OASIS Alert

You are left to do it the hard way, and it cost one agency $20,000.

CMS is happy to avoid paying up to $600 more based on M0175 answers - even if it does owe the home health agency the money.

Former CMS Administrator Tom Scully pledged in the Nov. 5 Open Door Forum for home care providers to "try" to correct answers to M0175 regardless of whether the change benefits home health agencies or Medicare. Scully made the move after an HHA calling into the forum said an internal audit uncovered that just one branch of the large agency had lost $20,000 due to the inability to identify SNF and rehab stays within 14 days of home care admission.

But at the Jan. 15 forum, the Centers for Medicare & Medicaid Services rejected this possibility. Come April, CMS edits will focus on not overpaying agencies that answer M0175 incorrectly.

And retroactive M0175 audits of prior claims will begin soon. But CMS has decided not to use its edit capabilities to correctly pay M0175 claims where the error is in the agency's favor.

"CMS staff and management have reviewed this issue carefully over recent weeks and we have decided that upcoding home health PPS claims in these cases is not the appropriate course of action for the Medicare program," a CMS official announced.

M0175 asks if a patient has been discharged from a hospital, rehab facility, skilled nursing facility or other nursing home within 14 days of the start or resumption of care. The patient earns no points if she had a hospital stay, one point if she did NOT have a hospital stay, and two points if she had a rehab or SNF stay.

The only reimbursement impact comes if the patient had no hospital stay and also had a rehab or SNF stay, explains consultant Laura Gramenelles with Hamden, CT-based Simione Consultants. You can add the no-hospital-stay point to the two points for a SNF or rehab stay and have three points in the service category of the home health resource group (see OASIS Alert, Vol. 4, No. 3). This can add $200 to $600 to the reimbursement for that episode.

Agencies can look up rehab and SNF stay information in the common working file when admitting patients (see "Profit and Comply - Use These 4 Tips for M0175 Success") CMS insisted in the ODF. "By maintaining our current policy, CMS maintains a payment incentive for careful and thorough admission practices at the home health agencies," the official said.

And HHAs have up to 27 months to adjust claims if they later find out the patient had a relevant inpatient stay, because a rehab facility or SNF failed to file claims before the agency admitted the patient, the CMS staffer pointed out.

Watch for: CMS will issue educational materials to agencies that will help them determine prior inpatient stay information, including a tool to assist in figuring out exactly when the 14-day window begins, CMS added.