OASIS Alert

Edits focus on "money M00s" M0230 and M0825.

Watch for medical necessity when caring for patients with a M0230 primary diagnosis of Parkinson's disease (332.x) -- or you'll find yourself providing free care.

Because of high error rates, regional home health intermediary Cahaba GBA is continuing for at least another quarter to apply edits to claims with a primary diagnosis of Parkinson's, a length of stay greater than 60 days and either no billed therapy (edit 5THCD) or high therapy use -- "yes" in M0825 --  (edit 5THBY).

"The highest percentage of denials was related to medical necessity for both edits," the RHHI reports in its December Home Health & Hospice Medicare A Newsline.

Double-Check M0230

A large number of claims denials for both these edits continue to come from downcodes because of "inappropriate use" of the Parkinson's disease ICD-9-CM code in M0230, Cahaba reports.

Remedy: Use the code for Parkinson's as primary only if you are treating multiple aspects of the disease, instructs coding consultant Sparkle Sparks with Redmond, WA-based OASIS Answers. Remind clinicians that the diagnosis in M0230 should be the chief reason for home care. If you have a patient with Parkinson's, but you're treating that patient only for abnormality of gait, you should not list Parkinson's as the primary diagnosis in M0230, Sparks explains

Beware: The Parkinson's code earns you 20 case mix points, while abnormality of gait earns you only 11, Sparks notes. "You could be charged with upcoding" if you inappropriately list Parkinson's as the primary reason for home care, she warns.

Check for carryover: Remind clinicians to check the recert OASIS to be sure the primary diagnosis code is appropriate for the new episode and not just carried over from the first episode, Sparks says.

Avoid The Medical Necessity Trap

Although Cahaba has focused on Parkinson's claims for at least a year, in the most recent quarter the RHHI denied 39 of 61 claims reviewed for edit 5THCD "because documentation did not support the continued need for skilled nursing."

Caution: For a nursing visit to be covered, the services must require the skills of a nurse and the services must be "reasonable and necessary to the treatment of the patient's illness or injury," Cahaba reminds providers.

But medical reviewers can find plenty of traction for medical necessity denials because the criteria for this requirement "is not very specific and is open to interpretation," says physical therapist and consultant Cindy Krafft with Atlanta-based USHA. So it's important to document why the services you are providing are skilled and necessary.

Be especially careful to document in the record the medical necessity for observation and assessment to avoid downcoding, experts warn. Observation and assessment are reasonable and necessary skilled services "when the likelihood of change in a patient's condition requires a skilled nurse to identify and evaluate the patient's need for modification in the plan of care until the treatment regimen is essentially stabilized," Cahaba instructs.

Example: These changes might include abnormal vital signs, edema, respiratory changes or weight changes.

Document what actions you took in re-sponse to these changes, recommends clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen. Be sure the intermediary can see what you did.

Watch for Therapy Documentation

In reviewing the Parkinson's claims with 10 or more therapy visits, Cahaba denied 23 of 41 claims because "documentation did not support the need for ongoing therapies."

Heads up: Document specific treatment provided during each visit, as well as an objective measurement of progress, Cahaba warns therapists. "Walking further" or "progressing well" is not enough, the RHHI says.

Anytime M0825 is answered "yes," you must be sure the documentation for every visit shows the skilled service provided and the quantifiable progress the patient is making, Krafft says. 

Note: Cahaba's December Newsline is at www.cahabagba.com/parta/educationandoutreach/newsletter/1206_rhhi.pdf.