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.

Try this: When reconciling claims, post the payment that is received, even if you know it’s incorrect, and record a positive or negative balance on the accounts receivable, advises consultant M. Aaron Little with BKD in Springfield, MO. “The balance will serve as a reminder that the episode did not pay correctly and that Medicare will likely run edits at some point … to reprocess and correct the payments,” Little explains.

Know the Ins and Outs of PPS Billing

Whatever you do, don’t just take CMS’ word for it that you’re receiving correct payments. “Billing staff need to understand the current problems, recognize when received payments are incorrect and understand if the error relates to one of these issues,” Little urges.

Billing staff must “monitor all differences between billings and adjustments on the remittance advice,” Adams stresses.

Hone M0110 skills: This OASIS item highlights more than any other the need for clinical and billing staff to talk to each other, Little notes. “Even though M0110 is an OASIS question, it requires good communication with the billing/clerical staff that are typically checking the CWF in order to answer the question with any accuracy.”

Don’t just count on the system to figure out M0110 for you, experts advise. “HHAs should make every effort to get the correct information for M0110 between their clinical and clerical staff,” Adams counsels.

In fact, billers should understand all the PPS payment drivers--particularly M0110, M0826 on therapy, and Nonroutine Supplies (NRS) …quot; and how those drivers are represented in HIPPS codes. “This is critical knowledge needed in reconciling payments,” Little emphasizes.

Go a step further: Dusek urges that agencies not wait around for their intermediary to fix their M0110-related errors. “If the agencies have filed a final claim where the episode has been downcoded, then I would recommend that agencies file an appeal on any claims where the agency knows that episodes were provided in 2007,” Dusek tells Eli. “Even though Cahaba states that action is not required by agencies, they are the ones that have been underpaid.” The 8 to 11 percent of reimbursement at risk can make this appeal worth it, Dusek says.

Meanwhile: HHAs should have one less PPS claims system error to deal with. Regional home health intermediaries have tested a fix and installed the software for a problem discussed in the latest home health Open Door Forum, a CMS staffer tells Eli.

Under that error, the system was returning to provider claims that had an episode that began in 2007 but had a first date of service in 2008 (see Eli’s HCW, Vol. XVII, No. 9).

However, CMS hasn’t set a date for a fix to another problem discussed in the forum, the CMS source says. In that error, the system applies a low utilization payment adjustment (LUPA) add-on to every line item in a claim, instead of just once to the entire claim.

Note: Cahaba’s M0110 notice is at www.cahabagba.com/part_a/claims/processing_issues.htm.