Home Health & Hospice Week

Keep on top of PPS problems to ensure accurate payment.

M0110 is hard enough for agencies to get right, and now a recently discovered claims system problem is making the new OASIS question on episode se-quence even more confusing.

“Seems like these problems just keep creeping up,” observes reimbursement expert Bobby Dusek in Abilene, TX.

Problem: The Medicare claims system is in-correctly recoding episodes as early when they should be later because the Common Working File isn’t recognizing 2007 episodes in the sequence of episodes, regional home health intermediary Cahaba GBA reports on its Web site.

“Home health agencies with Cahaba that have previous episodes for patients listed in HIQH are being repriced at the point of billing the claim because the system is not recognizing the previous episodes,” explains reimbursement consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville.

Sit tight: “At this time, no action is required by providers,” Cahaba advises agencies. The RHHI has reported the problem to the Centers for Medicare & Medicaid Services, it says.

“This will definitely have an impact on agencies financially due to the reduction of payment,” says consultant Michelle Enger with Optimal Reimbursement Strategies in Clearwater, FL.

The impact of being bumped down from a later to early episode is “considerable,” Dusek warns. “A late episode will pay an average of 8 to10 percent more than an early episode,” Dusek figures.

There is wide variation across the HHRGs, but “the average is 10.97 percent for episodes with 0 to 13 therapy visits and 8.86 percent for episodes with 14 to 19 therapy visits” when episodes are downcoded based on M0110, Dusek calculates.

Example: HIPPS code 3CHMV, which indicates a late episode, and CBSA of 36100 pays $3,766.43, Enger points out. When downcoded for an early designation, the episode receives a HIPPS code of 1CHMV and pays $3,355.55. That is $411.00 less in payment, Enger says. What Can You Do? HHAs can’t fix the system problem themselves, but they can take plenty of steps to minimize issues that arise from prospective payment system billing errors, experts advise.

“Ultimately, the RHHI should adjust these errors and settle any monetary differences with the HHAs,” expects consultant Judy Adams with LarsonAllen based in Charlotte, NC. “But since there is no set time frame for the corrections, HHAs need to track these claims and be sure that the correct adjustments are made.”

In reality, “who knows if they will ever get it back,” Gaboury says of the underpayments.

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