Home Health & Hospice Week

M0110 accuracy could make or break your 2008 claims.

Your prospective payment system billing is about to get a lot more complicated, and your bottom line could suffer if you don't know the ropes.

Under PPS refinements hitting Jan. 1, home health agencies will categorize patients into 45 home health resource groups (HHRGs), noted consultant M. Aaron Little in an Oct. 24 Eli-sponsored audioconference on the billing changes. That number is down from the 80 current HHRGs because the Centers for Medicare & Medicaid Services cut one severity level from the Clinical dimension and two levels from the Functional dimension. CMS did add a level to the Service dimension, however.

But a smaller group of HHRGs leads to a higher number of case mix categories and a whole lot more billing codes, pointed out Little, with BKD in Spring-field, MO. PPS will go from the current 80 case mix categories to 153 categories. And the system jumps to 1,836 unique HIPPS codes.

To master the billing changes, Little suggested agencies take these steps:

1) Understand the basics. Your billers should have a fundamental understanding of how the new system groups patients into payment categories. Learning how the five grouping categories work based on early/ late episodes and therapy thresholds is key, as well as understanding the Clinical, Functional and Service di-mensions and the Nonroutine Supplies (NRS) categories.

2) Examine the new codes. Billers should grasp the significance of the new HHRGs and HIPPS codes, including what each position in the codes stands for. And the 18-digit OASIS matching string has a critical new importance under PPS refinements, Little stressed.

3) Become a M0110 expert. The patient's whole payment grouping will depend on the early vs. late episode designation, Little explained. Billers must become adept at determining episode status by checking the Common Working File.

But the M0110 work doesn't stop there. Clerical staff must also communicate the correct ep-isode sequence information to the clinician filling out OASIS, Little counseled.

Tricky: Counting episodes may prove difficult at times. Agencies should remember that previous episodes furnished by other providers count in the sequence. And the definition of "adjacent" episodes means that agencies count episodes that are up to 60 days apart.

Tip: When checking the HIQH page on the CWF, the two most recent episodes display. But providers can check back further for episodes by using the "APP DATE" field to enter a requested date, Little advised a caller.

4) Verify therapy visits. Making sure an episode's therapy visits are on the final claim is more important than ever, Little noted. Under the PPS refinements, most visits between six and 20 mean extra payment (see chart, Eli's HCW, Vol. XVI, No. 33). One denied visit can mean a $1,400 downcode in the most extreme case.

"We need to make sure all of our therapy visits are getting billed because even one visit could impact our payment at many different thresholds," Little cautions.

5) Bill NRS accurately. Don't cop out and bill the code for no supplies just because you can't be bothered to include them on the claim. "We need to make sure we're capturing and billing our Nonroutine Supplies," Little urged.

Under the PPS changes, the fifth digit of the HIPPS code will be a letter if the agency furnished and billed supplies and a number if it did not. When the code contains the letter, the Medicare claims system will edit the claim for supplies charges. If no charges are on the claim, the claim will return to provider (RTP).

Edit bypass: On the other hand, if the HIPPS code contains a number in the last position, the system won't edit it for supplies line items.

CMS instituted the NRS requirement because so few agencies submit supplies charges under current PPS, and the agency needs supplies data to calibrate its NRS payment methodology.

HHAs will have a while before they have to worry about the supplies RTPs, however. CMS won't start editing for supplies until April, and even then it will allow a grace period for the edits, it says. How long CMS makes that grace period is still in question, Little notes.

But you should strive to make your NRS bil-ling right from the start. "Otherwise it will certainly trip up our billing processes come January," Little worried.

6) Keep tabs on payment errors. Under the system's new complexity, there are bound to be payment errors. HHAs will see numerous claims come back paid at a different HIPPS code, often under an entirely new grouping and code due to therapy or episode sequence changes.

Billers need to "make sure we monitor these payment differences [and] recognize them as being either correct or incorrect," Little exhorted. You should recognize the payment adjustments, know what the adjusted billing codes represent, know how to go about researching claim payment differences, and get the differences resolved.

7) Work with your vendor. Now's the time to forge a close relationship with your billing software vendor, making sure all the necessary adjustments are in place before the changes take effect Jan. 1, Little advised.

HAVEN watch: CMS has not yet released the new version of HAVEN, Medicare's free HHA billing software that takes into account the PPS refinement changes. Keep an eye out for that issuance, Little said.

8) Plan ahead. Don't rely on everything to go smoothly. You may run into payment problems if your software or other systems trip up. Create a backup billing plan in case your vendor isn't ready, Little counseled.

9) Stay tuned. CMS has yet to issue a number of vital PPS billing facts, including the HAVEN update, the date for the NRS edit supplies period, and more. Keep up to date on the new information released, Little urged.

Note: To purchase a recording of M. Aaron Little's Eli-sponsored audioconference on PPS billing, "Home Health PPS Refinements: Crucial 2008 How-To's Your Billing Staff Must Know Now," go to www. audioeducator.com/industry_conference.php?id=620 or call 1-800-508-2582.