Reimbursement:
Turn M0175 Losses Into Gains
Published on Thu Apr 15, 2004
Follow these experts' tips to estimate your M0175 takebacks - and mitigate them. If you're still struggling to figure out how much will come out of your pocket when retroactive M0175 recoupments hit this summer, you're not alone.
The percentage of takebacks found by the HHS Office of Inspector General in its series of reports on home health patients' prior hospital stays "is astounding to me," says consultant M. Aaron Little with BKD in Springfield, MO. "These statistics imply that all agencies could certainly be affected by takebacks," Little tells Eli.
The Centers for Medicare & Medicaid Services estimates each Medicare home health agency will owe $4,000 per year since the prospective payment system started in October 2000. But that is a generalization, and "determining the actual dollar amount will depend on the accuracy of each agency's OASIS data collection practices," Little notes.
HHAs trying to generate or fine-tune their M0175 estimates can try these steps: Identify M0175 targets. The M0175 recoupments will affect only claims that billed for a rehab or skilled nursing facility stay without a hospital stay in the 14 days before admission - a nearly $200 difference for non-therapy patients and nearly $600 for patients who received 10 or more therapy visits.
Tip: When looking for claims to sample, choose those with a service utilization domain score of "low" or "high," advises Bill Gardner, consultant with American Express Tax & Business Services in Timonium, MD. That means an S1 or S3 in the home health resource group. Those are the claims that contain the point for no hospital stay and the two points for the rehab or SNF stay.
In other words, episodes with a "K" or "M" in the fourth position of the HIPPS code should be sampled, Little explains. They are the ones that get downcoded to "J" ("minimum" service utilization domain score) or "L" ("moderate" service utilization domain score), respectively, when there is a non-marked hospital stay.
Many agencies' billing or information systems should be able to pull out those K and M claims for them in reports, Gardner says. Audit the claims. Choose a random sample of your K and M claims, perhaps 50 charts or so, Gardner suggests. Review the medical record for the claim carefully to see "if somewhere in the chart there is some indication of the stay," he says.
In its recent report reviewing M0175 mistakes for HHAs served by regional home health intermediary Cahaba GBA, the OIG insisted "in 28 of the 30 claims reviewed, the beneficiary's medical file maintained by the HHA indicated that an inpatient hospital discharge occurred within the 14 days preceding the HHA episode" (see Eli's HCW, Vol. XIII, No. 13, p. 100).
Go the extra step: Just looking [...]
