Home Health & Hospice Week

You'll have to rely on your own devices to keep your diagnosis coding correct under the home health prospective payment system grouper now in effect.

Old way: Formerly, the PPS grouper issued a data validation flag when home health agencies listed a manifestation code on a claim that would pay under PPS, but it lacked the required etiology code, explained Rich Fuller with CMS grouper contractor 3M. The flag wasn't intended to help agencies maximize payment, Fuller stressed in the Jan. 11 Centers for Medicare & Medicaid Services Open Door Forum for home care providers; it merely provided an opportunity for HHAs to check their diagnosis codes for errors, he explained.

New way: Under the new grouper that took effect for claims submitted Jan. 1 or later, the etiology and manifestation codes no longer have to be adjacent to one another, Fuller said. Now the HHA just must list the etiology code somewhere above the manifestation code in the case mix diagnosis code OASIS items, he said in response to a question from a forum participant.

However, another change accompanies that revision, Fuller said. Now the software checks only the case mix diagnosis code OASIS items for the match -- not all diagnosis code items.

Based on industry comment, the grouper will most likely change back to checking all the diagnosis codes, not just those in payment fields, Fuller predicted.

Other topics covered in the forum include:

• Outlier adjustments. When CMS put the10 percent cap on outlier payments into effect last year, there were two system problems that could result in over- or underpayments of outliers, CMS's Wil Gehne recalled in the forum. CMS detailed the problems in a May transmittal (see Eli's HCW, Vol. XX, No. 18, p. 139).

CMS made the system correction in October for the underpayment problem, but the correction for the overpayments took effect this month, Gehne explained in the forum. Adjustments for the overpayments have been processing this month and resulting in "odd reports" for those tracking such payments closely, he said.

If you haven't seen adjustments yet, you will shortly, Gehne pledged. You can contact your HHH MAC for more details about the individual outlier claim adjustments.

• CAHPS. Don't miss some important CAHPS deadlines this month. The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) exemption form is due Jan. 21, and CAHPS vendors must submit their third  quarter 2011 data by Jan. 23, CMS's Randy Throndset reminded providers in the forum.

If you appealed CMS's determination that you didn't submit CAHPS data for 2012, you already should have seen the response to your reconsideration request, Gehne said in response to a caller question. MACs should have mailed those letters by Dec. 28, he noted, so contact your MAC if you haven't received yours yet.

To help avoid having to appeal such a decision in the first place, you should check that your CAHPS vendor is submitting your data as agreed, Throndset advised. You can access the data submission report on the CAHPS website. Detailed instructions are online at https://homehealthcahps.org/HHAGuidanceforDataSubRept.pdf.

• OASIS. CMS will post its annual consolidation of 2011 questions and answers shortly at www.qtso.com/hhadownload.html (click on the "OASIS" link on the left and scroll down). Under the consolidation, CMS takes the four quarterly Q&A sets and organizes them under headings, noted CMS's Pat Sevast.

CMS has also posted the 2011 revisions to its OASIS-C User's Manual and OASIS-C PBQI Manual, pointed out CMS's Robin Dowell in the forum. And CMS has issued updates to the regression models for risk adjustment. The updates are available via the www.cms.gov/homehealthqualityinits website.