoiding penalties and revenue

reductions

• Submission requirements reduced

• No more rejected RAPs and

resubmissions

• Reduced posting

PPS

PDGM 2020

PDGM 2021

• RAP Reduction

– After the fifth day of the period of care, the

episodic payment is reduced by 1/30th.

– First late penalty is equal to 17% (5/30th) of

the episodic payment.

• Low Utilization Payment Adjustment (LUPA)

– If a claim is identified to as a LUPA and the

RAP is not submitted timely, visits conducted

prior to submission will not be reimbursed.

Late RAP Submission Penalties

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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• How will you monitor for the RAP countdown?

• How will you ensure that you meet the

guidelines for submitting a RAP?

• How will you manage LUPAs related to RAPs?

• What adjustments should be considered in

reporting?

• What role will technology play in your

operations?

Operational Action Items

• Visibility for late and missed visits

– EVV

• Perform timely assessments

• Rehab SOC OASIS performed by therapist

• 24 hours for assessment documentation

• Secondary disciplines with 24 hours

• Maximize workflow efficiencies

• Technology and clinical intelligence

• Ensure proper documentation for verbal order

• Ensure rapid quality assurance

• Determine billable visit on assessment visits

Operational Action Items

• Requirements for RAPs have been loosened

• “The appropriate physician’s written or verbal order that sets

out the services required for the initial visit has been received

and documented…”

• “The initial visit within the 60-day certification period has

been made and the individual is admitted to home health

care.”

• Timely submission is now enforced (similar to Hospice)

• RAP must be submitted and accepted by CWF by the fifth

calendar day within that period of care.

• Second billing period RAPs can be sent at the beginning of a certification period.

Requirements for RAP Submission

2020 Per Visit LUPA Rates

Home health aide $67.78

Medical social worker $239.92

Occupational therapy $164.74

Physical therapy $163.61

Skilled nursing $149.68

Speech therapy $177.84

LUPA Impact

LUPA THRESHOLD: 6 VISITS

LUPA SN $449.04 LUPA HHA $67.78

Total Loss $516.82

SOC SN SN HHA RAP

HHA HOSP

Total Payment

$ 67.78

Technology Considerations for 2021

• RAP aging tool

• Enhanced payer setup

• Reporting enhancements

• Business intelligence

RAP Aging

Questions and Answers

A. No sequential billing is required. RAPs for the first and second 30-day billing periods can

be sent at the beginning of the 60-day episode.

HHAs will be allowed to submit both the RAP for the first 30-day period of care and the

RAP for the second 30-day period of care (for a 60-day certification) at the same time

to help further reduce provider administrative burden (84 FR 60549).)

Q. Does billing have to be sequential in 2021?

Questions and Answers

A. Yes, since no payment will be associated with the submission of the RAP in CY 2021,

HHAs are to submit the RAP when: 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 at §§ 484.60(b) and 409.43(d); and 2) the initial visit within the 60-day

certification period has been made and the individual is admitted to home health care.

Q. Will RAPs only require a verbal order and first billable visit for

the episode to be completed prior to submission?

Question and Answer

A. The HIPPS code reported on the RAP is no longer required to match the HIPPS code calculated

on the assessment. Any valid HIPPS can be reported.

For RAPs with “From” dates on or after January 1, 2020, the HHA may submit the HIPPS code

they expect will be used for payment if they choose to run grouping software at their site for

internal accounting purposes. If not, they may submit any valid HIPPS code in order to meet

this requirement.

Q. How will the HIPPS code be determined on the RAP if the OASIS is

not required to be complete?

Questions and Answers

A. RAPs will no longer be subject to auto cancellation.

RAPs with “From” dates on or after January 1, 2021, will no longer be

automatically canceled because there will be no payment to recoup.

Q. Are there any changes to the automatic RAP cancellation process?

A. The first billable visit for the episode will satisfy the requirement for both first

and second 30-day billing period RAPs.

The initial visit within the 60-day certification period has been made and the

individual is admitted to home health care.

Q. What are the changes to the first billable visit requirement?

Questions and Answers

A. The date reported on the 0023 home health service line on RAPs is currently reported

as the date of the first billable visit for each billing period. Initial RAPs in CY 2021 will

report the first billable date for the initial billing period and the subsequent billing

periods will report the first day of the billing period.

Q. What dates will be reported on the home health service line

on the RAP submission?

Questions and Answers

1. Only the principal DX is required to be reported.

For “From” dates on or after January 1, 2020, the ICD code and principal diagnosis used for payment

grouping will be claim coding rather than the OASIS item. As a result, the claim and OASIS diagnosis

codes will no longer be expected to match in all cases. Typically, the codes will match between the first

claim in an admission and the start of care (Reason for Assessment –RFA 01) assessment and claims

corresponding to recertification (RFA 04) assessments. Second 30-day claims in any 60-day period will

not necessarily match the OASIS assessment. When diagnosis codes change between one 30-day

claim and the next, there is no absolute requirement for the HHA to complete an ‘other follow-up’ (RFA

05) assessment to ensure that diagnosis coding on the claim matches to the assessment. However, the

HHA would be required to complete an ‘other follow-up’ (RFA 05) assessment when such a change

would be considered a major decline or improvement in the patient’s health status.

Q. What DX codes need to be reported on RAPs?

Questions and Answers

Questions and Answers

A. Medicare will allow agencies to append a KX modifier to the HIPPS code reported on the final claim if

they believe they fall under an appropriate exemption reason outlined by CMS.

(CMS: The contractor shall accept the KX modifier when reported with the HIPPS code on the revenue

code 0023 line of TOB 032x (other than 0322 and 0320) as an indicator that a home health agency

requests an exception to the late RAP penalty. CMS: The four circumstances that may qualify the HHA

for an exception to the consequences of filing the RAP more than 5 calendar days after the HH period of care From date are as follows: 1. fires, floods, earthquakes, or other unusual events that inflict

extensive damage to the HHA’s ability to operate; 2. an event that produces a data filing problem due

to a CMS or A/B MAC (HHH) systems issue that is beyond the control of the HHA; 3. a newly Medicare-

certified HHA that is notified of that certification after the Medicare certification date, or which is

awaiting its user ID from its A/B MAC (HHH); or, 4. other circumstances determined by the A/B MAC

HHH) or CMS to be beyond the control of the HHA.)

Q. Will there be exceptions to the late submission penalty?

Next Steps

Top Four ConsiderationsSuccessful RAP 2021

1Knowledge

2Workflow

3Technology

4Change Management

Streamline ProcessResource Management

SchedulingOrders Management

Staff educationReferral source education

No pay RAPsRAP aging

Penalty adjustmentsEnhanced workflow

Business IntelligenceExpectations

Visibility

• Elimination of split percentage payments

• Penalty for delayed submission of RAPs

• Revenue reduction of 1/30th of episodic payment per day

• Reduced RAP submission requirements

• All reimbursement paid on final claims

• Operational changes should occur now to prepare for 2021

Summary 2021 RAP Billing Changes