OASIS Alert

Published on Sun Oct 03, 2010 PDF

HHAs' profit margins and coding accuracy will also go under the microscope.

The Centers for Medicare & Medicaid Services will soon have another set of eyes looking at the OASIS data you submit for payment.

The HHS Office of Inspector General plans to issue six new reports concerning home health agencies next year and one of those will focus on OASIS data, the OIG says in its newly released 2011 Work Plan.

CMS uses OASIS data for payment and for gauging agencies' quality of care, the OIG notes in the plan. "We will review CMS's process for ensuring that HHAs submit accurate and complete OASIS data. The other five reports will tackle profit margins, HHRG coding accuracy, payment controls, enrollment, medical supplies. There will also be two reports on hospices and 12 on durable medical equipment supplier issues.

Note: The Work Plan is online at http://oig.hhs.gov/publications/workplan/2011/FY11_WorkPlan-All.pdf.

Collect and Submit OASIS Data for Single Episodes Just when you had the rules for single visits down pat, the Centers for Medicare & Medicaid Services changed the rules. If you didn't follow suit, your bottom line is likely paying the price.

"There have been recent issues with claims denied or payment reduced because of the change in PPS payment regulations effective this past January," says Judy Adams, president of Adams Home Care Consulting in Chapel Hill, N.C.

Effective January 2010, CMS retired the Management of Single Visits document in favor of the PPS system, which requires agencies to submit an OASIS assessment whether they see a patient for a single visit or an entire episode of care. Before that, your single visit would be paid as a low utilization payment adjustment.

New way: You must submit an assessment if you want to be paid for any visit, CMS says. If you choose not to be paid, you do not need to perform an assessment for the single visit. CMS adopted this rule to ensure that agencies submit an OASIS assessment before submitting the final episode claim, and that both the claim and the assessment contain the same HIPPS code.

Brush up on the OASIS requirement for payment in the November 2009 Federal Register at http://edocket.access.gpo.gov/2009/pdf/E9-26503.pdf.

Edit Shoots Down Nearly All Hypertension Claims If you're submitting claims for long-stay patients with chronic diseases, you'd better beef up your documentation. That's because two edits at regional home health intermediary Cahaba GBA that focus on COPD and hypertension patients have seen sky-high denial rates.

Edit No. 1, 5THBX, reviews claims with a length of stay greater than 120 days and primary diagnosis of 496. xx, indicating COPD. The denial rate for the edit is a whopping 85 percent, Cahaba says in its September newsletter for providers.

Edit No. 2, 5023T, targets claims with a length of stay greater than 120 days, a primary diagnosis of 401.9 indicating hypertension, and five to nine nursing visits. The edit's denial rate is an even higher 98 percent.

The chief reason for denials for both edits is "5HMED:

Documentation does not support medical necessity of services billed," Cahaba notes.

"Although the topics of the edits are driven by a diagnosis, the denials were not due to 'coding,'" Cahaba said. "The entire medical record is reviewed, and for both edits, the overwhelming top denial was related to documentation of medical necessity of the skilled services."

Watch for this: Agencies' main problem was failure to provide enough documentation to support observation and assessment. "For a skilled service of observation and assessment to be covered by Medicare, there must be clear documentation of the patient's condition that warrants this service," Cahaba says. "Typically, documentation of changes in diagnosis, exacerbations, medication or treatment changes that continue to put the beneficiary at risk for further plan of care changes shows the medical necessity for observation and assessment."

Resource: More information about the edits is in the September Newsline at http://www.cahabagba.com/rhhi/news/newsletter/201009_rhhi.pdf.

Worried you might be missing your patients' falls risks?

The American Physical Therapy Association has a video in which PT Diane Nichols provides some fallproofing tips for seniors.

Links to the video and other falls prevention tools, such as a walking aid tips sheet, are at www. moveforwardpt. com/tips. One tip: A "walker or cane should be about the height of your wrists when your arms are at your sides," the tips sheet says.