OASIS Alert

Answering M0825 incorrectly could have cost you $1,800 to $2,200 per claim but there's a way to get that money back.

Chart audits may detect two therapy situations where you provided at least 10 therapy visits but were underpaid: when you answered M0825 incorrectly or when you provided an incorrect UB92 with your claim.

Providers often answer "no" to M0825 on the OASIS start of care assessment, but then wind up furnishing the patient with 10 or more therapy visits. While intermediaries automatically decrease the episode payment if you didn't provide the 10 or more therapy visits you anticipated, the reverse is not true. That means unless you speak up, you won't receive the payment you deserve.

Ten or more therapy visits includes physical, occupational and speech therapy therapy assistants' visits also count, experts remind providers.

Additional therapy often results from an incorrect estimate perhaps because the patient didn't progress as fast as you expected, counsels Terry Cichon with F R & R Healthcare Consulting in Deerfield, IL. "Analyze the cases carefully and document them carefully," because the intermediary probably will ask for additional documentation, she advises.

HHAs often don't realize they haven't been paid for the therapy they've provided, reports Dianne McKinney with the home health team of the accounting firm Abraham & Gaffney in St. Johns, MI. "Most agencies have at least one underpaid therapy claim; we've found agencies receiving from $2,000 to $250,000 less than they should have," she says.

Occasionally additional therapy needs will result from a significant change in the patient's condition,expertssay,andyoumayneedtoevaluate whether to file a SCIC (see OASIS Alert Vol. 3, No. 5, p. 56). Otherwise, the way to receive payment for the unexpectedly high therapy use is to cancel the original request for anticipated payment (RAP) and submit a new one, with the correct answer to M0825, Cichon instructs.

As long as there is no clinically significant change in the patient's health status, canceling the RAP is the way to handle under estimating therapy needs, the Centers for Medicare & Medicaid Services tells providers in the question-and-answer section of its OASIS Web site. "Agencies can make this non-key field change to their files and retransmit the corrected assessment," CMS explains.

Canceling and resubmitting the RAP doesn't mean you go back and change the answer on the original OASIS hard copy, regional home health intermediary Cahaba GBA reminds providers. The original OASIS assessment stays in the patient's chart as part of the permanent medical record.

Instead, you make the change in the information you transmit to the intermediary, and "retransmit the record to get the higher HIPPS code," Cahaba noted in its September Home Health Advisory Group minutes.

Document the reason for the change in assessment of therapy need, confirm documentation for each therapy visit and be sure you have the doctor's orders for the therapy before you answer "yes" to M0825, experts say.

When you correct an assessment, you must maintain both the original and the corrected assessment for at least five years in the patient's clinical record, CMS instructs. And if you maintain these records electronically, you must be able to retrieve and reproduce a hard copy, CMS adds.

One other therapy underpayment you may detect in chart audits is when you answered "yes" to M0825 and you provided at least 10 therapy visits, but you submitted the claim "without 10 visits listed on the UB92," Cichon notes. If you submitted an incorrect UB92, this claim would have been down-coded, she says.

Go back to October 2001 and look at all the therapy downcodes you received. Many agencies filed claims before they received all the therapy visit information, especially from contract therapists, Cichon explains. Correcting this error will increase revenue for each of these episodes by about $2,000.

To ensure you don't miss out on hard-earned reimbursement, develop a system to tally therapy visits as you provide them and compare that number with your original expectation, says consultant and therapist Linda Krulish with Home Therapy Services in Redmond, WA. Even something as low-tech as a box on the front of the patient's home chart for each therapist to check when she visits can give you an early warning, she adds. Then you can correct an under estimation and receive the correct paymentas early in the episode as possible.

Even if you already have submitted the final claim, you still can correct the error, explains Lynn Olson with Corpus Christi-based Astrid Medical Services. But the longer you wait to correct the under estimation of therapy needs, the more time-consuming the process is.

Besides unlocking the original OASIS, changing the answer to M0825, relocking and retransmitting, you may need to cancel, correct and refile the RAP if it is still active and refile the final claim with the correct HIPPS code. The upside is you'll eventually be paid for the care you provided, the downside is the fiscal intermediary will "take back the money" for the original RAP and claim, and you will need to wait for the system to pay the revised claims, Olson cautions.

While time has run out to fix claims for October 2000 to September 2001 episodes, you can enter changes for episodes from October 2001 to December 2002 until Dec. 31, 2003, McKinney says.