OASIS Alert

If you find significant changes in condition confusing, you're not alone - and your agency probably is losing revenue because of it. Here's how to master the SCIC challenge.

Many home health agencies continue to be confused about whether to file a SCIC, experts report. And if you file a SCIC when you don't have to, it's often not to your benefit because of the way payment works.

SCICs involve a two-step clinical and financial analysis, says consultant Pam Warmack, president of Clinic Connections in Ruston, LA. First, agencies determine when a SCIC occurs and then they decide whether they need to bill it. Errors in either part of the process can be costly, she adds.

First step: Avoid unnecessary filing by carefully defining what constitutes a SCIC, advises consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. "Too many agencies define SCIC too broadly in their policies and then run themselves ragged doing OASIS assessments," she observes.

The Medicare prospective payment system defines a SCIC as a "significant change in condition during a 60-day episode that was not envisioned in the original plan of care." In an August 2001 letter to the National Association for Home Care & Hospice, the agency further clarified that an unanticipated change is one in which "the patient's condition, disease course and plan of care as predicted at the start of care changed significantly so that a new plan of care and case mix are needed to reflect the patient as different than the start of care," NAHC reports in a recent question and answer.

One way: Agencies could define a change in condition as one that changes the case mix score, Selman-Holman suggests, although this definition requires understanding the M0 items that add case mix points. Changes such as a new diagnosis that will be the focus of care, a new pressure ulcer, increased dyspnea, incontinence, addition of infusion or enteral therapy, all change the reimbursement points, she illustrates.

Tip: If you decide the patient qualifies as a SCIC, pay special attention to the new OASIS assessment, Warmack advises. Many clinicians answer M0 questions from prior knowledge, rather than re-assessing and observing, and lose points that can cost hundreds of dollars per episode, she tells Eli.

Next step: Understand how to bill SCICs (see article 4). "The most common SCIC error is billing one when you don't have to," warns Terry Cichon with FR&R Healthcare Consulting in Deerfield, IL.

More often than not, SCICs decrease the episode payment, experts warn. This is because a SCIC separates the episode into parts that are paid differently. Whether the adjustment will be advantageous to the HHA depends on the timing of the event that triggered the reassessment, experts explain.

A SCIC payment is calculated based on billable visits rather than on a full episode, Selman-Holman says. For example, days between the two SCIC segments when the patient was in the hospital will be lost. So even when the case mix goes up, the payment may be less if you claim a SCIC, she adds.

Experts warn: You must file a SCIC whenever an unanticipated improvement in the patient's condition decreases the HIPPS code (resulting in a lower episode payment), the Centers for Medicare & Medicaid Services says. But remember to ask if the change was really unanticipated.