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Reimbursement:

Finally - Help In Answering M0175 Accurately

Published on Wed May 26, 2004

Follow this path through the CWF.

Just when you thought prior hospital stays would be hidden from you forever, the Centers for Medicare & Medicaid Services provides a map.

After the HHS Office of Inspector General released the information that it has recommended Medicare recoup $23 million in M0175 overpayments for fiscal year 2001, CMS has released a new provider education article. It instructs agencies on how to more accurately answer M0175 by accessing  patients' prior stay information via the Common Working File.

And it's not a moment too soon. Agencies that use Corpus Christi-based Astrid Medical Services to process their reimbursement claims "are seeing RTPs everywhere" for claims with an "M" in the HIPPS code, Astrid's Lynn Olson tells Eli. Starting April 1, an edit began returning to provider (RTP'ing) claims that fail to mark an inpatient stay within 14 days of home health admission.

Trap: When a patient has a skilled nursing facility or rehab stay within 14 days of admission to home health, but has not been discharged from a hospital within those 14 days, the patient receives three points in the service category of the home health resource group, explains Laura Gramenelles with Hamden, CT-based Simione Consultants.

This adds reimbursement of about $600 for a patient who breaks the 10-visit therapy threshold and $200 for a non-therapy patient. If you fail to mark an applicable hospital stay, the additional amount will be an overpayment.

On the other hand, if you don't find out about a SNF or rehab stay -- and there was no hospital stay -- you'll be underpaid the $200 to $600 you  are owed.

Where to start: To help determine whether a patient had an inpatient stay -- hospital, SNF or rehab facility -- you can access the CWF, CMS explains. You should get used to the acronym ELGA, which has replaced the old HIQA inquiry screen. On page 1 of ELGA, agencies should zero in on these items:

  • FULL HOSP: number of fully covered hospital days remaining to the beneficiary.
  • FULL SNF: number of fully covered SNF days remaining.
  • DOEBA: date of the earliest billing action, representing admission date of the hospital claim that started the spell of illness.
  • DOLBA: date of the latest billing action, date of latest inpatient claim in the period; can represent date of discharge from the inpatient facility.

    Medicare fully covers 60 hospital days and 20 SNF days, CMS says. So if the number under FULL HOSP is less than 60, because the patient used some of the days, the patient has been hospitalized during the spell of illness.

    Watch out: The trick is, the ELGA screen doesn't show whether those FULL HOSP days are acute care or rehab facility days. You'll have to ask the beneficiary and referral sources to find out for sure.

    Likewise, if the number under FULL SNF is less than 20, the patient had an inpatient SNF stay during the spell.

    Snag: Hospital, rehab facility and SNF stays matter for M0175 only if they are within 14 days of admission. That's where DOLBA comes in.

    If the FULL HOSP or FULL SNF columns indicate some type of inpatient stay, check to see if the DOLBA is within 14 days of the home health admission. If so, mark the appropriate type of stay. If not, mark NA.

    CMS offers seven different scenarios to help agencies understand how to use the four indicators to assist in determining inpatient stay status.

    Don't Expect Too Much

    The article will "help clarify how to read the information in the CWF," confirms reimbursement consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN.

    But providers that use the CWF must understand it has its limitations. Chief among those is timeliness of inpatient facilities' billing, experts warn. "The information is most likely not going to be present in the CWF when the patient is admitted to home health," Gaboury predicts.

    "The ELGA screens only report information on completed and processed claims from an inpatient facility," agrees Abilene, TX-based consultant and CPA Bobby Dusek. If the information isn't in the system yet, agencies can't look it up.

    Figuring out the ELGA eligibility screen isn't a piece of cake either, Dusek warns. "It is not like reading a postcard to determine what is being reported on the ELGA screens," he worries. "Billing personnel will need training and experience to quickly and accurately determine if a hospital or SNF discharge has occurred."

    And agencies won't use the CWF to help sleuth inpatient stays for past episodes, says consultant and CPA M. Aaron Little with BKD in Springfield, MO. If the patient is not admitted to an inpatient facility for 60 consecutive days, the ELGA information "resets upon the next inpatient admission," Little explains.

    That means researching episodes from fiscal year 2001 -- the year for which CMS will be recouping M0175 overpayments this summer -- is probably useless.

    Particularly complicated episodes won't be much good for the CWF research either, Little adds. Multiple admissions and discharges in one 60-day spell of illness won't clearly show up on the eligibility screen.

    Tips: Improve your use of the ELGA screen:

    1. Use ELGA as only one tool. "The data provided by Medicare inquiry screens will not provide complete answers to HHAs' questions in all cases prior to billing for an episode," CMS acknowledges in its article. "In these cases, it can be used to target further inquiries to beneficiaries, their caregivers or to the RHHI that will yield the information."

    "Agencies have got to implement something at the intake level that causes them to drill down to exactly what type of inpatient facility a patient has been in and exactly how many days they spent there," Gaboury urges (see Eli's OASIS Alert, Vol. 5, No. 3).

    2. Check, check again. You should check the ELGA screen upon a patient's admission, but chances are the inpatient facility's claim hasn't shown up yet. Check the ELGA screen again before sending in a final claim for a patient's episode, Dusek advises. "If a hospital discharge is detected, then the answer to M0175 could be corrected at that time to avoid a recoupment at a later date," he explains.

    Editor's Note: CMS' article is at www.cms.hhs.gov/medlearn/matters/mmarticles/2004/SE0410.pdf.

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