Home Health & Hospice Week

Have you increased your accuracy on this crucial OASIS item? 

You'll soon find out just how accurately you're answering an OASIS item on prior hospital stays, and the answer could cost you hundreds of dollars per patient.

Effective April 1, new pre-payment edits for M0175 will go into effect for home health agencies served by regional home health intermediaries Cahaba GBA, Palmetto GBA and United Government Services, Cahaba and Palmetto say in notices in their December provider bulletins. The edits will go into place May 1 for agencies serviced by Associated Hospital Service of Maine, the RHHI says in a Nov. 21 message to providers.

Under the edits, the claims payment system will check incoming requests for anticipated payment and claims against the patient's Medicare claims history.

If the HIPPS code on the RAP or claim indicates no hospital stay within 14 days of home health admission, but the claims history shows a hospital stay in that time, the system will return to provider the RAP or automatically bump down the payment level for the claim, the RHHIs explain. Agencies will have to correct and resubmit the RAP.

The M0175 downcoding will result in about $200 less for a non-therapy patient and about $600 less for a therapy patient, according to the HHS Office of Inspector General.

About 20 percent of the OASIS assessments Springfield, MO-based BKD has reviewed for accuracy have incorrect M0175 scores, says BKD consultant M. Aaron Little. That includes "both positive and negative adjustments," Little notes.

Prepayment edits aren't the only ones HHAs have to worry about. Annual post-payment edits, which will catch any claims that slipped through the cracks without reporting hospital stays, will recoup M0175-related funds, the RHHIs say.

"These would be inpatient claims that were received after the HH PPS claim had already been paid," the notices explain. "This post-payment identification is necessary because under Medicare timely [filing] guidelines, hospital claims may not be received for 15-27 months from the end of the hospital stay."

Adjustments Made Clear, RHHI Insists 

It will be clear when a RAP is RTP'd or a pre- or post-pay claim is downcoded based on M0175, Palmetto contends. The electronic remittance advice "will show both the HIPPS code submitted on the claim and the HIPPS code used for payment," the RHHI says. "A distinct remark code will also appear on the ERA for these claims." Remark code N180 says "This item or service does not meet the criteria for the category under which it is billed."

But agencies protest the remark code is way too vague to indicate a M0175 adjustment, and that they will have a hard time figuring out when claims have been adjusted based on the OASIS item.

M0175 adjustments are frustrating to the billing department because billers have little control over whether a clinician collects the correct information in M0175, Little says.

Even so, Little warns agencies against relying on the system to "clean up" M0175 answers automatically instead of searching out the correct information themselves.

"Agencies should be monitoring any billing/payment adjustments that they receive to ensure accuracy," Little recommends.

He points out that the claims payment system was supposed to automatically make partial episode payment (PEP) adjustments as well, but failed to do so in the first two-and-a-half years of the prospective payment system. Now, agencies are suffering an estimated $250 million in takebacks based on the error (see Eli's HCW, Vol. XII, No. 21, p. 162).

"I am an advocate for automation but I never advise or advocate that agencies be totally reliant on automation," Little adds.

Meanwhile, the Centers for Medicare & Medicaid Services says it still is considering paying agencies more for M0175 mistakes in their favor. CMS is "actively" looking at the matter and it is a "live issue," a staffer said in the Dec. 3 Open Door Forum for home health.

Former CMS Administrator Tom Scully told participants in the November forum that CMS would try to pay them for M0175 mistakes that benefit them, as well as taking away funds for mistakes that don't. But with Scully now departed from the agency, observers wonder if momentum for the measure will dwindle.