Home Health & Hospice Week

CMS relents on assessing only overpayments for OASIS item on prior inpatient stays.

How confident are you in your current M0175 information-gathering practices? A recent victory by the home care industry won't keep you from losing up to $600 per affected patient if they aren't up to snuff.
 
Much to home health agencies' delight, the Centers for Medicare & Medicaid Services has agreed to identify mistakes stemming from the OASIS item on prior hospital, skilled nursing facility and rehab stays that work both for and against providers. "Medicare will ... identify both overpayments and underpayments that resulted from inaccurate reporting of prior inpatient discharges for Federal fiscal years 2001, 2002 and 2003," CMS says in July 30 Transmittal No. 95.
 
The move has industry experts cheering. "I'm really glad that CMS is doing this," says Bob Wardwell with the Visiting Nurse Associations of America. "It seems only fair," says Wardwell, a former CMS top official who has lobbied for the change.

"This is a very positive result," concurs William Dombi, vice president for law with the National Association for Home Care & Hospice's Center for Health Care Law. "It means that a lawsuit is unnecessary." NAHC had been preparing a lawsuit if CMS didn't relent on identifying underpayments due to unreported SNF and rehab stays, in addition to the overpayments resulting from unreported hospital stays (see Eli's HCW, Vol. XIII, No. 10, p. 74).
 
HHAs can lose nearly $200 on non-therapy patients and $600 on therapy patients when they fail to report a SNF or rehab stay only within 14 days of discharge. Conversely, if they report only the SNF or rehab stay without an existing hospital stay, they owe Medicare the same amount.
 
What to expect: The impact of CMS' decision to play fair with prior inpatient data will vary from agency to agency. The more unreported rehab and SNF stays, the more money the HHA will see returned or used to offset unreported hospital stays.
 
Experts are split on whether underpayments will equal overpayments. It's likely there will be "close to as many errors that resulted in underpayments" as overpayments, predicts reimbursement consultant M. Aaron Little with BKD in Springfield, IL. "Many times it's easier to identify whether a patient was in the hospital than it is to identify whether the patient was in a SNF/rehab," Little tells Eli, so unreported SNF and rehab stays are more likely.
 
Identification of SNF and rehab stays is especially tricky in rural areas, where swing bed hospitals don't require a patient to move beds or rooms to switch from hospital status to SNF or rehab status, Little explains. "If over the last three years clinicians primarily relied on scoring M0175 based on interviews with patients or inpatient facility discharge coordinators, it is likely that many OASIS [assessments] have been  inaccurately scored."
 
Balancing out over- and underpayments could result in a "minimal" net effect for HHAs, Little predicts.
 
On the other hand, Abilene, TX-based reimbursement consultant Bobby Dusek expects to see "many more instances of acute care hospitalization than patients released from SNFs or rehab hospitals," he says. That means more money owed to Medicare than to HHAs.
 
"There will be some for whom the positive adjustments will offset negatives and some where the negatives will still prevail," Wardwell predicts.

Stopping Underpayment ID a Cop Out

HHAs shouldn't get too used to Medicare cleaning up their M0175 mistakes. "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 says in the transmittal.
 
"If CMS can run both a down-code and an up-code computer program for 2001, 2002 and 2003, they can easily do it for future years as well," Dusek criticizes. "This seems to be the old standard that CMS will do anything to take money from providers but will not provide any programs that will actually assist providers."
 
Wardwell wonders "why CMS would build a system to catch the problems for three years, but not continue it. Why get into whose fault it is that something was missed if the right information is at CMS?"
 
It is much more difficult for HHAs than CMS to run a search of common working file data 15 to 27 months after discharge to catch unreported SNF and rehab stays filed at the end of the billing period, Dusek contends. "The providers do not have access to the database to do a computerized search of the records," he complains. "The industry needs to continue to push CMS and Congress if necessary so that the up-code file is produced each year as well as the down-code file."
 
NAHC and the VNAA also want CMS to re-examine the M0175 adjustment to the prospective payment system payment rate altogether. Docking agencies when a patient has a hospital stay is counter-intuitive, Wardwell maintains.
 
And counting long-term care hospitals in the "hospital" category for M0175, which reduces PPS payment for the patient, is unfair when the LTC hospital provides rehab services comparable to a SNF or rehab facility's, NAHC argues. NAHC wants CMS to revise the case mix adjuster "to reflect the nature of care provided by these facilities" and to hold off recouping any overpayments resulting from inaccurate identification of LTC hospitals, the association says.

Stay Vigilant on Prior Stays

HHAs that see their M0175 messes cleaned up for them in the first three years of PPS may let down their guard and fail to collect accurate SNF and rehab stay information, Dusek worries. "Agencies may lose a great deal of money that they are in fact entitled to," he tells Eli.
 
Protect yourself: HHAs "could lose money by not taking more initiative to verify inpatient stays on 2004 and future episodes," Little warns. Many agencies Little works with still struggle to utilize all resources to accurately score M0175, he says.
 
"Many agencies will forget to take that extra step to check for the SNF/rehab stay since CMS isn't planning to automatically do it for them," he worries.
 
To counteract the possibility, and the $600 per patient it could cost, agency billing staff must be able to identify episodes with possible SNF or rehab stay information missing and have a reliable process for verifying M0175 information prior to billing, Little advises. 
 
Editor's Note: The transmittal is at www.cms.hhs.gov/manuals/pm_trans/R95OTN.pdf.
 
For more information on M0175, sign up for a teleconference presented by BKD's M. Aaron Little and Karen Vance and sponsored by Eli Research and The Coding Institute, "M0175: Get It Right the First Time!" Details are at http://codinginstitute.com/conference/conference.cgi under "Upcoming Teleconferences."