Home Health & Hospice Week

Know your nursing home categories.

If you're miscoding the highly scrutinized OASIS item on prior inpatient stays, it's like waving a red flag in front of your intermediary's medical reviewers.

The Centers for Medicare & Medicaid Services says it will have intermediaries crack down on home health agencies that are submitting a high number of claims that code M0175 incorrectly, according to a recent HHS Office of Inspector General report on the issue (see Eli's HCW, Vol. XV, No. 14).

Watch out: That means you may become a medical review target if your rate of adjustments for the OASIS item is high, warns consultant M. Aaron Little with BKD in Springfield, MO.

How it works: Upcoding M0175 can bring an agency an extra $600 per episode for a patient who reaches the 10-visit therapy threshold or an extra $200 for a non-therapy patient. The increase occurs when the agency marks that the patient had a rehab or skilled nursing facility discharge (response 2 or 3) without also marking a hospital stay (response 1) for the 14 days prior to admission.

Here are six tips to keep you off the intermediaries' radar screen for M0175 mistakes:

• Grill nursing facilities. Many clinicians still fail to understand the difference between a "skilled nursing facility" (response 3) and an "other nursing home" (response 4). You should mark SNF if the patient received skilled care under Medicare Part A while in the nursing home during the 14-day timeframe before admission, CMS says in the response-specific instructions in the OASIS User's Manual. When you mark "other nursing home," payment isn't increased.

Do this: When you receive a nursing home referral, ask whether the patient received Medicare Part A benefits during any part of her stay, Little advises. "If the answer is 'yes,' the patient was in a SNF." Then find out exact dates to see if they fall in the 14-day window.

• Make a referral source cheat sheet. It can be very difficult to discern which referral sources actually encompass which type of facilities under M0175. "Compile a list of referral sources and indicate which sources have a SNF or rehab unit, including the specific room numbers, floors, wings, etc. in which the units are located," Little recommends. Remember to include hospitals, because they may have a distinct skilled nursing or swing-bed unit that qualifies as a SNF.

"Distribute the list to the clinicians," Little says. That way staff have a resource to help guide their questions to referral sources, discharge planners, pa-tients and family members.

• Examine hospital stays. Don't just assume a hospital stay results in marking response 1. "If the patient was in the hospital setting for an extended period of time and received a high amount of therapy, chances are good that part or all of the stay was in a certified rehab unit" (response 2), Little cautions. "Be sure to ask that specific question."

• Use the CWF. Accessing the Common Working File can be a quick way to check on a patient's prior stay status. (For tips on how to use the CWF for M0175, see Eli's HCW, Vol. XIII, No. 17.)

Beware: Keep in mind the CWF is only as current and accurate as the claims the hospital, SNF or rehab facility has submitted so far, Little warns.

• Educate staff. Your intake and admission staff must understand what information is required to answer M0175 correctly, and why it's important. "Make certain they understand the significance of the question and are able to distinguish whether they are asking the right questions" of referral sources, Little urges.

• Educate referral sources. It may be an uphill battle, but educating referral sources on what information they need to provide will result in more accurate M0175 answers. "Persistence is the key to this whole process," Little tells Eli. 

Note: For more information on coding OASIS accurately, see Eli's OASIS Alert at www.elihealthcare.com or by calling 1-800-874-9180.