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Quality Reporting Compliance: What Qualifies as Quality Care Episode?

    Last month, the Centers for Medicare & Medicaid Services (CMS) issued notifications to home health agencies found to be non-compliant with the Home Health Quality Reporting Program (HHQRP) requirements for the calendar year (CY) 2022. Consequently, these agencies will face a 2% reduction in payment during the calendar year (CY) 2024 Annual Payment Update (APU).

    OASIS Quality Reporting Requirements

    In the home health quality reporting program, there are two primary components: the Home Health CAHPS survey and OASIS data. To maintain compliance, it is important to understand the OASIS data reporting requirement, which can be confusing. This requirement dictates that at least 90% of your OASIS transmissions must qualify as Quality Assessments, meaning they must qualify as a quality care episode. These episodes are defined from the Start of Care to Transfer or Discharge, as well as from Resumption of Care to Transfer or Discharge. During the compliance evaluation process, all transmitted OASIS data will be scrutinized to ensure that at least 90% of them align with a quality episode.

    Determining a quality care episode in OASIS assessments involves specific conditions:

    • An OASIS assessment isn’t part of a quality episode if there’s no follow-up after the initial Start of Care assessment. Compliance requires subsequent Transfers or Discharges.
    • New Start of Care OASIS forms without further submissions or Resumption of Care without additional OASIS submissions aren’t counted in a quality episode.
    • Compliance involves initiating a Start of Care and submitting multiple recertifications. Non-compliance happens when only the Start of Care assessment is submitted without follow-up or when recertifications are submitted without further action. An endpoint is necessary for compliance.
    • If there’s a gap with no submitted recertifications and no Transfer or Discharge, those assessments won’t count as part of quality episodes.

    Medicare Administrative Contractors (MACs) sent non-compliance notifications to Home Health Agencies (HHAs) through iQIES My Reports folders around October 6, 2023. If HHAs receive a non-compliance letter, they can request reconsideration from CMS by emailing before 11:59 pm on November 13, 2023. For instructions on reconsideration, check your notification and visit the Home Health Quality Reporting Reconsideration and Exception & Extension webpage.