Home Health & Hospice Week

V codes, manifestation codes and LUPAs may not work the way you think.

If you're looking for all your prospective payment system information in the final rule, you'll miss some vital details that could hurt your bottom line.

Old way: Under current PPS, any V code in M0230 or M0240 can trigger the case mix system to consider a diagnosis code from M0245 toward case mix.

New way: Under PPS refinements that take effect Jan. 1, only 25 V codes or code categories will trigger a possible M0246 payment.

The grouper "must be looking at a complete and appropriate V code before looking at M0246," explained Henry Goldberg of Abt Associates at the OASIS Certificate and Competency Board's first annual conference in Baltimore Nov. 12.

CMS lists the eligible V codes in the grouper pseudocode, Goldberg explains to Eli. The new PPS system will accept only V codes from that chart for payment purposes, said Goldberg at the conference that drew about 170 attendees.

Abt is the Centers for Medicare & Medicaid Services' contractor on a number of projects including PPS and pay for performance (P4P). OCCB administers COS-C credentialing and is CMS' contractor on certain OASIS issues.

"This information is not in the final rule," stressed OCCB's Linda Krulish at the session. Instead, home health agencies must wade through the grouper and pseudocode to ferret out this information. "It's extra stuff added to the final rule," noted Krulish, also with OASIS Answers in Redmond, WA.

Caution: If you fail to realize which V codes cause M0246 codes to count, you could think you have more money coming to you when you don't.

And you must realize that for the M0246 code to count toward payment, it must be in the same coding line as the V code that triggers it, Goldberg said.

Know When Your Manifestation Codes Count

Another area not covered in the final rule is etiology codes for manifestation codes, Goldberg noted.

Of the roughly 1,290 diagnosis codes that will now count as case mix codes, 184 are manifestation codes, Goldberg explained. ICD-9 coding rules don't allow coders to use manifestation codes first. Instead, those codes must follow a main etiology code.

Old way: Current PPS doesn't check what code a manifestation code follows.

New way: Under the refinements, the PPS grouper won't recognize a manifestation code "unless it's directly following an appropriate and complete etiology code," Goldberg emphasized.

Example: The manifestation codes 266.2 (B-complex deficiency NEC), 281.0 (Pernicious anemia) and 281.1 (B12 deficiency anemia NEC) will count toward case mix and payment only if 336.2 (Subacute combined degeneration of spinal cord in disease classified elsewhere) precedes it on the same line in M0230/M0240/M0246 in the OASIS assessment.

This could be a reimbursement drain if agencies fail to pair manifestation codes with the appropriate etiology codes, experts caution.

Don't Let LUPA Error Throw You For a Loop

HHAs could run into a problem of obtaining more money than is rightfully theirs under another PPS provision. A flaw in the PPS grouper will allow agencies to obtain payments for low utilization payment adjustment (LUPA) add-ons when they don't really apply, a CMS official confirms to Eli.

Because of the way CMS wrote the grouper, sometimes the system will award the $87.93 LUPA add-on intended for sole or initial episodes to patients' second episodes when they transfer agencies. This error "could cause some payment errors until the edits are corrected," notes consultant M. Aaron Little with BKD in Springfield, MO. "But I would not expect the errors to be too widespread."

CMS will correct the problem, but probably not until July 1, the CMS staffer says.

Not done yet: CMS is planning a reissuance of the grouper software to fix some other problems, however. Watch for corrected software on the CMS Web site "as soon as possible," the agency says in a release. The corrections will mostly fix diagnosis code-related software errors. 

Note: The grouper and pseudocode are available at www.cms.hhs.gov/center/hha.asp. At press time, CMS was aiming for a reissuance by Nov. 23.