OASIS Alert

Is it safe to answer 'Early' or 'Unknown' for every patient?

Think you know how to answer M0110 in every situation? Try choosing the correct response in the following examples.

Scenario 1: Another agency admitted our patient on July 5 (with an end of payment episode date of Sept. 2), then recertified him on Sept. 3 (with an end of episode date Nov. 1). Then, our agency admitted him on Jan. 1. Is our episode "Early" or "Later?"

Scenario 1 Answer: To determine whether two eligible episodes are adjacent, you'll need to count the number of days from the last day of one episode until the first day of the next episode.

Episodes are adjacent when the number of days from the last day of one episode until the first day of the next episode is not greater than 60. To get an accurate count, start counting with the first day after the last day of an episode as day 1. Then continue counting to, and including, the first day of the next episode.

In this example, Nov. 1 is the last day of the episode (day 120) and Jan. 1 is the first day of the next episode, the Centers for Medicare & Medicaid Services points out in an OASIS Q&A. When counting the number of days from the last day of the episode ending Nov. 1, Nov. 2 would be day 1. So Jan. 1 would be day 61.

"Since the number of days from the end of one episode to the start of the next is more than 60 days, these two episodes are not adjacent," CMS says. So, your agency would report the episode starting Jan. 1 as "Early."

What if? "If the second episode started Dec. 31 instead of Jan. 1, that episode would be adjacent since the number of days counted is not greater than 60, CMS says. So you would report the episode starting December as "Later." You would also report all other episodes beginning between Nov. 2 and Dec. 31 as "Later."

Scenario 2: We admitted our patient Oct. 1 and discharged him Oct. 15. Then we readmitted her Oct. 30 and discharged November 15. We readmitted her again on Nov. 20. Would this represent three distinct episodes for the purpose of answering M0110?

Scenario 2 Answer: When answering M0110, "episodes are considered adjacent if there was no greater than 60 days between the last day of one Medicare Fee-for-Service (or PPS payment episode) and the first day of the subsequent PPS payment episode," CMS says.

When you admit a Medicare patient who hasn't been in a Medicare FFS Payment episode in the previous 60 days, the correct M0110 response is "Early." So, if your patient was under the Medicare FFS benefit on Oct. 1 and was then discharged Oct. 15 and readmitted Oct. 30, a new payment episode begins.

Your agency would receive a partial episode payment for the Oct. 1-Oct. 15 episode. In a situation where an intervening event causes an episode to end, you'll see a partial episode payment [PEP] adjustment, and the last billable visit date is the end of the episode.

When you complete M0110 at the Oct. 30 episode, the patient would still be in an "Early" episode -- the second in a series of adjacent episodes. If you discharge that patient on Nov. 15 and readmit her on Nov. 20, you would answer "Later" in M0110 because the patient is in the third adjacent episode in the series.

Scenario 3: When we're unsure whether there have been any adjacent episodes, is it better to report M0110 -- Episode Timing as "Early" or "Unknown" (which defaults to "Early")? If Medicare makes the adjustment automatically to correct this response when it's incorrect, will it make a difference if you mark "Early" instead of "Unknown" initially?

Scenario 3 Answer: It's up to your agency to determine when it's appropriate to choose the "Unknown" response for M0110. "Some agencies may choose not to invest the resources necessary to determine whether the patient is in an early or later episode. It is perfectly acceptable for an agency to select 'UK' consistently for M0110," CMS says.

But if your agency wants to ensure an accurate RAP payment, in the case of later episodes you may find it worthwhile to determine whether the episode is early or late.

Bottom line: If your M0110 response is inaccurate at the time of the final claim, CMS will automatically adjust payment to the correct episode amount.

Editors note: Read all of the M0110 OASIS Q&As at https://www.qtso.com/download/Guides/hha/CAT4_01_03_12.pdf.