Home Health & Hospice Week

Case mix overhaul demands fast action.

Come January, your staff's OASIS assessment skills will be even more vital to securing the payments your agency deserves.

The final rule on the home health prospective payment system, released Aug. 22 by the Centers for Medicare & Medicaid Services, makes significant changes in how the OASIS will be used to calculate case mix payment groups, notes Mark Sharp of BKD in Springfield, MO.

Time it right: The new PPS and the related changes to OASIS will go into effect Jan. 1. Because of the five-day window on OASIS assessments, Dec. 27 is the first date agencies can collect OASIS data that must be used for the new PPS, confirms Judy Adams with Charlotte, NC-based LarsonAllen.

CMS is working to make sure OASIS and HAVEN will be ready in time for Dec. 27, when home health agencies will have to start collecting the new PPS data, CMS' Pat Sevast assured stakeholders listening to a forum on proposed changes earlier this summer (see Eli's HCW, Vol. XVI, No. 20).

That means it's not a minute too soon to start training staff about the revisions--including a refresher on the need for OASIS accuracy in general.

Reality: Most agencies already spend plenty in labor costs related to catching and correcting OASIS errors, says Melanie Duerr of VNA of Hudson Valley in Tarrytown, NY. Training can help stop that drain on the bottom line--and will prove especially valuable now given the OASIS changes.

In revamping OASIS, CMS stuck closely to the plan laid out in its proposed rule. Here are the key ways the final rule affects OASIS coding:

• The final rule shakes up the items in case-mix calculations. As proposed, CMS will eliminate M0175 (From which of the following inpatient facilities was the patient discharged during the past 14 days?) from payment rate determinations starting next year.

Out with the old: In addition to dropping M0175 from the case mix, the final rule drops these items from the payment equation: M0530 (incontinence), M0440 (skin lesions) and M0610 (behaviors observed).

In with the new: Starting next year, M0800 (injectable meds) will be added to the list of OASIS items used to determine case mix.

• Like it or not, you'll have to determine if an episode is "early" or "late." The final rule creates the OASIS item M0110 (episode timing), designed to capture whether a given assessment is for an "early" or "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes (see Eli's HCW, Vol. XVI, No. 26).

Coding basics: For M0110, you can choose from these options: "early" for sole, first or second episode in a sequence of adjacent episodes; "later" for third or later episodes; "UK" for unknown if the HHA is uncertain of the episode timing and "NA" for not applicable when the assessment is not meant to define a Medicare case-mix group. The new claims system will assign an early episode if you choose "UK" as a re-sponse, resulting in less payment for the patient.

• You'll need to look carefully at all OASIS items related to diagnoses. The final rule modifies the format of these items to accommodate payment changes associated with patients' diagnoses.

Big change: Specifically, the final rule calls for M0246 (case-mix diagnoses) to replace M0245 (payment diagnosis). Why? The new payment system will assign points for some secondary diagnoses--and will assign points for some combinations of conditions in the same episode. M0246 will allow for multiple coding for both primary and secondary diagnoses.

The new system also includes clinical domain scores for infected surgical wounds, abscesses, chronic ulcers, gangrene, dysphagia, tracheostomy, and cystostomy. And it adds gastrointestinal, pulmonary, cardiac, hypertension, cancer, blood disorders, and affective and other psychoses diagnosis groups

Tip: The logic for determining both the primary and secondary diagnoses remains unchanged, coaches CMS in the final rule. The primary diagnosis is the condition most related to the current plan of care.

• There's a key new item related to therapy. The new PPS final rule introduces item M0826 (therapy need).

New and improved: This item will ask, "In the plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-pathology visits combined)?" This question contrasts with M0825's query regarding whether the projected number of therapy visits would meet the therapy threshold or not.

The new therapy thresholds are at 6, 14 and 20 visits with smoothing payments in between.

Expect More OASIS Changes

CMS issued the PPS final rule less than a month after it released a July 27 OASIS revised draft. That means more OASIS changes are on the horizon.

Eleven HHAs are slated to test that new tool this fall. If all goes as expected, those additional OASIS changes will take effect in early to mid-2009, a CMS official tells Eli.