Home Health & Hospice Week

 Do you know your way around ELGA? The Centers for Medicare & Medicaid Services has come through on its promise to help home health agencies answer M0175 better.

CMS gives instructions on how to access patients' prior stay information via the Common Working File in a new provider education article. The information should help HHAs answer OASIS item M0175 correctly more frequently.

And the help is coming just in time. Agencies that use Astrid Medical Services to process their reimbursement claims "are seeing RTPs everywhere" for claims with an "M" in the HIPPS code, Astrid's Lynn Olson tells Eli. Starting April 1, an edit began returning to provider (RTP'ing) claims that fail to mark an inpatient stay within 14 days of home health admission.

To help determine whether a patient had an inpatient stay -- hospital, skilled nursing facility or rehab facility -- you can access the CWF, CMS explains. And you should get used to the acronym ELGA, which has replaced the old HIQA inquiry screen. On page 1 of ELGA, agencies should zero in on these items:

FULL HOSP: number of fully covered hospital days remaining to the beneficiary.
FULL SNF: number of fully covered SNF days remaining.
DOEBA: date of earliest billing action, representing admission date of the hospital claim that started the spell of illness.
DOLBA: date of latest billing action, date of latest inpatient claim in the period; can represent date of discharge from the inpatient facility.

Medicare fully covers 60 hospital days and 20 SNF days, CMS says. So if the number under FULL HOSP is less than 60, because the patient used some of the days, the patient has been hospitalized during the spell of illness.

Watch out: The trick is, the ELGA screen doesn't show whether those FULL HOSP days are acute care or rehab facility days. You'll have to ask the beneficiary and referral sources to find out for sure.

Likewise, if the number under FULL SNF is less than 20, the patient had an inpatient SNF stay during the spell.

Hospital, rehab facility and SNF stays matter for M0175 only if they are within 14 days of admission. That's where DOLBA comes in.

If the FULL HOSP or FULL SNF columns indicate some type of inpatient stay, check to see if the DOLBA is within 14 days of the home health admission. If so, mark the appropriate type of stay. If not, mark NA. (See "Don't Oet 15-Day Window Close On You", for tips on counting the days).

If you miss an inpatient stay that you should have marked along with a SNF or rehab facility stay, CMS will dock you about $600 for a patient that breaks the 10-visit therapy threshold and $200 for a non-therapy patient. [...]