OASIS Alert

Published on Wed Oct 26, 2005 PDF

A little detective work could save you $600 per episode.

If you've been improving your ability to answer M0175 on the OASIS assessment, put your new-found skills to work in the next few weeks.

Home health agencies have only five weeks--from Oct. 24 to Nov. 28--to inspect and question errors in the fiscal intermediary's file showing agency mistakes in answering M0175 during fiscal year 2001, the Centers for Medicare & Medicaid Services says in a recent Medlearn Matters article. On Nov. 28 the adjustments will begin and any disputes will then have to follow normal appeals processes.

Issue: M0175 asks about prior inpatient stays within the 14 days before the admission assessment. If the answer shows a skilled nursing facility or rehab stay  without a hospital discharge within that time period, the agency's reimbursement for that episode increases by $600 for a high-therapy-use patient and $200 without the therapy.

So if agencies noted the SNF/rehab stay but missed the hospital stay, they were overpaid. On the other hand, if they missed the SNF/rehab stay and there was no hospital stay, they were underpaid.

Try this: Once you know what adjustments the FI plans, take time to verify their accuracy. Most agencies have not gone back to research older claims, even if they're still having trouble with M0175 on new claims, says Ft. Lauderdale-based consultant Susanne Justice-Moran with Justice-Moran & Associates.
 
Check the prior stay information against the Common Working File, using the "APP Date" field on the HIQA/ELGA CWF inquiry screen, instructs consultant M. Aaron Little with BKD in Springfield, MO. "This option allows providers to view hospital and SNF inpatient stay information from past periods," he tells Eli.

But don't make the mistake of assuming the CWF is always right. "Because the CWF data is based on provider claims data, there is certainly the possibility for errors," Little notes. If you have conflicting information, you can follow up with your own detective work, including speaking to the institution that billed the prior stay.

Hidden trap: The term "hospital" in Response 1 includes both acute care and long term care hospitals, CMS clarifies.

Also, if the patient was never admitted to the hospital, he was not discharged, reminds consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates.

For example, a patient may have outpatient surgery without being admitted to the hospital. And many times elderly patients are kept at the hospital for observation for a day--and sometimes more--without being admitted. Agencies may need to contact the hospital billing department to determine how the stay was billed, experts suggest.

What to do: If you find an adjustment for which you "are certain there was no prior inpatient stay," contact your regional home health intermediary to request that the error be corrected, CMS instructs in the Medlearn Matters article. 

Note: The Medlearn Matters article is online at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0561.pdf.