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Home Health & Hospice Week

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 through the file isn't enough if you want an accurate picture of your M0175 mistakes, Gardner cautions. You may have to call referring facilities, referral sources and/or patients to get to the bottom of potential previous stays.
     
    Even then, there's no guarantee your fact-finding mission will turn up the real answer on whether a patient had a hospital stay in the time period indicated, Gardner acknowledges. "You don't know if it's the correct information," he laments.

     

  • Reserve. Take the error rate you've calculated for your sample and apply it to the entire universe of K and M claims you billed in that time period, Gardner counsels. Then reserve against that percentage.

    Don't Let Rehab & SNF Dollars Get Away
     
    M0175 takebacks for unreported hospital stays will be no fun for most HHAs, and could be significant hardships for some. But there is a way to capitalize on the issue, Little suggests.
     
    It may be worth your while to go through the first two steps of the M0175 process for J and L claims as well as K and M ones. "In our OASIS accuracy audits, which are not limited exclusively to K/M or J/L episodes, we have found that agencies inaccurately reported prior hospital stays 8 percent of the time," Little reveals. "However, we have found that agencies inaccurately reported prior SNF/rehab stays 11 percent of the time."
     
    That means you could make more money rebilling for J and L claims that deserve upcodes than CMS will take away for K and M codes that deserve downcodes.
     
    How to do it:     To correct a J or L claim that really should be a higher-paying K or M bill, "agencies would need to make a correction to the OASIS on file with the state first and then cancel and rebill the RAP and final claim with the new HIPPS code," Little explains.
     
    But you have to decide if it's worth the effort of manually auditing all your J and L charts, Gardner says. He advises conducting a small random sample - if you find you've missed enough SNF and rehab stays in that sample to make it worth the time, go ahead and investigate more of your past J and L claims.
     
    You also must remember that HHAs are allowed to correct claims only back to Oct. 1, 2002, Little says. On the other hand, CMS is recouping M0175 funds a full two years earlier than that, when PPS began. That double-standard timeline is one of the issues that may be covered in a lawsuit the National Association for Home Care and Hospice is preparing.

    Keep Your Eye on the Prize
     
    The most important thing is for HHAs to tighten up their M0175 procedures "from today forward," Gardner suggests. That's especially true in light of the ongoing M0175 edits CMS put in place April 1.
     
    "The real issue at hand is OASIS accuracy," Little agrees. "These statistics demonstrate the importance of continued education on accurate and effective OASIS data collection practices ... to improve not only reimbursement, but regulatory compliance as well."
     
    Gardner suggests agencies adopt practices similar to those for the 10-visit therapy threshold. Some HHAs "have excellent processes" verifying that when billing for 10 or more therapy visits, the visits actually were delivered, he notes. Likewise, when agencies almost hit the threshold - eight or nine visits - some agencies look closely to make sure they didn't actually deliver 10 visits and deserve the reimbursement upgrade.
     
    HHAs can adopt similar procedures for hospital, SNF and rehab stays, he recommends.

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