Home Health & Hospice Week

Deadline for correcting 2003 claims approaches.

You could be letting thousands of dollars in reimbursement slip through your fingers if you haven't reviewed your fiscal year 2003 claims for common errors - and time is running out on correcting them.

You have until Dec. 31 to find and correct mistakes on claims for episodes ending from October 2002 through September 2003, advises consultant Karen Crosby with accounting firm Abraham & Gaffney in St. Johns, MI. There are three areas where home health agencies are especially likely to find errors:

1. Underpayments for episodes with 10 or more therapy visits. "We're encouraging agencies to start looking at this to allow time to correct claims, because we're still finding people are losing money on therapy claims errors," Crosby tells Eli.

HHAs frequently shortchange themselves on the $2,000 per episode therapy upgrade by answering "No" to M0825 on the OASIS assessment, then furnishing 10 or more therapy visits.

Your fiscal intermediary does not automatically adjust payment upward for you, unlike when you predict the visits and don't deliver. "Medicare does not upcode, [it] only downcodes" automatically, warns Debby Cox with Astrid Medical Services, a Corpus Christi, TX-based billing company.

As long as the additional therapy resulted from an incorrect estimate - not from a significant change in condition (SCIC) - you can go back and correct the claim. To correct an underestimation you must go back and change the answer to M0825. Then, to correct the final claim, you must cancel the original request for anticipated payment (RAP), submit the corrected RAP, cancel the original final claim and then submit the new claim, explains Astrid's Lynn Olson.

2. Uninvestigated therapy downcodes. Don't just accept M0825 downcodes, advises consultant Terry Cichon with FR&R Healthcare Consulting in Deer-field, IL. Problems arise when an agency anticipates 10 or more therapy visits but submits the claim without 10 visits listed. Your FI will downcode this claim.

Or the FI can deny some of the listed therapy visits as not medically necessary.

Tip: Keep in mind your FI would be glad to find that some of your therapy visits didn't count, because then it wouldn't have to pay you the higher rate. Investigate every therapy downcode to verify that it is valid; frequently an agency fails to bill legitimate therapy visits, Cichon says.

3. Incorrectly billed SCICs. Billing SCICs when you don't have to can be a big financial drain, Cichon reports. HHAs sometimes forget that when you bill a SCIC, you get paid per day for each SCIC segment. But the days between the last visit of the first SCIC segment and the first visit of the second SCIC segment get completely cut out of reimbursement.

A SCIC early in the episode or one that adds therapy - changing the response to M0825 to "yes" - often results in a financial benefit to the agency, says consultant Judy Adams with Charlotte, NC-based LarsonAllen Health Care Group. But without calculating both portions of the episode (pre-SCIC and post-SCIC), you cannot determine if filing will gain or lose money for the agency, she adds.

Even if your computer system doesn't do the math for you, calculating whether to file a SCIC when the HIPPS code increases "is relatively easy," says Pam Warmack, president of Clinic Connections in Ruston, LA. Follow these steps to ensure your agency files optional SCICs only when they will benefit your bottom line: