OASIS Alert

Published on Tue Apr 11, 2006 PDF

Accuracy is worth $200 to $600 per episode.

If you're not using all the information post-acute referral sources have, you could be stuck paying back thousands of dollars.

The HHS Office of Inspector General estimates intermediaries have paid home health agencies more than $70 million too much be-cause of M0175 errors on claims from 2001 through 2003, the OIG says in a Mar. 31 report (A-01-04-00527).

Big error: When the clinician marks only a skilled nursing facility or rehab stay in answering M0175, and the patient has also been discharged from an acute care hospital within the 14 days preceding the start of care, the claim will incorrectly pay an extra $200 to $600, explains Laura Gramenelles with Simione Consultants in Hamden, CT.
 
Errors Found in 142,000 Claims

HHAs have failed to establish controls that allow them to correctly identify all inpatient facility discharges within 14 days before the home health episode begins, the OIG asserts.

Background: The OIG selected HHA claims from fiscal years 2002 and 2003 that included codes indicating the patient was discharged only from a post-acute care facility within 14 days of the home health admission. It then matched those claims with beneficiary information on acute care hospitalizations and found 142,469 claims where patients had been in the hospital within 14 days of HHA admission, but HHAs indicated no hospital discharge within that period.

Overpayments for the 400 of those claims the OIG sampled totaled $122,674, the OIG reports. Estimated overpayments for all the matched claims is $48 million, the report says. Underpayments--where the agency correctly marked no acute hospital stay, but missed the post-acute skilled nursing or rehab stay--are likely to significantly offset this amount, predicts the National Association for Home Care & Hospice.

The Centers for Medicare & Medicaid Services estimated that total fiscal year 2001 M0175-related overpayments were $30 million, and that underpayments for that period were about $15 million, NAHC reports.

OIG Urges Crackdown on M0175 Errors

From the selected 200 claims from each of the two years, the OIG contacted 87 agencies for 100 of these erroneous claims to determine "the underlying cause of noncompliance with Medicare requirements," the report explains.

Problems the OIG identified include failure to educate staff about how to determine relevant hospital admissions, reliance on the information patients and families provide without checking it and not inspecting the medical record for hospital discharge information.
 
The dilemma: There's only so much agencies can do to determine prior stays, be-cause the hospitalization information often isn't available when the episode begins.

Hospitals have two years to file claims, so accurate responses to M0175 result from agency efforts. "Postacute care facilities are the most reliable source of the information that HHAs need to complete question M0175 on the OASIS," the OIG says in the report.

High M0175 Adjustments Could Trigger Medical Review

The OIG is concerned about a continuing pattern of errors on this M0 item because "when hospitals submit their claims after HHAs submit theirs, CMS will not identify the HHA billing errors until the postpayment review. The resulting overpayments will need to be recovered through offset or collection activities," the OIG notes.

Watch out: CMS should identify agencies with high M0175 error rates and "subject those HHAs to appropriate corrective action," the OIG advises. "If certain HHAs continue to submit claims improperly, contractors will follow the Progressive Correction Action plan and take appropriate action to ensure that claims are submitted appropriately," CMS agrees in its response to the report.

Avoid Common M0175 Errors
 
Keep your finance department happy by making your M0175 response accurate as early as possible, says Wanda Strickland with Professional Healthcare Resources in Annandale, VA. Good communication between intake, finance and OASIS review staff can head off many errors, although not all, she reports.
 
To prevent unexpected costs and recoupments, experts recommend the following:

• Question referral sources. Provide intake staff with a list of questions and follow-up questions to ask about prior discharges. Don't stop with the most recent discharge--ask about all admissions, transfers and discharges. Leave enough space on referral forms for multiple hospitalizations. And pass along information to staff about facilities that are tricky, such as where the facility name says rehab but it bills as a hospital, Strickland advises.

• Know what counts. An emergency room visit or "hold" without admission doesn't count as an inpatient discharge, says home care consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. "If you weren't admitted, you can't be discharged," she stresses.  

• Educate staff about M0175 accuracy. Train staff on the importance of M0175, on where to find the information you need and on interviewing strategies, Strickland says. Emphasize that M0175 requires you to select all the answers that apply, explains Carol Conrad, also with Simione.

Tip: Provide staff with a small calendar for counting the 14 days. The day of admission is Day 0, CMS explains in MLN Matters--formerly Medlearn Matters--article SE0410. For example, if the episode start date is May 25, Day 14 for answering M0175 is May 11, CMS illustrates.

• Don't stop too soon. The OIG found the agencies it examined had entered only the most recent discharge, the post-acute facility. Remind clinicians that the directions indicate that all facilities that apply must be indicated, not just the last one, says fiscal intermediary Associated Hospital Service in its Web site questions and answers.

• Review all the records. Try to account for the patient's whereabouts during all 14 preadmission days, suggests Deborah Barton with Wheeling, WV-based VNA of Medical Park.

Note: the MLN Matters article is at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0410.pdf.