OASIS Alert

Published on Thu Sep 27, 2007 PDF

OASIS answers affect case mix points.

OASIS items will be even more important to episode payment under the 2008 PPS final rule -- so concentrate on accuracy or risk losing money.

Under the final Home Health Prospec-tive Payment System Refinement and Rate Up-date for Calendar Year 2008 ("final rule"), home health resource group calculations become much more complicated. When the payment diagnosis shifts from M0245 to M0246 on Jan. 1, the pro-cess of getting case mix payment for a home care episode also becomes more complex.

Good news: If a V code is placed in the primary or any of the secondary diagnoses positions in M0230 and M0240, and the V code replaces a case mix diagnosis, you have an opportunity to gain case mix points for the episode.

Extra step: But besides putting the case mix diagnosis in M0246, you also need to determine if the ICD-9-CM code the V code replaced "achieved case mix status" for reimbursement, says consultant and coding specialist Tricia Twombly with Foundation Management Ser-vices in Denton, TX.

The base rate case mix score uses 22 OASIS items versus 23 in the current system, says consultant Mark Sharp with BKD in Springfield, MO. But the scoring across the four equation case mix model and the interaction between items makes the new PPS system much more complex than the old one, he says.

Don't miss: What used to be called clinical domains in the old OASIS scoring are now called clinical dimensions under the new PPS system, Sharp notes.

Under the final rule, the fact that the diagnosis a V code replaces is on the case mix list (Table 2B in the rule) is helpful for your agency's risk adjustment, explains clinical and coding consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Asso-ciates. But the code also must fit one of the line items on Table 2A of the final rule to add to your reimbursement, she says. A case mix diagnosis in M0246 as well as other M0 items may give you clinical points (Cx in the HHRG CxFxSx) under the new PPS.

Consult both Table 2A and Table 2B in the final rule to see if the underlying diagnosis for a V code placed in M0230 or the M0240 spaces gives you clinical dimension points, Selman-Holman says.

Example: You admit a patient who has difficulty swallowing due to a stroke. The physician orders speech therapy and the therapist expects to see the patient six times. The patient has never been seen in a home health setting prior to this admission.

Because the primary reason for home care is speech therapy for dysphagia secondary to a stroke, code V57.3 (Speech therapy) in M0230, Twombly says. But does this give you case mix reimbursement? Follow these steps to find out:

Step 1: Determine what underlying diagnosis the V code replaced. Because the dysphagia is secondary to a stroke, the underlying diagnosis would be 438.82 (Late effects of CVA with dysphagia), Twombly says. When you consult Table 2B, you find this is a case mix code from the Neuro 3 category. So it provides risk adjustment, but what about payment?

Step 2: Check for variables in Table 2A. Under the final rule, this scenario is an early episode with low therapy use expected. Table 2A, line item 15, refers to "Neuro 3 " Stroke" and indicates that a stroke code can achieve case mix payment status independent of other variables if it is an early episode with high therapy, Twombly explains. This rule excludes our example from accumulating case mix points unless it fits within another variable, she notes.

Our example: Line item 6 allows case mix points for a combination of stroke and dysphagia. "If a code is used from the Neuro 3 category and the patient has dysphagia, the code for dysphagia (787.2x) is also available for points in early episodes with low or high therapy," Twombly explains.

Other line items in the table also refer to Neuro 3 " Stroke. Line item 16 allows case mix points for the stroke diagnosis combined with difficulty dressing the upper or lower body in M0650 and M0660. Line item 17 allows case mix points for stokes in early episodes with significant ambulation problems in M0700.

Payoff: Each line item in Table 2A is an opportunity for case mix points, Twombly says. In the first 30 line items co-morbidity diagnoses can add points under this new system. Under the next 21 line items, clinical and functional M0 items also add points. If the patient meets the criteria in the line item, the points are cumulative in the home health resource group calculation, she adds.