Home Health & Hospice Week

Don't let CMS take away your rightful reimbursement.

You'll soon receive M0175 demand letters if you have an overpayment based on the OASIS item from 2001. Here's how to make sure the recoupments are valid, according to consultant M. Aaron Little with BKD in Springfield, MO.

1. Confirm the HIPPS code that was billed for that episode.

2. Look up the patient episode in the common working file (CWF) using the command 'HIQA.' You can also use 'ELGA,' but it provides a bit less pertinent data, Little offers.

Warning: Most home health providers access the CWF using 'HIQH' or 'ELGH,' but those commands will not provide you with the data needed to confirm M0175 information.

3. Utilize the 'APP Date' field on the HIQA/ELGA screen to locate the relevant data. "This will allow the provider to pull up the inpatient stay data closest to the date entered in the APP Date field," Little explains.

Example: When the date 03/01/2001 is entered in the APP Date field, the CWF will retrieve the benefit data relevant for that time point. "If no date is entered in the APP Date field, the CWF will retrieve only the current benefit information, which will likely be useless for confirming episode data from 2001," Little relates.

4. Compare the HIPPS code against the benefit data you retrieved from the CWF. If the HIPPS code billed contained an 'M' or 'K' in the fourth position, but the CWF indicates there was a hospital stay OR that there was no inpatient rehab/SNF stay in the 14 days prior to the episode start date, then the overpayment is likely to be correct, Little says.

However: Your records could indicate the dates, and therefore the downcodes, are wrong. "Because the CWF is only as accurate as the claims that are billed and paid, it's possible that the hospital/SNF/rehab billed incorrectly using the wrong dates or bill type," Little allows.