Home Health & Hospice Week

CMS reveals faulty downcoding when patients had a prior hospital stay and a SCIC.

You may have been the victim of invalid downcoding in the past year - and your intermediary will fix the problem only if you bring it up.
 
M0175 and significant changes in condition are two concepts that confuse lots of home health agencies. And apparently they've confused the Medicare claims processing system too, according to a Jan. 14 transmittal (Change Request 3616).
 
In April 2004, the Centers for Medicare & Medicaid Services implemented ongoing edits to check whether agencies answer the OASIS question on prior hospital stays (M0175) correctly, a CMS official tells Eli. If an agency indicates a patient had a skilled nursing facility or rehab stay in the 14 days prior to admission but no hospital stay, it receives an extra $200 for a non-therapy patient and $600 for a therapy patient episode.
 
The new edits started downcoding such claims, indicated with a "K" or "M" in the fourth position of the HIPPS code, if a hospital stay was present in addition to the SNF or rehab stay, reminds consultant M. Aaron Little with BKD in Springfield, MO.
 
The problem: When those edits went into effect, the claims system started to downcode both sections of a SCIC included on a claim, the CMS official explains. The system should downcode only the first section of the SCIC, because a hospital stay prior to admission wouldn't affect the second section of a SCIC that starts later in the episode.
 
The solution: In July, changes to the claims processing system will take effect ensuring that only the first portion of the SCIC gets downcoded when there is a qualifying hospital stay, the transmittal says.
 
In other words, the claims processing system will check for a prior hospital stay only against the earliest 0023 revenue code, an official with regional home health intermediary Palmetto GBA says.
 
The faulty M0175/SCIC downcodes began last April, when the M0175 edits went into place, says a staffer with RHHI United Government Services.
 
If HHAs want their intermediaries to correct M0175/SCIC downcoding problems, they must bring the affected claims to the RHHI's attention, adds a Cahaba GBA source.
 
Because SCICs are relatively rare, and SCICs containing incorrect M0175s are even less common, providers should see fairly few claims and limited reimbursement affected, expects Abilene, TX-based consultant Bobby Dusek.
 
"Based on RHHI reports, there are a very small number of claims affected nationally," the CMS source confirms.

Do You Exceed the 3% SCIC Threshold?

Agencies that bill a high proportion of SCICs will see more reimbursement affected, Little notes.

Red flag: But if HHAs bill more than 1 to 3 percent of their claims as SCICs, that's a danger sign anyway, Little warns.
 
Agencies billing more than that percentage as SCICs "have typically lost thousands of dollars by inaccurately billing the adjustments," Little relates. "I've yet to find an agency that has accurately billed a high percentage of SCICs."
 
"This most recent discovery of the claims processing error is just one more reason for agencies to critically examine their SCIC billing practices and perform an audit," Little urges. 
 
Editor's Note: The transmittal is at www.cms.hhs.gov/manuals/pm_trans/R427CP.pdf and a related Medlearn Matters article is at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3616.pdf.
 
Learn more about SCIC billing pitfalls, by ordering M. Aaron Little's Jan. 19 teleconference, "Boost Agency Revenue with Accurate SCIC Adjust-ment Billing," at http://codinginstitute.com/conference/tapes.cgi?detail=218 or by calling 1-800-508-2582.