Home Health & Hospice Week

Information on prior hospital stays not easy to come by. 

The list of complaints about M0175 takebacks is a mile long, but that won't stop the Centers for Medicare & Medicaid Services from reaching into your pocket starting in April.

That is, unless you are served by regional home health intermediary Associated Hospital Service of Maine. "The Arkansas Part A Shared System is exempt from making the changes described," CMS said in its instruction mandating M0175 edits and takebacks. That means AHS providers are let off the hook, confirms the National Association for Home Care & Hospice in its analysis of the measure.

CMS decreed Oct. 24 that HHAs will have to pay back money they received for patient episodes in which a hospital stay wasn't marked when it should have been (see Eli's HCW, Vol. XII, No. 39, p. 306). And new edits will go into place to prevent such overpayments in the first place.

Although CMS expects M0175 recoupments to be only about one-tenth the size of the partial episode payment (PEP) funds also being recouped now, the takebacks are likely to rankle HHAs more than PEPs, suspects Bob Wardwell with the Visiting Nurse Associations of America. In most cases, agencies have put forth "honest efforts" to collect accurate hospital stay information to the best of their abilities.

"Since this money comes out of current PPS payments, it just means less care for current patients," Wardwell says.

It's very difficult for agencies to obtain accurate hospital stay information from all patients, notes OASIS expert Linda Krulish with Home Therapy Services in Redmond, WA. "Unfortunately, agencies have to go to so much effort to get information already known" by CMS and the intermediaries, Krulish laments.

HIPAA's privacy rule hasn't made it any easier to wring information out of referral sources and hospitals, points out consultant John Gaynor with the Chicago office of Frost, Ruttenberg & Rothblatt. Even though the law shouldn't prohibit information-sharing between entities for this purpose, it has made it more difficult in reality.

Many agencies don't pick up on the fact that some hospitals have beds designated for different purposes - acute stay, skilled nursing facility and rehab among them, notes consultant Rose Kimball with Med-Care Administrative Services in Dallas. And they often are operating under the misapprehension that they are supposed to check only one answer under M0175, instead of all that apply.

HHA staff often mark just the most recently concluded stay instead of the hospital stay and a following stay in a SNF or rehab facility, Kimball adds. That's where overpayments often occur.

As CMS and the RHHIs emphasize M0175 accuracy more, and agencies see reimbursement cuts due to the item, accuracy of that OASIS item is bound to improve, predicts reimbursement consultant Bobby Dusek in Abilene, TX. HHAs need to improve their intake processes and OASIS collection procedures to make that happen, notes consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD.

The good news is that like therapy down-codes, it appears the automatic RTPs and adjustments for M0175 won't count against agencies' in their denial statistics. That will help minimize difficulties emerging from focused medical review, among other things, notes Kimball, who formerly worked for RHHI Palmetto GBA.