OASIS Alert

Published on Fri Nov 28, 2008 PDF

These 2 key items may surprise you.

You may not find the prospective payment system grouper and pseudocode thrilling bedtime reading, but 2008 could get very exciting if you don't know their secrets.

To the surprise of many agencies, all the 2008 PPS information is not in the final rule. Details about V codes and manifestation codes are buried deep in these additional documents.

Example: Under current PPS, any V code in M0230 or M0240 can trigger the case mix system to consider a diagnosis code from M0245 toward case mix. But under the PPS refinements that take effect Jan. 1, only 25 V codes or code categories will trigger a possible M0246 payment.

The grouper "must be looking at a complete and appropriate V code before looking at M0246," said Henry Goldberg of Abt Asso-ciates at the OASIS Certificate and Compe-tency Board's first annual conference in Baltimore Nov. 12.

CMS lists the eligible V codes in the grouper pseudocode, Goldberg explains to Eli. The new PPS system will accept only V codes from that chart for payment purposes, said Goldberg at the conference that drew about 170 attendees.

Abt is the Centers for Medicare & Medi-caid Services' contractor on a number of projects including PPS and pay for performance (P4P). OCCB administers COS-C credentialing and works with CMS on OASIS clarification issues.

"This information is not in the final rule," stressed Linda Krulish, OCCB's president, at the session. Instead, home health agencies must wade through the grouper and pseudocode to discover this information. "It's extra stuff added to the final rule," noted Krulish, also with OASIS Answers in Redmond, WA.

Caution: If you fail to realize which V codes cause M0246 codes to count, you could think you have more money coming to you when you don't.

Heads up: For the M0246 code to count toward payment, it must be on the same coding line as the V code that triggers it, Goldberg said.

Another area not covered in the final rule is etiology codes for manifestation codes, Goldberg noted.

Of the roughly 1,290 diagnosis codes that will now count as case mix codes, 184 are manifestation codes, Goldberg explained. ICD-9 coding rules don't allow coders to use manifestation codes first. Instead, those codes must follow a main etiology code.

Currently: Until Jan. 1, PPS doesn't check what code a manifestation code follows.

In 2008: Under the refinements, the PPS grouper won't recognize a manifestation code "unless it's directly following an appropriate and complete etiology code," Goldberg said.

Example: The manifestation codes 266.2 (B-complex deficiency NEC), 281.0 (Pernicious anemia) and 281.1 (B12 deficiency anemia NEC) will count toward case mix and payment only if 336.2 (Subacute combined degeneration of spinal cord in disease classified elsewhere) precedes it on the same line in M0230/M0240/ M0246 in the OASIS assessment.

This could be a reimbursement drain if agencies fail to pair manifestation codes with the appropriate etiology codes, experts caution.

Latest corrections: CMS posted another version of the grouper software, with new corrections, to its Web site on Nov. 16. It is available at http://www.cms.hhs.gov/center/hha.asp.

Because of the short time left to update and test software before the new PPS takes effect Jan. 1, the National Association for Home Care & Hospice has asked CMS to discuss contingency plans to prevent cash flow interruptions. Agencies should also establish cash reserves or lines of credit before the end of the year in anticipation of potential implementation problems, NAHC urges its members.