Eli's Rehab Report

Lack of documentation for OASIS M0 items edged out face-to-face as the chief reason for denials in Palmetto GBA’s latest medical review of high-therapy claims.

Palmetto reviewed claims with a HIPPS code of 5BHK*, processed Feb. 1 to April 15. 5BHK* are claims with the highest (20-plus visits) therapy category, mid-clinical score (2) and highest functional score (3). It has a 2014 case-mix weight of 2.0230 — the fifth-highest possible.

Of the 309 claims Palmetto reviewed in Florida, Texas, Illinois, Louisiana, and Mississippi, 84 had denials at least partly due to “Medical Review HIPPS Code Change/Documentation Contradicts M0 Item(s),” Palmetto says on its website. That compares to 73 claims that had F2F problems, according to the audit results.

However, the dollar impact of the two types of denials will differ, since entire claims are denied due to F2F while the M0 item reason generally carries downcodes.

For a list of states affected and stats broken out by region, see the articles at www.palmettogba.com/medicare — click on “J11 MAC – Home Health and Hospice” in the left column, then click on “Medical Review” in the left column and choose the “Results” tab below it. Choose the 5BHK results articles in the right column.

Functional-Status Quality Measures On The Horizon

The Centers for Medicare & Medicaid Services (CMS) is pushing hard to develop new functional-status quality measures. Here’s what a technical expert panel (TEP) has to say.

CMS contracted with RTI International to develop cross-setting functional-status quality measures for skilled nursing facilities (SNFs), as well as for long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs), according to a March 28 CMS announcement. RTI assembled the TEP in September 2013, and now the results of that meeting are posted.

Rehab clinicians, researchers, and administrators with expertise in functional assessment, quality improvement and quality measure development across settings comprised the TEP. The panel meeting aimed to gather input on functional-status quality measures that CMS wants to use on the Continuity Assessment Record and Evaluation (CARE) item set.

Here are some of the recommendations that the TEP members provided:

• Although some of the more challenging mobility activities, such as car transfers, are not assessed as CARE self-care and mobility items in all SNFs and IRFs, they are important to assess for patients returning to home or a community-based setting.
• Patients with incomplete stays should be excluded from the quality measure calculation. This should include patients who died during the stay and those who were unexpectedly discharged to acute care.
• Patients who receive the maximum scores on all function items at the time of admission should be excluded from the quality measure calculation, because no improvement in function is measureable with the existing items.
• Age is an important determinant of functional outcomes, so age categories should be used for risk adjustment of the functional outcomes quality measures.
• Prior functional status and history of falls should be tested in the risk adjustment models, because these variables may potentially affect functional outcomes.
• The post-acute care diagnosis, not the prior acute diagnosis, should be used for risk adjustment of the functional outcome quality measures, because the post-acute care diagnosis reflects the reason for the patient’s admission to the facility.

You can read the entire TEP meeting summary in the Downloads section at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html.