OASIS Alert

Published on Thu Jan 13, 2005 PDF

Warning: Your intermediary will no longer identify M0175 underpayments.

If you put M0175 accuracy on the back burner because the Centers for Medicare & Medicaid Services agreed to fix your mistakes, now is the time to turn up the heat.

Edits are in place to automatically correct your answer to M0175 if you fail to report an acute hospital stay within 14 days of admission to home care. This keeps Medicare from paying you $200 to $600 you're not supposed to receive (see OASIS Alert, Vol. 5, No. 9).
 
But if you fail to report a patient's rehab or skilled nursing facility stay in addition to a hospital stay, your intermediary will no longer correct your mistake and pay you that money - even though you're entitled to it, experts warn.
 
CMS agreed to make the automatic underpayment correction retroactively for the first four years of the prospective payment system. But the agency drew the line at providing the automatic increase going forward.

"For claims with dates of service in Federal fiscal year 2004 and for future years, Medicare will maintain the process of identifying overpayments only," CMS said in July 30 Trans-mittal No. 95.

Bottom line: You need to strengthen your system for identifying prior SNF and rehab stays - or your profitability will suffer.

Tactic: One quick way to catch unreported SNF and rehab stays is by asking for patients' length of stay in the hospital, advises consultant Karen Vance with BKD in Springfield, MO.

In these cost-conscious times, hospitals will very rarely keep patients for significantly longer than the average length of stay for their diagnosis related group (DRG), Vance notes. So a LOS noticeably longer than the average is a signal that you should look more closely.

Chances are if a patient's LOS was twice as long as normal, she was in a rehab bed part of the time, Vance points out. In swing bed facilities, patients can change from hospital to SNF or rehab status without even changing beds.
 
The overly long stay is your signal to find out if that's the case, or whether "there is something else going on with the patient" that you don't know about, she urges.

Don't: Requiring staff to compare every single patient's hospital stay to the average LOS for the condition isn't efficient, Vance acknowledges.

Do: HHAs should keep a list of the top DRGs their patients have in prior hospital stays and check those figures, she recommends. "The whole idea is to reduce effort and get the most accurate information," she tells Eli.

For example, the average LOS for a hip replacement patient (DRG 209) is 4.8 days, CMS says in its hospital inpatient PPS final rule in the Aug. 11 Federal Register. So if your hip replacement patient was in the hospital 10 days, you'd better do some investigating to see if part of that stay was in SNF or rehab.

HHAs can keep a short reference list of the top DRGs their referred patients have, Vance counsels. Then the clinician filling out the OASIS assessment can quickly check to see if the patient's LOS closely tracks that average.

For even more specific comparisons, HHAs can obtain hospital-specific LOS averages from their local facilities, Vance suggests. "That's a very, very good next step," she says.

Tip: You can look up national stay lengths for all DRGs in the IPPS rule at http://a257.g.akamaitech.net/7/257/2422/10aug20041800/edocket.access.gpo.gov/2004/pdf/04-17943.pdf, starting on p. 678, under the "Arithmetic Mean LOS" column.