Home Health & Hospice Week

New 'early/later' question could pose major billing problems under revised PPS.

Home health agencies M0175 payment troubles are nearly behind them, but there's a brand new OASIS question on patients' prior home health episodes that will cause agencies similar billing turmoil.

In its finalized prospective payment system revisions, the Centers for Medicare & Medicaid Services cuts OASIS item M0175 on patients' prior inpatient stays from the case mix calculation, but adds OASIS item M0110 on prior home health episodes. The question reads "Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an 'early' episode or a 'later' episode in the patient's current sequence of adjacent Medicare home health payment episodes?"

Definitions: "Early" means the first or second episode while "later" is a third or later episode. "Adjacent" means episodes don't have to directly follow one another but can be spaced apart up to 60 days, CMS confirms in the just-released final rule. And the definitions apply whether the subsequent or adjacent episodes take place at one HHA or across multiple agencies.

CMS will pay HHAs more for third or later episodes than early episodes. Despite industry arguments that initial episodes cost more due to administrative and visit frontloading, HHA cost report data shows more intensive costs in third and later episodes, CMS contends.

"M0175 is old news," insists reimbursement consultant Melinda Gaboury with Nashville, TN-based Healthcare Provider Solutions. For more accurate payment, agencies should begin focusing on getting M0110 correct once PPS revisions take effect Jan. 1. Get To Know Your Patients Even Better M0175 got HHAs into a lot of billing and compliance trouble, with millions of dollars in M0175 overpayments per year and a string of HHS Office of Inspector General reports on the item.

M0110 is likely to rival, if not surpass, the M0175 accuracy headaches, experts predict.

When the PPS revisions first take effect and agencies have to deal with the brand-new question, there's bound to be confusion and "some inevitable missed calls," forecasts Bob Wardwell with the Visiting Nurse Associations of America.

HHAs will actually have more difficulty answering M0110 than the expiring M0175, expects William Dombi, vice president for law with the National Association for Home Care & Hospice. That's because the question will require "agencies to have knowledge as to the patient's home health services use for as much as 121 days (two episodes plus a day)," Dombi tells Eli. And it actually may encompass more time, since the "adjacent" episodes can be up to 60 days apart themselves.

In contrast: M0175 requires patient history for only 14 days prior to admission.

Adjacent episodes will be even more difficult to determine than HHAs may think, warns Abilene, TX-based reimbursement consultant Bobby Dusek. The [...]