Home Health & Hospice Week

And you can still appeal this common denial.

Is your OASIS documentation costing you your rightful reimbursement from Medicare? The answer to that question could surprise you.

Downcoding for documentation that contradicts the OASIS assessment is the most common denial reason for home health agencies, experts agree. And Palmetto GBA's latest denial reason stats back up that assertion, with 5DOWN in the top spot (see Palmetto's top denial codes, Eli's HCW, Vol. XIV, No. 12).

"The OASIS must support itself, and the rest of the documentation in the record must support the OASIS," stresses consultant Lynda Dilts-Benson with Reingruber & Co. in St. Petersburg, FL. "Otherwise, you will be downcoded."

HHAs' documentation can fail to support any of the 23 M0 items that set payment for the patient, but here are the problems experts say they see the most:
  M0490 (Dyspnea), 6 points. The assessing clinician will mark box 2, 3 or 4 on the assessment, but subsequent visit notes will fail to document any shortness of breath when the patient is ambulating or performing other activities, Dilts-Benson relates.
  M0420 (Pain), 5 points. The clinician will mark that the patient has pain daily or all the time, but the visit notes will record that the patient has no pain, notes billing consultant Rose Kimball with Med-Care Administrative Services in Dallas.
  M0390 (Vision), 6 points. The OASIS says the patient is partially or severely impaired, but the documentation doesn't reflect that impairment, Dilts-Benson says.
  M0230 (Diagnosis), 11 to 20 points. "Many times the exact reason for the downcode has been because the documentation didn't support the diagnosis codes billed," reports reimbursement consultant M. Aaron Little with BKD in Springfield, MO.

When HHAs have case-mix diagnoses such as arthritis or diabetes as primary in M0230 and non-paying diagnoses such as congestive heart failure, hypertension or COPD as secondary (M0240), Palmetto often will bump the paying diagnosis down to the secondary spot and strip the HIPPS code of the related points, Kimball relates.

Denials hurt agencies' bottom lines because either HHAs have to take the time, effort and expense of appealing the denial, or they never appeal and lose out on the money altogether. With the rural add-on expiring April 1, rural agencies will find they have less margin for billing errors than ever before, Little predicts. 5 Solutions to Beat Your OASIS Denial Blues OASIS-based downcodes may flood your agency, but you can stem the tide by following these tips from the experts: 1. Share OASIS. Staff will have a tough time making sure their documentation supports the OASIS assessment if they don't know what's on it. Often, HHAs have OASIS specialists fill out the assessments, and rank-and-file nurses, therapists and aides make routine visits, notes Dilts-Benson.

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