OASIS Alert

Without a SCIC, can you change the HHRG?

Question: A new patient had a large contusion/hematoma on her leg with a large blister on top of the hematoma. It was not open or draining at the time of the start of care OASIS. We admitted her to service to monitor it. Our initial OASIS assessment showed our reimbursement to be $1,588.

Within a week, the large blister began leaking and the patient saw a plastic surgeon who debrided the wound and found tunneling. Her doctor now ordered bedrest with bathroom privileges only. When we did a number five follow-up OASIS, we saw that our reimbursement would have increased to $2,200 -- because of new codes and decreased functional ability. However, it is our understanding that we cannot submit the follow-up OASIS to capture the increased money. Must we discharge and readmit the patient in order to capture the funds needed to provide care for this patient?

Answer: You cannot receive an adjustment in payment during an existing episode because the 2008 prospective payment system eliminated the Significant Change in Condition (SCIC) billing process, says senior clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen Healthcare. Thus the home health agency will receive the original home health resource group payment until the next episode assessment is completed.

Caution: Technically, the HHA could discharge the patient and readmit to receive a higher paying HHRG. But the beginning of the episode will be subjected to Partial Episodic Payment adjustment (PEP) with the readmit establishing a new 60-day episode. Before discharging and readmitting, the agency needs to understand the following three potential problems, Adams warns:

1. Payment. The agency may still not receive adequate payment because of the PEP adjustment;

2. Compliance. Surveyors (and some regional home health intermediaries) take a dim view of discharging a current patient just to obtain a higher payment; and

3. Quality Improvement. Outcomes could be negatively affected for the first portion of the episode, when the Centers for Medicare & Medicaid Services compares start of care and discharge scores on OASIS items.

Bottom line: Make this decision on a case-by-case basis, Adams advises. In the situation in question it does not sound as if the patient was admitted for the debridement. Agencies are more likely to face this decision when a patient is being transferred to an inpatient facility, since you can choose to transfer with discharge or without discharge, she adds.