Medicare Compliance & Reimbursement

HHAs should prepare for scrutiny of this high-dollar OASIS coding revision.

There will be no more free lunch when it comes to counting healed pressure ulcers on OASIS.

That's the message the Centers for Medicare & Medicaid Services is sending with a new policy change to how home health agencies should code healed pressure ulcers on OASIS.

Effective Sept. 1, HHAs should not count healed Stage 1 or Stage 2 pressure ulcers in M0440 (Does this patient have a Skin Lesion or Open Wound?) and M0445 (Does this patient have a Pressure Ulcer?), CMS instructs. So unless the patient has other qualifying ulcers, clinicians should respond "No" to both questions when the patient has healed pressure ulcers that were Stage 1 or 2 at their worst.

"Prior guidance on healed pressure ulcers to not 'reverse stage' a Stage 1 or Stage 2 pressure ulcer no longer applies," CMS explains in the notice posted to its OASIS Web site.

The prohibition on reverse staging for Stage 1 and 2 ulcers does still hold true while the wound is healing, however. During healing "a stage 2 pressure ulcer does not become a stage 1 pressure ulcer; it remains a stage 2 pressure ulcer until it is healed," CMS says.

The change's reimbursement impact could pack a wallop. An OASIS item not mentioned in CMS' missive, M0460 (Stage of Most Problematic [Observable] Pressure Ulcer), especially could cost agencies big. "Under the old rule ... a patient with a Stage 1 or 2 ulcer would receive 15 points at M0460" if the healed ulcer was the most problematic (i.e., probably the only) one, explains clinical consultant Pam Warmack with Clinic Connections in Ruston, LA. "These 15 points are applied regardless of the healing status of the ulcer, since the question does not ask the healing status but only the stage," Warmack tells MLR.

Now, HHAs could lose 15 points for multiple episodes of care, Warmack summarizes. And while 15 points doesn't sound like much, it can knock a patient's clinical domain level down one or even two categories, which can add up to a whopping $900 per patient.

Likewise, in M0440 the patient could lose 21 points in the clinical domain score, although only if she has a burn or trauma diagnosis.

For example: Losing 15 points could put a serious dent in agencies' reimbursement. A patient who has 41 points (C3) could drop to 26 points (C2) for a loss of $887 depending on the functional and service scores, Warmack explains. And a patient who drops from 20 points (C2) to 5 points (C0) could rack up a loss of $597, before wage index calculations.

"Assessment accuracy results significantly affect reimbursement," Warmack warns.

And with this much money potentially on the line, you can be sure authorities ranging from the intermediaries to the HHS Office of Inspector General will be putting this OASIS topic under a microscope, observers caution.

The fraud spotlight that's sure to come could catch many agencies unaware and with poor training on these OASIS items.

Confusion surrounding the pressure ulcer questions already abounds, contends clinical consultant Lynda Dilts-Benson with Reingruber & Co. in St. Petersburg, FL. Those OASIS items "haven't been done right in the first place," with many clinicians often failing to record healed pressure ulcers, she says.

HHAs only shortchange themselves by leaving pressure ulcers off OASIS, so the feds haven't focused on it as a problem area even if it makes OASIS data unreliable.

But now that the rule has changed, if agencies record ulcers they should leave off OASIS, the mistake certainly will receive a lot more attention thanks to the overpayment implications.

Beware the Red Flag Pressure Ulcer Mistakes Will Send Up

And mistakes in pressure ulcer coding will be a red flag for intermediaries and others, motivating them to comb through HHAs' OASIS document and medical record, looking for other errors that could prove very costly, Dilts-Benson warns.

Some clinicians are likely to be confused and upset about this new policy change because reverse staging rules seem counterintuitive, predicts clinical consultant Karen Vance with BKD in Springfield, MO. And now reverse staging is in effect in some instances (for ulcers in the process of healing or for Stage 3 and 4 ulcers) but not others (healed Stage 1 and 2 ulcers).

Warmack expects the most common mistake will be clinicians reverse-staging a Stage 2 to a Stage 1 ulcer when the ulcer is healing, which is still prohibited.

CMS' notice is at www.cms.hhs.gov/oasis/npuap.pdf.