Medicare Compliance & Reimbursement

CMS backtracks on pledge to clean up HHAs' responses to tricky OASIS item.

Back in November, it looked like the Centers for Medicare & Medicaid Services would play fair with M0175. But home health agencies recently found out they could be out $600 per patient if they answer the OASIS item on prior rehab and skilled nursing facility stays incorrectly.
 
"CMS staff and management have reviewed this issue carefully over recent weeks and we have decided that upcoding home health PPS claims in these cases is not the appropriate course of action for the Medicare program," a CMS official announced in the Jan. 15 Open Door Forum for home care providers. "CMS has a duty to use Medicare's program management funds to protect the Medicare trust fund and Medicare program resources."
 
Former CMS Administrator Tom Scully pledged in the Nov. 5 forum to "try" to correct answers to M0175 either when the change benefits HHAs or Medicare. Scully made the move after an HHA calling into the forum said an internal audit uncovered that just one branch of the large agency had lost $20,000 due to the inability to identify SNF and rehab stays within 14 days of home care admission.
 
Providers had been bemoaning CMS' proposal to correct only M0175 answers that benefited Medicare - those that failed to identify a hospital stay within the 14 days. But now CMS has abandoned any plans to correct the OASIS item if it favors agencies. "By maintaining our current policy, CMS maintains the payment incentive for careful and accurate coding of home health PPS claims for payment," the CMS official claimed in the forum.
 
Agencies can look up rehab and SNF stay information in the common working file when admitting patients, CMS insisted. "By maintaining our current policy, CMS maintains a payment incentive for careful and thorough admission practices at the home health agencies," the official said.
 
And HHAs have up to 27 months to adjust claims if they later find out the patient had a relevant inpatient stay, because a rehab facility or SNF failed to file claims before the agency admitted the patient, the CMS staffer pointed out.
 
CMS will issue educational materials to agencies that will help them determine prior inpatient stay information, including a tool to assist in figuring out exactly when the 14-day window begins, CMS added.
 
Bob Wardwell with the Visiting Nurse Associations of America voiced agencies' frustration with CMS' one-sided payment policy. "I'm naturally disappointed to see that apparently someone has reversed Administrator Scully's decision on going after M0175 positive adjustments," Wardwell said in the forum.
 
"Historically CMS has taken the position that it's concerned with the correct payment of claims," maintained Wardwell, a former high-ranking CMS official himself. "And this is apparently, at least in my view, a new page where they're only concerned with making correct payments if it's in the benefit of the government."
 
"We're not a claims paying consultant for people in general," retorted a testy CMS official.
 
M0175 edits on current claims will begin April 1, and retroactive M0175 audits of prior claims will begin soon.