OASIS Alert

Published on Fri Jul 11, 2008 PDF

Use these 4 tips to get the dollars you earned.

If you don't correctly identify a wound on the start of care assessment, you lock yourself into losing money.

Now that the Centers for Medicare & Medicaid Services has eliminated significant-change-in-condition adjustments from the prospective payment system, proper reimbursement for the cost of wound care depends even more on getting the assessment right from the very beginning. Both supply reimbursement and the basic episode payment amounts come from the interaction of OASIS M0 item answers and diagnosis codes, says senior consultant Debbie Dawson with HealthCare Strategies Inc. in Chattanooga, TN.

Background: Under the 2008 PPS, a patient will fit into one of six non-routine supplies severity levels based on answers to nine OASIS questions: diagnosis coding (primary and other) in M0230/M0240, wounds (M0450, M0470, M0476, M0488), ostomies (M0550), IV therapy (M0250) and urinary catheterization (M0520), explains consultant Mark Sharp with BKD in Springfield, MO. Forty-nine conditions within 19 diagnosis categories -- including 42 skin conditions -- are factored into the NRS calculation, Sharp says.

Diagnoses translate directly into points both for the home health resource group (HHRG) score and for NRS. And NRS points are additive, he says.

Reimbursement for wound care under the 2008 PPS is better than before, but still may be less than providing the wound care costs, experts say. So don't throw any of the money away through misunderstandings or carelessness. Use these four tips to get all the reimbursement you earned:

1. Don't forget to code the diagnosis. Diagnoses translate directly into points for non-routine supplies. Without the correct diagnosis, you are not going to receive the correct NRS reimbursement. Check out the following examples:

Good: Your patient has a non-healing surgical wound that you identify in M0488. Table 10A in the final PPS rule shows that you get 14 points toward the NRS severity level for this, says home care consultant Lynda Laff with Hilton Head Island, SC-based Laff Asso-ciates. This puts you in NRS severity level 2 (according to Table 9) and provides an NRS re-imbursement of $51.

Better: If you also include a diagnosis for the non-healing surgical wound (such as ICD-9-CM code 998.83) in M0240 as an "other diagnosis," you get 15 additional NRS points, Table 10B shows. Added to the 14 points from M0488, you now have 29 points, which is a severity level 4 for NRS and an NRS payment for that episode of $207.76, Laff said.

Lesson learned: Something as simple as including a diagnosis may add money to the episode reimbursement, she illustrated.

2. Accurately stage pressure ulcers. A patient with one Stage 3 pressure ulcer (M0450) scores 31 HHRG points, while one Stage 4 pressure ulcer scores 52 points.

Similarly, a patient with three or more Stage 3 pressure ulcers gets 57 NRS points, while three or more Stage 4 pressure ulcers adds 104 points. Even if the patient has no other NRS points, the difference be-tween 57 and 104 points translates into $230 of reimbursement, explains senior consultant Judy Adams with Charlotte, NC-based LarsonAllen.

3. Determine the correct status of stasis ulcers. Remember, NRS points are additive. First, you get NRS points for the number of stasis ulcers (M0470) and then you add more points for their status (M0476). In the final rule, a stasis ulcer that is "early/partial granulation" adds 18 points, while "not healing" adds 28 points, Adams says.

Example: A patient with four early/ partial granulation stasis ulcers (M0470 and 476) would garner 52 NRS points. If the patient also has a urinary catheter, add 17 points for a total of 69 points, Adams says. The additional points for the catheter move the patient from NRS Severity Level 4 to Severity Level 5, for additional reimbursement of $112, she illustrates.

4. Focus on answering OASIS wound items precisely. Wound items M0450, M0470, M0476 and M0488 directly affect NRS reimbursement, Laff stresses. For example, imagine you admit a patient for dressing changes to a sacral pressure ulcer. You hurry through the OASIS assessment and find the scores add up to an HHRG of C1F2S2.

First pass: The episode reimbursement for this HHRG is a $2,132.51 payment, plus an extra $14.12 for an NRS severity level of 1.

Smarter: You review your assessment and find you forgot to mark the Stage 2 pressure ulcer in M0450. Correcting that error adds points that move the HHRG to C2F2S2 and the NRS severity to level 2, Laff explains. The improved OASIS accuracy will add $342.37 to the base episode HHRG payment and $36.88 to the NRS reimbursement, she calculates.

Bottom line: Staging the pressure ulcer in M0450 adds $379.25 to this episode.