OASIS Alert

Recoupments for first PPS year may start soon.

More money could be flowing out of agencies' pockets and back to the government from newfound M0175 errors.

The HHS Office of Inspector General is leaning hard on the Centers for Medicare & Medicaid Services to recoup M0175 overpayments, and home health agencies will soon be under the spotlight.

The basics: M0175 asks if a patient has been discharged from an inpatient facility within 14 days of the start or resumption of care. Possible answers are hospital, rehab facility, skilled nursing facility, other nursing home, other facility or "Patient was not discharged from an inpatient facility." The question instructs the clinician to "Mark all that apply."

A hospital stay earns zero points, no hospital stay earns one point and a rehab or SNF stay earns two points. So if a patient has a SNF or rehab stay, but no hospital stay, the patient gets three points in the service category of the home health resource group, explains Laura Gramenelles with Simione Consultants in Hamden, CT.

The reimbursement impact of the three points depends on whether the episode involved high therapy use--10 or more therapy visits. Without therapy, the three points increases the episode payment by about $200. With the four additional points resulting from high therapy use, the episode payment increases by about $600.

Hidden traps: Home health agencies often don't have complete information when admitting patients. Hospital discharge claims are usually not in the system yet, patients are unaware of the classification of the bed they occupied and families are confused by the complicated medical system they are navigating, notes consultant Rose Kimball with Med-Care Administrative Services in Dallas.

Between poor information given by sick or confused patients and difficulty getting information out of hospitals, "it's hard to get the level of prior-stay data that is available years later in the CMS database that OIG taps," explains Bob Wardwell with the Visiting Nurse Associations of America.

Next step: Beginning with fiscal year 2004, fiscal intermediaries have used pre- and post-payment edits to identify M0175 inaccuracies. Recoupment of overpayments for 2001 are still on hold.

A CMS official says the agency is "currently working on revised instructions intended to ensure our recovery process is compliant with the requirements of section 935 of the MMA." The M0175 recoupments for 2001 could start as early as mid-summer, the CMS source tells Eli.