New Release of Hospice PEPPER Includes New Target Areas
Tuesday, April 7, 2015
by: Visiting Nurse Associations of America

Section: Public Policy and Advocacy




The next release of the Hospice Program for Evaluating Payment Patterns Electronic Report (PEPPER), scheduled for April 13, will include four new target areas, added in response to the recently-released Office of Inspector General (OIG) report identifying concerns with hospice services provided to beneficiaries residing in an assisted living facility (ALF). The OIG found "Medicare payments for hospice care in ALFs more than doubled in five years, totaling $2.1 billion in 2012. Hospices provided care much longer and received much higher Medicare payments for beneficiaries in ALFs than for beneficiaries in other settings…. This report raises concerns about the financial incentives created by the current payment system and the potential for hospices to target beneficiaries in ALFs because they may offer the hospices the greatest financial gain."

What is PEPPER?

PEPPER is a free educational tool available to providers to help them proactively monitor their claims and work to prevent improper Medicare payments. PEPPER summarizes a hospice's Medicare claims data in areas that may be at risk for improper Medicare payments (target areas). It compares the hospice's statistics with aggregate statistics for the nation, Medicare Administrative Contractor (MAC) jurisdiction and the state. If a hospice's statistics are at/above the national 80th percentile the provider is identified as an "outlier" and may be at risk for improper Medicare payments. PEPPER cannot identify the presence of improper payments.

To date, the Hospice PEPPER has included two target areas: "Live Discharges" and "Long Length of Stay". The new Hospice PEPPER will include four new target areas:

TARGET AREA

TARGET AREA DEFINITION

Live Discharges

For discharges prior to July 1, 2012:

Numerator (N): count of beneficiary episodes discharged alive by the hospice (patient discharge status code not equal to "40" (expired at home), "41" (expired in a medical facility) or "42" (expired place unknown)) with occurrence code "42" (date of termination of hospice benefit)

Denominator (D): count of all beneficiary episodes discharged (by death or alive) by the hospice during the report period (obtained by considering all claims billed for a beneficiary by that hospice)

For discharges beginning July 1, 2012:

Numerator (N): count of beneficiary episodes who were discharged alive by the hospice (patient discharge status code not equal to "40" (expired at home), "41" (expired in a medical facility) or "42" (expired place unknown)), excluding:

· beneficiary transfers (patient discharge status code "50" or "51")

· beneficiary revocations (occurrence code "42")

· beneficiaries discharged for cause (condition code "H2")

· beneficiaries who moved out of the service area (condition code "52")

Denominator (D): count of all beneficiary episodes discharged (by death or alive) by the hospice during the report period (obtained by considering all claims billed for a beneficiary by that hospice)

Long Length of Stay

N: count of beneficiary episodes discharged (by death or alive) by the hospice during the report period whose combined days of service at the hospice is greater than 180 days (obtained by considering all claims billed for a beneficiary by that hospice)

D: count of all beneficiary episodes discharged (by death or alive) by the hospice during the report period

Continuous Home Care Provided in an Assisted Living Facility

*new as of the Q4FY14 release

N: count of beneficiary episodes discharged (by death or alive) by the hospice during the report period where at least eight hours of Continuous Home Care (revenue code = "0652") were provided while the beneficiary resided in an Assisted Living Facility (HCPCS code = "Q5002")

D: count of all beneficiary episodes ending in the report period that indicate the beneficiary resided in an assisted living facility (HCPCS code = "Q5002") for any portion of the episode

Routine Home Care Provided in an Assisted Living Facility

*new as of the Q4FY14 release

N: count of Routine Home Care days (revenue code = "0651") provided on claims ending in the report period that indicate the beneficiary resided in an assisted living facility (HCPCS code = "Q5002")

D: count of all Routine Home Care days (revenue code = "0651") provided by the hospice on claims ending in the report period

Routine Home Care Provided in a Nursing Facility

*new as of the Q4FY14 release

N: count of Routine Home Care days (revenue code = "0651") provided on claims ending in the report period that indicate the beneficiary resided in a nursing facility (HCPCS code = "Q5003")

D: count of all Routine Home Care days (revenue code = "0651") provided by the hospice on claims ending in the report period

Routine Home Care Provided in a Skilled Nursing Facility

*new as of the Q4FY14 release

N: count of Routine Home Care days (revenue code = "0651") provided on claims ending in the report period that indicate the beneficiary resided in a skilled nursing facility (HCPCS code = "Q5004")

D: count of all Routine Home Care days (revenue code = "0651") provided by the hospice on claims ending in the report period

 

When will the new Hospice PEPPER be released?

The new Hospice PEPPER (version Q4FY14) summarizing statistics for fiscal years 2012, 2013 and 2014 will be available on April 13, 2015 through the PEPPER Resources Portal.

How can I learn more?

Updated recorded PEPPER training sessions are available on theHospice Training and Resources page atPEPPERresources.org, along with the updated Hospice PEPPER user's guide. In addition, TMF will conduct a web-based training session on April 30, 2015. Join the email list at PEPPERresources.org to receive notifications of upcoming training opportunities and report distribution.

PEPPER is distributed by TMF Health Quality Institute under contract with the Centers for Medicare & Medicaid Services. Visit to access more information on PEPPER.PEPPERresources.org

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