Home Health & Hospice Week

Get to know 'APP DATE'  field if you want to know whether recoupments are right.

How will you know if the M0175 payments Medicare is taking back are fair and square? Avaluable new tool could make your research on patients' prior hospital and skilled nursing facility stays easier.

If you're like most home health agencies, you're already seeing requests for anticipated payment returned for hospital stay correction or are having final claims downcoded, thanks to the ongoing M0175 audits that took effect April 1.

And this summer, the Centers for Medicare & Medicaid Services will recoup $23 million from HHAs for missed hospital stays in the first year of the prospective payment system alone. CMS will take back similar amounts for subsequent years of PPS, observers expect.

Don't let CMS make a costly mistake: You should confirm every downcode you receive, and you should do the same with the upcoming takebacks, experts urge. Claims processing systems aren't foolproof and you could get docked for an inpatient stay that never really took place.

Now there is an easier way for HHAs to research hospital stays that took place three or four years ago -- the Common Working File. Agencies can "obtain prior inpatient stay information via ELGA," regional home health intermediary Cahaba GBA instructs in its June newsletter to providers. "By typing a date in the APPDATE field you can access prior eligibility information" for hospital and SNF stays via the ELGAscreen, the RHHI explains.

Here's how it works: Page 1 of the ELGA screen displays hospital and SNF stay information. (See Eli's HCW, Vol. XIII, No. 17. for instructions on how to decipher hospital stays from the information on the ELGA screen).

When you enter the patient information on the ELGA inquiry screen but leave the "APPDATE" field blank, ELGA gives you the most recent stay information, Cahaba says. To look up stays from previous time periods, simply enter a date in the 'APP DATE' field and it will search for stays after that date.

Having the APP DATE function available for hospital and SNF stays "will be beneficial not only to home health agencies, but to hospitals and SNFs as well," cheers consultant M. Aaron Little with BKD in Springfield, MO. "The APPDATE will be very helpful when agencies are researching M0175 takebacks to identify whether the takeback was appropriate," Little says.

"Using the APPDATE field is important when prior beneficiary eligibility information is needed," Cahaba notes.

Of course, there are limits to the CWF's usefulness in researching prior inpatient stays. The data displayed "is only as good as the last bill" submitted by the hospital or SNF, warns Lynda Dilts-Benson with Reingruber& Co. in St. Petersburg, FL.

"If a hospital/SNF has not yet billed its claims, ELGA will not be updated with the current inpatient stay information," Little cautions.

But looking up stays from years ago, after the hospitals' 27-month billing window has closed, is likely to garner more useful information than using ELGA only a few days after the patient has been discharged from the hospital.

Dilts-Benson recommends using CWF data in conjunction with the "tried-and-true" methods of M0175 research -- questioning patients, their families, referral sources and hospital case managers and discharge planners.

Editor's Note: Cahaba's newsletter is available online at www.iamedicare.com/Provider/newsroom/newslines/060104.pdf.