Home Health & Hospice Week

CMS wants you to enter different dates in M0090 for end-of-year window.

The transition to the prospective payment system refinements just got more confusing.

But home health agencies are glad to have official guidance from the Centers for Medicare & Medicaid Services about how to complete OASIS in the five-day window before PPS takes effect Jan. 1.

In a new set of questions and answers, CMS explains how to fill out assessments to result in correct HIPPS codes for episodes. When an episode begins in 2007 it needs a HIPPS code from the current PPS, while an episode starting in 2008 needs a refinements HIPPS code.

"The guidance offers clarification about assessment timing and completion dates that is critical for assignment of correct case-mix weights," the National Association for Home Care & Hospice stresses. The right case-mix assignment will ensure "accurate payment during transition to the reformed home health prospective payment system," NAHC says.

"A lot of agencies will have those complications," consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN says of the Q&A examples. "They will need to try to figure out what to do"--and the Q&As should help them with that.

CMS offers these three situations when clinicians will have to put different or "artificial" dates in M0090 to obtain the correct HIPPS code:

Scenario 1: You complete a recertification assessment during the last five days of 2007 and that assessment must provide the HIPPS code for an episode that begins before Jan. 1.

The problem: The new version of OASIS that supports PPS changes and the grouper software will use recert OASIS data from Dec. 27 to Dec. 31 to generate a HIPPS code under PPS refinements, CMS explains in the Q&A. "To allow for the 5-day recertification window for episodes of continuous care that begin on 1/1/2008 through 1/5/2008, the new OASIS data specifications are effective for OASIS RFAs 04 or 05 with completion dates (M0090) of 12/27/2007 or later."

The solution: So, agencies must use an "artificial" date of Dec. 26 in M0090 to obtain a HIPPS code that will pay correctly for the episode that begins before Jan. 1, CMS instructs. Staffers should enter a date of 12/26/2007 in M0090 even though the actual assessment date was between Dec. 27 and Dec. 31.

The requirements: To qualify for this waiver, the episode must be a Reason for Assessment (RFA) of 04 (recert) or 05 (other followup); an assessment completion date between Dec. 27 and Dec. 31; and a need for the assessment to produce a HIPPS code for a 2007 episode.

The M0090 waiver is "a one-time exception, to facilitate the transition to the revised HH PPS case-mix system and save HHAs the burden of completing two separate assessments in these instances," CMS says.

Tip: When you enter the artificial M0090 date, the state system may return a warning message that the assessment is outside the recert period. You can just ignore it.

Scenario 2: The episode begins between Dec. 27 and Dec. 31, but you don't complete the start or resumption of care assessment until Jan. 1 or later.

The problem: OASIS and the grouper will use SOC or ROC data from Dec. 27 to Dec. 31 to generate a HIPPS code for 2007 billing and SOC or ROC data from Jan. 1 and after to generate a HIPPS code for 2008 billing. You need a 2007 code but your data will generate a 2008 one.

CMS urges HHAs to complete such assessments before Jan. 1 to head off this billing problem. "CMS believes that in a majority of cases this should be possible," the agency says.

The solution: Providers that can't avoid it must use an "artificial" date of Dec. 31 in M0090 to obtain a 2007 episode HIPPS code. This is a temporary waiver, CMS stresses.

The requirements: To qualify for this waiver, the episode must have an RFA of 01 (SOC) or 03 (ROC); an assessment window that begins Dec. 27 or later and ends Jan. 1 or later; and a need for the assessment to produce a HIPPS code for a 2007 episode.

CMS will alert state surveyors to these one-time exceptions, according to the Q&A.

Scenario 3: Your patient goes into the hospital and comes out in the five-day window, so you complete a ROC between Dec. 27 and Dec. 31, but her next episode begins on or after Jan. 1.

The problem: Again, OASIS data and the grouper will use ROC data from the last five days of the year to generate 2007 HIPPS codes. But in this case, you need a 2008 billing code for the next episode.

The solution: Enter the date of Jan. 1 in M0090, even though the ROC assessment occurred before 1/1/2008. "When the Grouper software is run, it will calculate the correct HIPPS code and treatment authorization code needed for the claim for an episode starting in 2008," CMS notes.

Again, you may receive a warning that the assessment is outside the recert period. You can disregard it.

The requirements: To qualify for this waiver, the episode must have an RFA of 03 (ROC); an assessment window between Dec. 27 and Dec. 31; and a need for the assessment to produce a HIPPS code for a 2008 episode.

Tip: Some software may not allow entry of a M0090 date that is after the current date, CMS cautions. In that case, you'll have to defer entry until Jan. 1 or later.

Know Which OASIS To Use When

The Q&As neglect to spell out which OASIS dataset to use in each scenario. But CMS has told NAHC that agencies should use the current OASIS dataset (OASIS-B1 12/2002) for all episodes that begin in 2007, "even if completed late," according to the trade group.

"For episodes that begin on or after Jan 1, 2008, agencies should use the revised OASIS (OASIS-B1 1/2008), including for recertification assessments carried out in the last five days ... of 2007," NAHC adds.

Note: More details about the waiver scenarios are in the Q&As at www.cms.hhs.gov/HomeHealthPPS/Downloads/TransitionEpisodesQA.pdf.