Home Health & Hospice Week

Is your software automating you toward lower payments?

When a change in a patient's condition necessitates a follow-up assessment, don't let the billing codes do all of the talking.

Rather, billers and coders should do some critical thinking, coaches M. Aaron Little of BKD in Springfield, MO.

A significant change in condition (SCIC) most commonly results in a higher code on the Health Insurance Prospective Payment System (HIPPS). But that's only the beginning.

"A significant jump in the score of a patient doesn't necessarily mean that billing a SCIC is the agency's best move financially," stresses Little.

Instead, once you determine a code change is in order, ask yourself how it will affect your total payment from Medicare. The key to making that determination is pro-rating, explains Little.

Case in point: Say a patient enters the hospital after day 30 in an episode of care. He returns to the care of the home health agency on day 40, with a decline in his condition which results in a SCIC and a higher HIPPS code assignment. He remains under the home health agency's care until day 55, when he is discharged.

Key calculation: You can bill the SCIC, but in that case Medicare will pay you only for the 46 days your agency actually provided care, a pro-rated payment. If you refrain from billing the SCIC, however, Medicare will pay you for the full 60-day episode. In many cases, therefore, it pays to not switch to a SCIC claim.

Beware: When it comes to SCICs, too much billing automation can definitely be a bad thing. Some software systems send SCICs out unchecked.

Remember, you don't have to claim a SCIC unless an unanticipated improvement in the patient's condition decreases the HIPPS code, the Centers for Medicare & Medicaid Services instructs.

"And those types of changes are rare to never," says Little.

Bottom line: If a SCIC increases the HIPPS code, don't bill until you determine whether a SCIC claim will help or hurt your profit margin.