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Home Health & Hospice Week

Reimbursement:

These M0175 Problems Stick In HHAs' Craws

Published on Thu Nov 06, 2003

Difficulty obtaining accurate M0175 information isn't the only problem the home care industry sees with the impending edits and takebacks related to the OASIS item regarding prior hospital stays.

Other problems agencies have include:

  • Downcoding versus upcoding. CMS is quick to make system changes to take back money when a M0175 error gives an agency extra money, but it's doing nothing about the opposite situation - when an HHA failed to mark a rehab or SNF stay in M0175 that would bring them higher reimbursement. "An analysis should be carried out on the impact of incorrect responses to M0175 that resulted in lower payment to home health agencies, as well as those resulting in higher payment," insists the National Association for Home Care & Hospice.

    It comes as no surprise that CMS is quick to downcode and not upcode, even if it's "unfair," notes reimbursement consultant Bobby Dusek in Abilene, TX. It's the same logic that applies to therapy reimbursement - if an HHA claims 10 or more visits but doesn't provide or bill for them, the system downcodes the claim. But if they provide those 10 or more visits and don't claim them in billing, the system doesn't pay more.

    "They never want to pay out money if they don't have to," observes consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD. "You have to work for it."

  • Budgeting. A M0175 downcode will mean less money for the episode, and agencies' systems may not be equipped to show the change. That will lead to HHAs thinking they have more money coming in than they actually do, warns Linda Krulish with Home Therapy Services in Redmond, WA.

  • Retroactivity. The retroactive, post-pay edits take away from one of the strengths of the prospective payment system - keeping revenues fairly stable and predictable for HHAs, says Bob Wardwell with the Visiting Nurse Associations of America. "It's hard enough to manage an HHA these days without always looking over your shoulder and wondering how much of the Medicare revenues you have will be subject to retroactive recovery four years from now," Wardwell observes. He urges the Centers for Medicare & Medicaid Services to limit recoupments to a few months at most.

  • Case mix. It's counterintuitive that the PPS case mix system pays agencies less money for patients who have a hospital discharge, NAHC claims. Patients discharged from a hospital generally require more intensive services. NAHC asks CMS to reevaluate that case mix item.

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