OASIS Alert

Published on Mon Jan 14, 2013 PDF

Regional home health intermediary Palmetto GBA has some important guidance about medical review in frequently asked questions concerning additional development requests (ADRs) for significant change in condition (SCIC) claims under review.

Home health agencies had better be sure to include OASIS assessments supporting both the original claim and the SCIC when they send in their documentation supporting the claim.

In the case of SCICs, medical reviewers first will validate the original HIPPS code using the original OASIS assessment, Palmetto explains in its FAQ for November 2002, recently posted to its Web site. If there is no second OASIS assessment reviewers can use to validate the SCIC, “the SCIC HIPPS code will be downcoded to the same level  as the initial HIPPS code validation,” the RHHI says.

Conversely, if agencies send in only the OASIS assessment for the SCIC, medical reviewers will deny the entire claim. “The OASIS, which generated the initial HIPPS code, is necessary to complete the review of the claim,” Palmetto stresses. “Appropriate payment cannot be determined without the OASIS for the initial HIPPS code.”

Failing to send in multiple OASIS assessments for SCIC cases “can cost agencies thousands of dollars” per claim, laments consultant Melinda Gaboury, with Healthcare Provider Solutions in Nashville, TN. Many HHAs are unlikely to realize more than one assessment is required. “Most agencies aren’t careful about sending in information for ADRs,” she admits.

HHAs aren’t allowed to submit medical documentation after the 30-day time limit is up, Palmetto adds. Intermediaries now deny those claims outright rather than returning  them to provider (RTP), and agencies must go through the reconsideration process.

HHAs confused about what to submit for an ADR can refer to Palmetto’s Home Health Training Manual, Section 8, p. 8, the RHHI advises. Palmetto’s 100-question long  medical review FAQ is at www.pgba.com/; click on ‘Providers,’ ‘RHHI,’ and ‘FAQs.’ The Training Manual is at www.pgba.com/; click on ‘Providers,’ ‘RHHI,’ and ‘Manuals.’

• The Centers for Medicare & Medicaid Services’ new home health quality improvement Web site will be at www.cms.hhs.gov/providers/hhqi, reports the American  Association for Homecare. The HHQI project will publicly compare agencies’ patient outcomes data.

HHQI is well under way, although it might not kick off until the middle of April, a few weeks behind the original schedule. CMS expects to formally announce the pilot project  states and measures to be used within a few weeks, CMS Administrator Tom Scully said at the Feb. 5 Open Door Forum for home health, durable medical equipment and hospice providers.

• The GAO is taking its campaign for tougher home health agency surveys up a notch in a new report outlining risks to government departments.

In its report to Congress, the watchdog agency’s chapter showcasing the greatest risks to the Department of Health and Human Services focuses on tougher surveys for  HHAs, nursing homes and other providers.

The January report, “Major Management Challenges and Program Risks: HHS” (GAO-03-101), builds on a GAO report from last July that bashed home care surveys and  called for CMS to tighten them up.

The GAO said surveyors too often let HHAs off the hook by passing off serious deficiencies as understated. They also survey agencies too seldom and fail to check  compliance with every condition of participation. And, surveyors use inconsistent survey practices, with some states never citing condition-level deficiencies.

The GAO builds on these arguments by comparing surveys for HHAs to surveys for nursing homes, and finding home health scrutiny lacking. “CMS may have shifted its focus and resources to nursing homes at the expense of adequate oversight of home health agencies,” the agency cautions.

• Cahaba GBA expects home health agencies to cover supplies used to care for PICC lines under prospective payment system payments. “The dressing supplies and syringe are included in consolidated billing,” Cahaba says in a set of frequently asked questions for January 2003. “Therefore, the home health agency is responsible to provide these supplies.” However, the heparin and saline used to flush a PICC line are considered drugs, so “the beneficiary is responsible for the charges,” the RHHI explains.

The FAQs, are available at www.iamedicare.com/Provider/educate/faqs.htm.