Home Health & Hospice Week

CMS offers clarification on how to answer the OASIS therapy item.

Don't overlook one important facet of M0826 if you want to ensure correct payment--how to answer the OASIS item on therapy for a resumption of care assessment.

In response to a question in the recent home health Open Door Forum, the Centers for Medicare & Medicare Services sent an email to providers clarifying how home health agencies should complete M0826 for ROCs.

The question: Can agencies mark N/A (Not Applicable) for M0826 for ROC assessments?

The answer: Usually yes, but not always.

"Since the NA response actually reads 'NA Not Applicable: No case mix group defined by this assessment,' it would be an acceptable response for a Medicare patient when the assessment will not be used to define a case mix (as in most ROC situations)," CMS explains in the email.

The exception is when the ROC assessment is also in the last five days of the patient's episode and will be used to set the HIPPS code for a new episode. In these instances, "the M0826 response will require a projected number of visits for the upcoming episode," CMS says.

CMS points agencies to an upcoming OASIS question-and-answer that the OASIS Certificate and Competency Board will issue next month. "When a ROC assessment will be 'used as a recert' ... then the ROC data will be necessary to define a case mix (payment) group," the Q&A says. In that case, "the total number of therapy visits planned for the upcoming 60 day episode should be reported."In other words, "N/A should be used when the agency is not billing Medicare PPS or requesting a Medicare case-mix group," explains reimbursement consultant Michelle Enger with Optimal Reimbursement Strategies in Clearwater, FL.

"M0826 is a prediction question and needs to be answered any time a HIPPS code is required," adds Abilene, TX-based financial and billing consultant Bobby Dusek.

Software requirements: "Vendors will need to determine how to accommodate either scenario," CMS adds in the email.

Settle on Your M0826 Strategy

However: Some states aren't accepting OASIS assessments with an N/A in M0826, says consultant Judy Adams with LarsonAllen based in Charlotte, NC. "There seems to continue to be conflicting information from the state OASIS educators," Adams tells Eli.

Some HHAs also have software that won't let them enter that response in the OASIS item, Adams points out. One such agency called into the forum, prompting CMS to clarify the issue.

Try this: Agencies may want to enter 000 in M0826 instead of N/A, Adams suggests.

Or just enter the total number of therapy visits for the episode in M0826 every time, Dusek offers. "There is nothing wrong with answering the question on every OASIS even though a HIPPS code is not required," he points out. "The benefit of this approach is that the clinician completing the OASIS does not have to make a determination if a HIPPS code is required, they just answer the question."

Tip: If you do decide to enter the number of therapy visits for ROCs, be sure to tally the visits from both before and after the patient resumes service, Adams reminds providers.

"The number of therapy visits should always be the total number expected to be provided during the episode," Dusek agrees.

Pitfall: If agencies plan "to enter the actual tally of therapy visits pre and post ROC, there needs to be communication with their IS vendors to avoid assigning the HIPPS generated at the ROC to the end of episode claim," Adams cautions.

Agencies can decide how to tackle the M0826 issue for ROCs based on what works best for their own organization, CMS says.

Your choice: "If the ROC assessment will not be used to determine payment, then it does not matter which of the ... approaches an agency chooses," the Q&A advises.

Note: The CMS OASIS Q&As distributed by OCCB are at www.oasiscertificate.org --click on the "Resources" button.