Home Health & Hospice Week

If you've been letting your software handle your OASIS matching string without much thought, you'd better change your ways.

Another prospective payment system glitch recently brought to light shows that the information contained in that string is very important for recoded claims.

The problem: The PPS Pricer software re-codes an episode to Payment Grouping 5 if an epi-sode has 20 or more therapy visits, so the five-digit HIPPS code would start with a 5. The rest of the HIPPS code is then recoded based on the OASIS matching string an agency submits with its claim, instead of the Common Working File. The system then doesn't compare the HIPPS code against the CWF for accuracy because it starts with a 5.

What this means: The early/late episode information in an agency's OASIS matching string may be incorrect, points out reimbursement consultant M. Aaron Little with BKD in Springfield, MO. That can be due to provider error or because the CWF may reflect different information that wasn't available at billing time, such as an earlier episode from another HHA.

The current PPS system will pay the claim based on the agency's erroneous early/late indicator in the matching string instead of the real information contained in the CWF, Little explains. A Centers for Medicare & Medicaid Services official has confirmed this problem, Little tells Eli.

For example: Say an agency billed HIPPS code 2CGKS, OASIS matching key 08AG08AG1I FTGEIVH and 20 total therapy visits on a final claim, Little suggests. The system would recode the claim to Payment Grouping 5 for high therapy using OASIS matching string positions 13 and 14 to recode the clinical and functional dimensions, re-sulting in a paid HIPPS code of 5CGKS.

But since the CWF shows the episode was actually a later one, the system should recode the claim based on OASIS matching string positions 17 and 18 instead, Little says. That would result in a paid HIPPS code of 5CHKS -- a different third digit.

The difference: The point thresholds for the clinical and functional categories are different for early versus later episodes, Little says. So even though the episodes all fall into the fifth payment grouping step for 20-plus therapy visits, the criteria for meeting the clinical and functional levels are different based on early/later episode timing.

In this example, the payment difference is $438 in Springfield, MO, Little explains. "The incorrectly paid HIPPS of 5CGKS would be $6,697 and the correct HIPPS code of 5CHKS would pay $7,135," he says.

Agencies paid incorrectly due to this problem will have to change claims themselves, the CMS official has indicated to Little.

This is just the latest in a long line of highly technical errors in the pricer software, Little laments. Each new problem uncovered makes it that much more difficult for HHAs to determine whether they are receiving accurate payment under PPS.

And providers continue to wait on mass adjustments that will account for the system problems found to date, such as the problem counting 2007 episodes toward M0110 (see Eli's HCW, Vol. XVII, No. 30, p. 234).

Agencies need to keep on their toes to make sure the early/late status and resulting OASIS matching string is correct in the first place and then be sure they have received the payment they should have, Little advises. When talking to clients about claims reconciliation, billers often "just get this glazed-over look," he says. It's vitally important to check your claims and make sure the reason your claim was recoded is valid.

Thanks to changes in early/later episode status and therapy visit number, an average agency may see 40 percent of its claims adjusted with a different HIPPS code, Little expects. Providers should be verifying those recoded claims as correct.

Pitfall: And don't rely on your software system to do everything for you, Little warns. Upon claims submission, software can't predict if a patient's early/later episode status will change due to Common Working File updates, for example. "The most savvy systems are still not going to be able to predict everything," he says.

Billing staff may be tempted to let adjustments slide by without examination because they are for small dollar amounts or are confusing. Don't fall into that trap, Little urges.

Do this: Make sure your billers have a firm grasp of PPS principles so they can investigate recodes and know which recodes are for legitimate reasons and which ones are due to errors that you'll see adjusted by CMS later. This may require more education for your billers, Little notes.