CMS Technical Instructions: Reporting personal care and home health services in T-MSIS

Technical Instructions History

Brief Issue Description

This technical instructions document outlines the challenges states have faced in reporting complete, accurate, and consistent data for personal care services (PCS) and home health care services (HHCS) in Transformed Medicaid Statistical Information System (T-MSIS) records and provides clarification for reporting these data. The guidance in this document addresses reporting complete and accurate data on PCS and HHCS in the T-MSIS Other Claims (OT) file.

Background Discussion

Context

Medicaid services provided in home and community-based settings, of which PCS and HHCS are a key component, encompass a growing share of Medicaid’s long-term care spending. All states are expected to report PCS and HHCS data completely and accurately. Proper reporting of these data will help ensure the accurate interpretation of enrollment, utilization, and payment data for these services captured in T-MSIS.

PCS (also known in States by other names such as personal attendant services, personal assistance services, attendant care services, and so on) include a range of assistance that enables people to accomplish tasks that they would normally do themselves if they did not have a disability. Such tasks are called Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL).^[1] PCS typically includes activities such as bathing, dressing, toileting, laundry, and preparing meals that are provided by personal care attendants. Provision of PCS might allow individuals to retain independence and stay in their homes and states can offer PCS through various Medicaid authorities.^[2]

HHCS is care provided to individuals in a home setting rendered by medically trained professionals. It includes nursing services, home health aide services, as well as the distribution of medical supplies, equipment, and appliances suitable for use in any setting in which normal activities take place.   It may also include physical therapy, occupational therapy, and speech pathology and audiology services at the state’s option.

In December 2016, Section 12006 of the 21st Century CURES Act (114 U.S.C. 255) established electronic visit verification (EVV) requirements for PCS and for HHCS delivered under several Medicaid authorities. States must require EVV use for all Medicaid-funded PCS by January 1, 2020 and HHCS by January 1, 2023, although states with approved requests for Good Faith Effort Exemptions (GFE) had until January 1, 2021 for PCS and have  until January 1, 2024 to implement for HHCS.^[3] For both PCS and HHCS, states must electronically verify data on the type of service performed, the individual receiving the service, the individual providing the service, date of the service, start and ending time of the service, and location of service delivery. Data collected via an EVV should be appropriately mapped and reported to T-MSIS.

Challenges

States face challenges in collecting complete and consistent PCS and HHCS data. Key data from PCS and HHCS claims that are frequently missing include dates of service and units of service provided. Some PCS providers do not have a National Provider Identifier (NPI), and therefore provider identifier numbers are also frequently missing from PCS and HHCS claims. States use a variety of different procedure codes and units of service for PCS claims, leading to a lack of consistency across these data elements within a state and across states. To address the administrative burden of enrolling each individual direct care provider and other challenges in reporting PCS and HHCS, CMS shared promising practices for states using EVV.^[4]

CMS Technical Instruction

The guidance here clarifies reporting claims for beneficiaries receiving PCS and HHCS.

When reporting claims for PCS in T-MSIS, states should report all data available in their state systems for these services that can be mapped to T-MSIS by January 1, 2020. By January 1, 2023, this provision should include any HHCS data collected via EVV that can be mapped to T-MSIS (unless granted a GFE).  Although a standard list of procedure codes that corresponds to types of services provided as PCS or HHCS has not yet been established, reporting available data completely is a vital first step to establishing timely, accurate, and complete data that may be used for research purposes in the future. A list of relevant claim OT data elements that should be reported for PCS and HHCS claims, for both fee-for-service (FFS) claims and encounter records, and that align with the EVV requirements to go into effect January 1, 2020 for PCS and January 1, 2023 for HHCS, follows.

1. MSIS-IDENTIFICATION-NUM: This identifies the individual receiving the service. The MSIS ID reported on the claim must correspond to an MSIS ID in the Eligible file, which contains eligibility characteristics that reflect whether any special authorities (other than the general optional Medicaid state plan benefit authority) were used to justify coverage of the claim, such as STATE-PLAN-OPTION-TYPE, WAIVER-TYPE, HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE and so on.
2. Dates of services including BEGINNING-DATE-OF-SERVICE and ENDING-DATE-OF-SERVICE: The date(s) the service was provided should be reported using these data elements.
3. Service quantities including SERVICE-QUANTITY-ACTUAL, PRESCRIPTION-QUANTITY-ACTUAL (both formerly known as OT-RX-CLAIM-QUANTITY-ACTUAL), SERVICE-QUANTITY-ALLOWED and PRESCRIPTION-QUANTITY-ALLOWED (both formerly known as OT-RX-CLAIM-QUANTITY-ALLOWED): The quantity or unit for the service, both the allowable and actual amounts, should be reported. In the case of PCS and HHCS the relevant unit is time, such as hours or some smaller increment of time (15-minute or half-hour increments).
4. Provider Information, including SERVICING-PROV-NUM and BILLING-PROV-NUM: All providers should report this identifier, even those with an NPI. In cases where PCS providers do not have NPIs, another state-issued ID should be reported so the provider^[5] can be appropriately identified and associated with the PCS provided on the claim and linked to the provider file. Providers delivering PCS or HHCS should also have a corresponding record in the T-MSIS Provider file. For providers rendering PCS that do not have an NPI, the best classification match for his/her specialty type will likely be PROVIDER-CLASSIFICATION-TYPE “4” (Authorized Category of Service) with a PROVIDER-CLASSIFICATION-CODE of “51” (Personal Care Services). For providers rendering HHCS that do not have an NPI, the best classification match for his/her specialty type will likely be PROVIDER-CLASSIFICATION_TYPE “4” (Authorized Category of Service) with a PROVIDER-CLASSIFICATION-CODE best matching the type of HHCS they are providing (e.g., “016” Home health services - Nursing services). Providers with an NPI should use the taxonomy or taxonomies that the provider has self-assigned in NPPES that most accurately reflects the services they provide.
   • Providers not enrolled in Medicaid: For EVV providers rendering or billing for PCS or HHCS that are not enrolled in Medicaid, in T-MSIS we would expect that these providers should be reported in the T-MSIS Provider File with the information that is available, consistent with how other atypical providers are reported. It is anticipated that many of the EVV providers that are not enrolled in Medicaid are individuals. The information collected for these providers should be sufficient for tax reporting purposes (e.g., to populate a Form-1099-MISC) with basic identifying information such as name, address, and Social Security Number. The state should be able to further identify the individuals as a person who provides HHCS.
5. PLACE-OF-SERVICE: Medicaid agencies and managed care organizations should not hard-code PLACE-OF-SERVICE values just for T-MSIS mapping purposes. PLACE-OF-SERVICE is a pass-through data element, meaning that the state should report the field in T-MSIS as reported by the provider or constructed by the EVV system.
6. PROCEDURE-CODE: Although a standard list of procedure codes to use for PCS and HHCS has not yet been established, PCS and HHCS claims should report the Current Procedural Terminology (CPT) or Healthcare Common Procedural Coding System (HCPCS) procedure code used to adjudicate the claim.
7. Service categorization: Table 1 displays all of the relevant data elements and valid values for PCS below. Table 2 displays all of the relevant data elements and valid values for HHCS below.
   • For PCS:
     • TYPE-OF-SERVICE: PCS should be reported with a TYPE-OF-SERVICE valid value of “051” (Personal care services) or “065” (HCBS  - Personal care services).
     • XIX-MBESCBES-CATEGORY-OF-SERVICE: “19A” (Home & Community-Based Services - Reg. Pay. (Waiver)), “19B” (Home & Community-Based Services - St. Plan 1915(i) Only Pay. ), “19C” (Home & Community-Based Services - St. Plan 1915(j) Only Pay), “19D” (Home & Community Based Services State Plan 1915(k) Community First Choice), “23A” (Personal Care Services - Reg. Payments), or “23B” (Personal Care Services - SDS 1915(j))^[6]
     • XXI-MBESCBES-CATEGORY-OF-SERVICE: “21” (Home and Community)^[7]
     • HCBS-TAXONOMY: “08030” (Personal Care)
     • BENEFIT-TYPE: PCS should be reported with a BENEFIT-TYPE valid value of “045” (Personal care services) (that is, State Plan PCS); “054” (Community First Choice); or “106” (Self-directed Personal Assistance Services under 1915(j)) depending on the beneficiary’s eligibility to receive PCS.
     • PROGRAM-TYPE: For individuals receiving PCS under
       1. 1905(a)(24) State Plan PCS, the state should report a valid value of “00” (No Special Program)
       2. Home and community-based care waiver, the state should report a valid value of “07”
       3. 1915(i) Home and Community Based Services State Plan Option , the state should report a valid value of “13”
       4. 1915(k) Community First Choice, the state should report a valid value of “11”
       5. 1915(j) authority for self- directed personal assistance services or personal care under State Plan or 1915(c) waiver, the state should report a valid value of “16”
   • For HHCS:
     • TYPE-OF-SERVICE: HHCS should be reported with a TYPE-OF-SERVICE valid value of “016” (Home health services - Nursing services); “017” (Home health services - Home health aide service); “018” (Home health services - Medical supplies, equipment, and appliances suitable for use in the home); “019” (Home health services - Physical therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services); “020” (Home health services - Occupational therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services); “021” (Home health services - Speech pathology and audiology services provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services); or “064” (HCBS - Home health aide services).
     • XIX-MBESCBES-CATEGORY-OF-SERVICE: “12” (Home Health Services)
     • XXI-MBESCBES-CATEGORY-OF-SERVICE: “19” (Home Health)
     • HCBS-TAXONOMY: “08020” (Home Health Aide); “05010” (Private Duty Nursing); “05020” (Skilled Nursing); “11080” (Occupational Therapy); “11090” (Physical Therapy); “11100” (Speech, Hearing, and Language Therapy); “14031” (Equipment and Technology); “14032” (Supplies)
     • BENEFIT-TYPE: HHCS should be reported with a BENEFIT-TYPE valid value of “015” (Home Health Services - Intermittent or part-time nursing services provided by a home health agency); “016” (Home Health Services - Home Health Aide Services Provided by a Home Health Agency); “017” (Home Health Services - Medical supplies, equipment, and appliances suitable for use in the home); “22” (Home Health Services - Physical therapy; occupational therapy; speech pathology; audiology provided by a home health agency); “068” (Home Health Services - Home health aide services provided by a home health agency); or “076” (Home Health Aide) depending on the type of home health services the individual is authorized to receive.
     • PROGRAM-TYPE: For individuals receiving home health services under
       1. 1905(a)(7) State Plan Home Health Services, the state should report a valid value of “00” (No Special Program)
       2. Home and Community Based Waiver, the state should report a valid value of “07” (Home and Community Based Care Waiver Services)
8. Billed and Payment Amounts: All relevant payment fields for the claim, such as TOT-MEDICAID-PAID-AMT and MEDICAID-PAID-AMT, should be reported with the correct billed and paid amounts. For additional information specific to populating these data elements for encounter records, please consult the CMS Technical Instruction: Reporting Paid and Billed Amounts on Managed Care Encounters in T-MSIS (see link below).