Home Health & Hospice Week

5 Solutions to Beat Your OASIS Denial Blues

OASIS-based downcodes may flood your agency, but you can stem the tide by following these tips from the experts:

1. Share OASIS. Staff will have a tough time making sure their documentation supports the OASIS assessment if they don't know what's on it. Often, HHAs have OASIS specialists fill out the assessments, and rank-and-file nurses, therapists and aides make routine visits, notes Dilts-Benson.

In these cases, every visiting staff member should have a copy of the OASIS so they can document accordingly. Furnishing staff members with an OASIS copy "will give them a basis from which to make their own continuing assessments to how the patient is re-sponding to the POC," she explains.

2. Document the 23 M0 payment items. Teach your staff members to make sure their documentation supports those 23 OASIS items that set payment. "If you don't educate your employees on the front end, you'll pay on the back end," Dilts-Benson cautions. "And it's really hard to get off focused medical review."

For example, if the OASIS assessment documents incontinence of urine, then the condition should be assessed and documented, Dilts-Benson instructs.

3. Rethink pain assessment. If the OASIS describes a patient as having intractable pain but the visit notes say the patient is having no pain, you'll raise big red flags in addition to denials.

One problem is that staffers may be asking if the patient is having pain, and the patient answers that she isn't. But what the staff don't realize is that the patient is referring to pain only at the moment the staffer is asking the question, Kimball says.

Instead, have staffers ask "When is the last time you had pain?" Kimball suggests. Then patients are likely to answer in a way that gives a more comprehensive picture of their pain - for example, that they had pain that woke them up in the night.

4. Get the downcode 411. HHAs often lose money on OASIS-based downcodes because they don't even realize what they were downcoded for, Little says. "Many providers ... don't have a savvy biller who recognizes when payments are less than expected or knows how to identify why the claim is less," he tells Eli.

When agencies receive a full or partial denial/downcode, "the first thing to do is find out the exact reason for the denial," Little urges. If you don't know the reason from the denial code, call the intermediary and speak to someone in the medical review department if necessary, he advises.

5. Exercise your appeal rights. Once you've figured out why the claim is denied or downcoded, look over your documentation to determine whether you think the denial was warranted, Little recommends. If not, request a reconsideration of the claim at the intermediary level. HHAs are often successful at this first level of appeals, he adds.

If your intermediary upholds its denial, you can proceed to the administrative law judge level, notes consultant Pam Warmack with Clinic Connections in Ruston, LA. The amount of the denial must exceed $100 to go before the ALJ, Warmack points out. After the ALJ comes the Medicare Appeals Council and then the federal court system.

Don't forget: Starting this summer, you'll have to navigate a new second level of appeals at Qualified Independent Contractors (QICs) (see Eli's HCW, Vol. XIV, No. 10).

Editor's Note: You can find pointers on OASIS in Eli's OASIS Alert and tips on diagnosis coding in Eli's Home Health ICD-9 Alert, both available at www.elihealthcare.com or by calling 1-800-874-9180.