OASIS:
Draw On DRGs To Sniff Out Correct M0175 Answers
Published on Fri Dec 17, 2004
Avoid a $600 mistake with one simple step. One quick question about patients' prior hospital stays could save your agency cash and compliance headaches.
Under current reimbursement rules from the Centers for Medicare & Medicaid Services, Medicare will automatically dock you about $600 for a therapy patient or $200 for a non-therapy patient if you fail to report an acute hospital stay within 14 days of admission in M0175. But Medicare does not automatically bump up your payment by the same amount when you fail to report a skilled nursing facility or rehab stay in addition to a hospital stay in the OASIS item, experts warn.
CMS agreed to make the automatic bump-up retroactively for the first four years of the prospective payment system. But the agency drew the line at providing the automatic increase going forward. "For claims with dates of service in Federal fiscal year 2004 and for future years, Medicare will maintain the process of identifying overpayments only," CMS said in a July transmittal (see Eli's HCW, Vol. XIII, No. 28, p. 218).
Your move: That means it's up to you to secure your rightful reimbursement by sniffing out patients' prior SNF and rehab stays.
Red flag: One quick way to catch unreported SNF and rehab stays is by asking for patients' length of stay in the hospital, advises consultant Karen Vance with BKD in Springfield, MO.
In these cost-conscious times, hospitals will very rarely be keeping patients for significantly longer than the average length of stay for their diagnosis related group (DRG), Vance notes. So a LOS noticeably longer than the average is a signal that something is up.
Chances are if a patient's LOS was twice as long as normal, she was in a rehab bed part of the time, Vance points out. In swing bed facilities, patients can change from hospital to SNF or rehab status without even changing beds. The overly long stay is your signal to find out if that's the case, or whether "there is something else going on with the patient" that you don't know about, she urges.
Requiring staff to compare every single patient's hospital stay to the average LOS for the condition isn't efficient, Vance acknowledges. Instead, HHAs should keep a list of the top DRGs their patients have in prior hospital stays and check those figures, she recommends. "The whole idea is to reduce effort and get the most accurate information," she tells Eli.
For example, the average LOS for a hip replacement patient (DRG 209) is 4.8 days, CMS says in its hospital inpatient PPS final rule in the Aug. 11 Federal Register. So if your hip replacement patient was in the hospital 10 days, you'd better do some investigating to see if part [...]
