Background

On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) final rule, which updates Medicare payment policies and rates for Home Health Agencies (HHAs).

This topic lists selected items of importance to wound care clinicians in the CY 2025 HH PPS final rule. 

CY 2025 Medicare Home Health Final Rule: Essential Updates for Wound Care Clinicians

Payment Adjustments & Rate Updates

• Aggregate Increase: Medicare payments to HHAs will see a slight aggregate increase of 0.5%, or about $85 million.
• Behavioral Adjustment: A permanent prospective adjustment of -1.975% to address the gap between anticipated and actual behavior changes under the PDGM.
• Revised Case-Mix Weights: Annual recalibration of PDGM weights, thresholds, and comorbidity adjustments based on CY 2023 data to match patient needs.
• Occupational Therapy (OT) LUPA Add-On Factor: OT now has a dedicated LUPA add-on factor for more precise payment.

LUPA Add-On Factors

• OT LUPA add-on factor is 1.7238, to be used when that discipline is the first skilled visit in a LUPA episode that occurs as the only episode or an initial episode in a sequence of adjacent episodes.
• The SN, PT, and SLP LUPA add-on factors are 1.7200, 1.6225, and 1.6696, respectively.

OASIS-E Crosswalk for Data Consistency

• CMS introduces a crosswalk mapping OASIS-E to OASIS-D responses to ensure consistency in data collection and analysis for accurate payment assessment.

Wage Index & Statistical Area Updates

• Updated Wage Index: Adopting new labor market delineations based on the latest census data for a more accurate reflection of labor market conditions.

Conditions of Participation (CoPs) Updates

• Patient Acceptance Policy: HHAs must now have a publicly available, consistently applied policy for patient acceptance based on agency capacity and patient needs.

Home Health Quality Reporting Program (QRP)

• New Social Determinants of Health (SDOH) assessment data items (e.g., living situation, food access, utilities) to be collected from CY 2027 to address health equity in care delivery.  The current transportation item will be modified in CY 2027.
• Data collection to begin with the start of care OASIS data collection timepoint instead of the discharge timepoint.

Health Equity and Future Measures for HHVBP

• Expanded Home Health Value-Based Purchasing (HHVBP) Model: Future measure concepts to address gaps, like functional assessments for daily activities (e.g., bathing, dressing).
• CMS plans to work with stakeholders on health equity advancements within the HHVBP model.

Provider Enrollment & Fraud Prevention

• Enhanced oversight for providers reactivating Medicare billing privileges to prevent fraud, including a provisional period for reviewing claims.

Resources

• Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) final rule 
• PDGM and Wound Management: Where Does Your Home Health Agency Stand? A Guide to Self-Analysis
• OASIS and Wound Assessment for Home Health Agencies