Home Health & Hospice Week

HHAs still getting this OASIS question wrong could be in hot water.

The HHS Office of Inspector General thinks you should be trying harder to secure correct information for M0175.

Home health agency staff should contact post-acute care facilities to see if patients also had a hospital discharge within 14 days of admission to home care, the OIG says in a new report on M0175 errors.

Thirty post-acute care facilities the OIG contacted "informed us that they were able to readily access hospital discharge dates through various documents included in the beneficiaries' medical records," the report notes. And the facilities say they often include hospital discharge dates in the referral information they provide to agencies.

"Postacute care facilities are the most reliable source of the information that HHAs need to complete question M0175 on the OASIS," the OIG maintains.

The tab: HHAs received more than $48 million in erroneous payments in fiscal years 2002 and 2003 combined due to marking a rehab facility or skilled nursing facility stay without also marking an existing hospital stay in the 14 days before admission, the OIG estimates. That figure is similar to the OIG's earlier estimate that agencies received $23 million in error for the same problem in the first year of the prospective payment system.

Beware M0175-Sparked Medical Review

Agencies may have thought the M0175 scrutiny would let up once the Centers for Medicare & Medicaid Services implemented pre- and post-payment review for the troublesome OASIS item a year ago. But the problem isn't fixed, the OIG warns in the report.

"Further actions are necessary at the HHA level because HHAs can bill incorrectly and receive Medicare payments before hospitals submit their claims," the OIG says.

"In other words, when hospitals submit their claims after HHAs submit theirs, CMS will not identify the HHA billing errors until the postpayment review. The resulting overpayments will need to be recovered through offset or collection activities," the OIG explains.

The OIG also may be worried about what M0175 accuracy means for the reliability of the rest of the data collected by OASIS, suggests consultant M. Aaron Little with BKD in Springfield, MO. "If M0175 is consistently found to be incorrectly scored, what other OASIS items have a pattern of incorrect answers?" Little asks.

Watch out: The OIG urges CMS to crack down on agencies billing M0175 incorrectly, and CMS agrees that it will. "If certain HHAs continue to submit claims improperly, contractors will follow the Progres-sive Correction Action plan and take appropriate action to ensure that claims are submitted appropriately," CMS says in its response to the report.

In other words, "agencies could become targets for medical review if their M0175 adjustments are high," Little warns.

M0175 More Trouble Than It's Worth

High error rates during the report's time period, the second and third years under PPS, are expected because M0175 "wasn't on anyone's radar," Little notes. In fact, the OIG found that agencies improperly coded all 400 claims it sampled for 2002 and 2003.

HHAs have since redoubled their efforts to get the data correct, reports Bob Wardwell with the Visiting Nurse Associations of America. But there's only so much agencies can do.

Between poor information given by sick or confused patients and difficulty getting information out of hospitals, "it's hard to get the level of prior-stay data that is available years later in the CMS database that OIG taps," protests Wardwell, a former top CMS official.

And calling post-acute facilities for every patient just isn't feasible, Little says.

Even if you do, "that does not mean they are going to respond accurately, or at all," Wardwell tells Eli. Sometimes agencies don't even know if a patient has been in a post-acute facility.

Wardwell hopes CMS eventually will do away with this OASIS question as a payment factor altogether. "It's a shame for folks to spend so much effort on this when agencies would rather be giving care and [intermediaries] and OIG would be better off looking for real crooks," he insists.  

Did You Know?

 M0175 overpayments come about when home health agencies fail to mark all the correct responses to the OASIS item on prior inpatient stays.  If they mark that the patient had a rehab or skilled nursing facility discharge without also marking that the patient had a hospital discharge in the 14-day time period prior to admission, the episode receives an extra point in the service utilization domain.

That extra point bumps the HIPPS code up from a "J" or "L" in the fourth position to a "K" (without therapy) or "M" (with therapy). That results in an extra $200 for a non-therapy patient and an extra $600 for a therapy patient.

Underpayments occur when the reverse happens--agencies mark a hospital stay without a rehab or SNF stay when one occurred.

Source: HHS Office of Inspector General.