Home Health & Hospice Week

A little bit of effort can save you up to $600 per episode.

You may feel the pinch as you pay back M0175 overpayments from the first year of PPS in the next few weeks. But the real loss may occur with your current OASIS reporting and billing.

Billing consultant Melinda Gaboury is concerned home health agencies aren't monitoring the OASIS item on prior inpatient stays and thus are cheating themselves of their rightful reimbursement. "There's probably a lot more of that going on" than mismarking the item resulting in overpayments, expects Gaboury, with Healthcare Provider Solutions in Nashville.

How it works: M0175 overpayments occur when HHAs 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.

Check Your Mail For Demand Letters

The Centers for Medicare & Medicaid Services agreed to calculate and recoup or distribute both over- and underpayments for the first three years of PPS. Demand letters for 2001 went out on Jan. 18 for most HHAs (see Eli's HCW, Vol. XVI, No. 2).

The problem: After fiscal year 2003, CMS will collect only M0175 overpayments. So if agencies mark an incorrect M0175 answer when they really should receive more money for that patient, they will lose that money.

The solution: Tighten up your M0175 practices, advises consultant M. Aaron Little with BKD in Springfield, MO. "It's never too late to re-examine agency procedures for correctly scoring M0175," Little urges. "We frequently find opportunities to improve the process for collecting this data and it's worth the little bit of extra time."

Common mistake: Agencies often mark a hospital stay when the patient comes out of any type of institution, Gaboury notes. "Don't just mark the hospital box if the patient comes from a facility," she stresses. It can be a $600 mistake if you mark a hospital stay in error when the patient also has a rehab or SNF stay.

This is a particular problem when the patient has had a swing-bed SNF stay that was in the hospital, Little offers.

Other M0175 mistakes BKD often finds are:

• Incorrectly scoring only one of multiple types of inpatient stays. Providers need to understand that the question asks them to "mark all that apply," Little says.

• Incorrectly scoring a hospital or other inpatient stay that was not within the 14-day period. Make sure you're counting the days for M0175 correctly, Little advises.

• Incorrectly scoring a SNF stay when a patient was actually discharged from a nursing facility. There's a difference between a SNF (Response 3) and other NF (Response 4)--check the OASIS User Manual's Response-Specific instructions in Chapter 8 for details.

• Incorrectly scoring a rehabilitation stay that was actually an acute hospital stay. This can be especially confusing if the hospital has rehab in its name but the stay is acute, experts point out.