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Compliance:

NAMES AND DATES REALLY MATTER ON M0175

Published on Sat Mar 01, 2003

Whether your new patient calls the institution she just left a hospital, a nursing home or a rehab facility may not make much difference to herbut it can mean hundreds of dollars or a fraud investigation to you.

The HHS Office of Inspector General is working with the four regional home health intermediaries on a nationwide audit focusing on whether home health agencies have accurately reported hospital stays in response to M0175, a spokesperson for IG Janet Rehnquist tells Eli. The audit covers claims with dates of service from Oct. 1, 2000 to Sept. 30, 2001, the OIG source says.

M0175 asks if a patient has been discharged from a hospital, rehab facility, skilled nursing facility or other nursing home within 14 days of the start or resumption of care. A hospital stay earns zero points, NO hospital stay earns one point, and a rehab or SNF stay earns two points.

The only reimbursement impact comes if the patient had no hospital stay and also had a rehab or SNF stay, explains consultant  Laura Gramenelles with Hamden, CT-based Simione Consultants. You can add the no-hospital-stay point to the two points for a SNFor rehab stay and have three points in the service category of the home health resource group.

Three points moves the patient from S0 to S1 in the HHRG a difference of about $170, depending on geographic location, experts say. The points become even more lucrative if the patient requires 10 or more therapy visits which adds 4 points to the service category with the combination pushing the patient from S2 to S3, for a difference of as much as $525.

In other words, those scenarios take the fourth digit of the patient's HIPPS code from a 'J' to a 'K' for non-therapy cases and from an'L' to an 'M' for therapy cases, for therapy cases,explains the National Association for Home Care & Hospice. And if the information is wrong, that additional money may be an overpayment, NAHC points out.

The OIG believes HHAs inappropriately have collected more than $25 million by omitting a hospital stay when claiming a rehab or SNF stay for a patient, NAHC reports. Agencies had "better be prepared for recoupments," warns Gramenelles.

It's not easy for agencies to know exactly where the patient has been during the last two weeks, since they rely on patient recollection and information from referral sources. Meanwhile the OIG can check just by looking at hospital, SNF and rehab facility claims data, notes clinical consultant Cyndi Rohret with West Des Moines, IA-based Briggs Corp.

Experts offer these tips for making sure your M0175 answers are on track:

  • Target education. Identify the folks in your organization who need to understand the reimbursement impact of answering M0175 correctly, experts advise. Answer it wrong and you lose up to $530 or risk focused medical review.

    The person who takes referrals and the clinician who fills out OASIS are the most likely targets for training and education.

  • Audit. Look over your past charts to see if you have a problem with accurate M0175 answers. If you do, you're likely to be hit with recoupments down the line. And you'll want to avoid such problems in the future.

    If you discover a significant problem with this OASIS item, you may want to implement a prebilling audit, Gramenelles advises.

  • Examine processes. Look at how and where the information on M0175 is collected and how it is communicated to the person who enters the OASIS data, advises Gramenelles. In audits and chart reviews she has conducted, it often turns out one person in the organization had the correct discharge information, but the information didn't trickle down to the person entering the OASIS data.

    Note where those communication break downs occur and brainstorm ideas for fixing them, she counsels.

  • Add prompts. On referral and OASIS forms, agencies might want to add trigger questions reminding staff to ask about discharge dates, Gramenelles says. If patients have been in a rehab facility or skilled nursing facility for more than 14 days prior to start of care, they should be in the clear for earning three points on M0175.

  • Go the extra step. Clinicians have been content to rely on one source for discharge information. But you should check for continuity between discharge information given by patients, caregivers and referral sources, suggests Rohret. In some cases, you may want to check facts with a facility, she says.

  • Check back. Once you've implemented a fix for any problems you find, go back and check on it periodically to make sure it stays fixed.

  • Add M0175 to reviews. If your agency conducts supervisory reviews of OASIS assessments, make M0175 accuracy a key item to check in those reviews, Gramenelles suggests.

     

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