Home Health & Hospice Week

You may have to adjust your PT eval timing, according to CMS.

If you feel like there are a million things to do between now and Jan. 1 with little time to do them, you're not alone.

Attendees at the OASIS Certificate and Competency Board's first annual conference in Baltimore Nov. 12 were feeling the same way. "There's not enough time to do this," exclaimed one attendee during the session examining how the prospective payment system grouper will use OASIS data to calculate payment levels.

More attendees told Eli they hadn't started their PPS refinements staff training yet.

But diagnosis coding of your patients shouldn't change, stressed Abt Associates' Henry Goldberg in the session. "You're not supposed to change anything," he said of diagnosis coding. "Don't mold your coding to the new guidelines."

You should already be coding your patients and completing OASIS accurately, Goldberg noted. Just continue to do so and work toward understanding how that will affect reimbursement under the prospective payment system refinements that take effect Jan. 1.

"Paint the picture of your patient" with diagnosis coding, urged Sparkle Sparks with OASIS Answers in the session. Don't focus on whether it brings you more reimbursement, but whether it accurately depicts the patient, said Sparks, who taught two days of intensive coding training at the OCCB conference Nov. 13 and 14.

The new system is so complicated, it will be hard to change your coding to your advantage anyway, suggested Gene Tischer with the trade group Associated Home Health Industries of Florida. "Less than 1 percent of us are intelligent enough to game the system," he joked.

It's a Brave New Coding World

That said, the way diagnosis coding will affect payment will be changing drastically under PPS refinements, the experts admitted. The coding OASIS items, M0230/M0240/M0246, have a totally different look on the assessment form--a four-column box asking on one line for 1) the M0230 primary or M0240 other diagnosis description; (2) the corresponding ICD-9 code and its severity; (3) the M0246 case mix diagnosis if it's bumped out of column 1 and 2 with a V code (optional); and (4) the M0246 case mix diagnosis if it's a manifestation code that was bumped (optional).

PPS will use codes from all six lines in the box, Goldberg stressed. "It's important to pay attention to all six positions," he advised.

Remember: Only one diagnosis per line in the box scores case mix points, he reminded attendees. And for bumped case mix and manifestation codes in M0246 to count, they must correspond to the correct V code or etiology code on the same line.

"Welcome to the new world," said Pat Sevast with the Centers for Medicare & Medicaid Services in a separate session at the conference. The new PPS will give much more consideration to diagnosis coding and related conditions in the case mix system.

"It's no longer just primary diagnosis," Sevast noted. "It's not the same as before and it's not simple." (See Eli's HCW, Vol. XVI, No. 35 for more details on coding-related clinical dimension changes under PPS refinements).

M0110 Will Give Billers New Headaches

A completely new OASIS item--M0110 on whether the patient is in an early (first or second) or later (third or later) adjacent episode--will require more work from agencies.

Pitfall: The tricky part will be figuring out episode sequence in light of the definition of "adjacent episode" that allows 60-day gaps.

Example: A patient seen by another agency for two episodes, discharged and referred to you 30 days later, will be in a third (later) episode. The episode designation totally changes the grouping step and thus the points awarded under the case mix system.

Good news: At least CMS will auto-adjust M0110 during billing for the correct answer, Sevast noted. The agency will move payments both up and down automatically based on information in the Common Working File.

Auto-correction will bring its own headaches for billers trying to reconcile payments with claims submitted, but at least agencies won't rack up overpayments like they did with the current OASIS item on prior inpatient stays, M0175. (PPS will be cutting M0175 from payment consideration starting Jan. 1.)

And agencies will more often accidentally code a patient as an early episode when they're really in a later one. Because patients garner more payment for later episodes, agencies likely will find they have money coming to them under the auto-adjustment.

Rethink Your PT Strategy

Another big change for the OASIS form is M0826, the new item on therapy utilization. Where the current M0825 asks only whether the patient will exceed the therapy threshold, the new item asks for the specific number of therapy visits.

When an attendee asked Sevast whether the PT eval needs to be completed before filling out M0826, she responded "I'm going to say yes."

For the new item "there should be a reason you put the number down, based on the plan of treatment," Sevast instructed.

CMS will also auto-adjust for M0826 answers, Sevast reminded providers. And agencies won't have to go back and revise their OASIS data when the claims get auto-adjusted for M0110 or M0826.

Don't forget: HHAs should pay attention to the OASIS assessment requirements for the five-day window at the end of the year, urged OCCB's Linda Krulish at the session. Agencies will have to use "artificial dates" to get the system to assign the correct year's payment code for certain episodes (see Eli's HCW, Vol. XVI, No. 39 for details on figuring out when to use different M0090 dates). And they will have to know which OASIS form to use--the old or new one--for which types of assessments on which days.

Key: Your staff have to be able to access both OASIS datasets during that five-day window, Krulish stressed. You'll be initiating both 2007 and 2008 episodes during that time.

Out of luck: Agencies hoping to use up their stock of current OASIS forms will be disappointed with CMS' ruling on that issue. In its latest quarterly Q&As, CMS says it won't allow use of the current OASIS form (OASIS-B-1 12/2002) after Jan. 1. HHAs will have to use the new updated form (OASIS-B-1 1/2008), even if they had planned to use an addendum with the new or changed OASIS items.

The new forms have too many new items and patterns to allow old form usage after Jan. 1, Sevast explained.

Note: The new OASIS dataset is available for download at www.cms.hhs.gov/HomeHealthQualityInits/12_HHQIOASISDataSet.asp.