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Reimbursement:

Your FI May Not Tell You - But Mistakes Could Be In Your Favor

Published on Mon Nov 17, 2003

Accuracy on M0175 will ensure you receive the $200 to $600 per episode if you're entitled to it and you won't have to pay money back later if you're not.

Past M0175 mistakes may not be held against you - except monetarily - but future errors could lead to downcoding and medical review.

As fiscal intermediaries prepare to recoup overpayments identified in the HHS Office of Inspector General's campaign against M0175 errors, smart agencies are focusing on getting it right from now on.

Home health agencies that fail to improve their M0175 collection procedures may find themselves the targets of medical review, and even fraud and abuse scrutiny, predicts consultant John Gaynor with the Chicago office of Frost, Ruttenberg & Rothblatt.

Once the M0175 edits and ensuing adjustments begin, regional home health intermediaries will be able to track those numbers and see who repeatedly answers the OASIS item incorrectly, instead of getting the information wrong only every once in a while.

No agency will get M0175 right for every patient, Gaynor notes. But HHAs that repeatedly get the OASIS item wrong could earn a bad reputation.

Errors on this question can lead to several hundred dollars in overpayments per episode, resulting in increased intermediary scrutiny now and going forward, agreed Carol Conrad of Hamden, CT-based Simione Consultants, speaking at a recent Eli teleconference, "Strategies for OASIS Precision."

In the more than 200 OASIS accuracy audits consulting firm BKD has completed for its clients, almost 9 percent of assessments turn up with "variations" in the service domain, consultant Karen Vance in Springfield, MO tells Eli. Of those errors, 74 percent occur because of inaccurate M0175 responses, she says.

TIP: Not all mistakes cost the government money - some shortchange the agency. "I've seen more OASIS assessments that have not captured the rehab or skilled nursing facility stay than I have agencies indicating there was no hospital stay," says Chapel Hill, NC-based clinical consultant Judy Adams with the LarsonAllen Health Care Group.

To protect your agency's bottom line, have a system in place to review the OASIS and the medical record - referral, hospital summary and any home health clinical notes - to ensure the information is consistent, Adams recommends. Agencies can use software programs designed to verify OASIS accuracy or review the information manually. If a staff member performs a manual review, concentrate primarily on the case mix items, she suggests.

Experts recommend HHAs take these steps to increase M0175 accuracy:

  • Audit first. As an initial step in improving accuracy, agencies should perform random audits of past charts to see who collects information, how they determine the answers and what trigger questions HHA staff might use to improve M0175 accuracy, Conrad suggested.

  • Focus on intake. Agencies can eliminate many M0175 errors by making sure the intake department gathers the correct discharge information up front. Make discharge information a priority and be sure to have intake staff ask referral sources pointed questions about it.

    HHAs can draw up a "cheat sheet" that lists referring facilities and what types of beds they contain (acute, skilled nursing facility and rehab), experts recommend. Then if the facility that discharged the patient has only one type of bed, it's simple to figure out what kind of stay the patient had.

  • Compare length of stay. Intake staff should determine the patient's diagnosis related group for the hospital stay. Then you should compare the patient's LOS against a list of average stays per DRG. If your patient's stay is significantly longer than average, that's a signal to go back and ask questions about discharge, Vance advises.

  • Ask a few simple questions. Whenever a patient is discharged from the hospital, a few quick questions from the clinician completing the OASIS assessment may head off M0175 trouble. Simply asking "did you move beds while you were in the hospital" or "did you move floors" can show you whether to research the patient's discharge further. Ask if the inpatient unit had a specific name. "You can do these quickly with little effort," but with a big impact on your billing and OASIS accuracy, Vance says.

  • Answer completely. M0175 offers six answer choices. Remember to select all the answers that apply, but include only inpatient stays, Conrad instructed. An emergency room visit or "hold" without admission doesn't count as an inpatient discharge.

  • Train staff. HHAs may be tempted to slack off on obtaining hard-to-find prior stay information once edits are in place and they know the claims payment system will automatically correct the item anyway. But smart agencies will err on the side of caution and strive for accuracy, experts say.

    HHAs should stress in OASIS training that RHHIs and the Centers for Medicare & Medicaid Services will be able to track how often agencies don't get OASIS right the first time, Gaynor advises. This may come back to haunt agencies and result in increased scrutiny.

    "Management must make sure that thinking doesn't go too far," Gaynor says of falling back on the automatic corrections.

    Editor's Note: To order Carol Conrad's teleconference "Strategies for OASIS Precision" go to http://codinginstitute.com/conference/tapes.cgi?detail=462.

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