OASIS Alert

Published on Wed Jul 28, 2004 PDF

Confirm downcode appropriateness with 'APP DATE' field.

You say you're not sure you can trust the feds to get it right? Agencies wishing to check their fiscal intermediary's M0175 downcodes have a valuable new tool to help them.

Most agencies are paying attention to M0175 because new edits that began April 1 have produced downcoded claims or requests for anticipated payment returned for correction.

And the promised takeback of $23 million for overpayments to home health agencies for M0175 errors in the first year of the prospective payment system will begin soon.

Experts warn: Don't let your FI make a costly mistake: You should confirm every downcode you receive, and you should do the same with the upcoming takebacks, experts urge. Claims processing systems aren't foolproof, and you could get docked for an inpatient stay that never really took place.

M0175 asks if a patient has been discharged from a hospital, rehab facility, skilled nursing facility or other nursing home within 14 days of the start or resumption of care. The patient earns zero points if she had a hospital stay, one point if she did NOThave a hospital stay, and two points if she had a rehab or SNF stay.

The reimbursement impact comes if the patient had no hospital stay and also had a rehab or SNF stay, explains consultant Laura Gram-enelles with Hamden, CT-based Simione Consultants. You can add the no-hospital-stay point to the two points for a SNF or rehab stay and have three points in the service category of the home health resource group (see OASIS Alert, Vol. 4, No. 3).

What to do: Now there is an easier way for HHAs to research hospital stays that took place three or four years ago -- the Common Working File. Agencies can "obtain prior inpatient stay information via ELGA, "regional home health intermediary Cahaba GBA instructs in its June newsletter to providers. "By typing a date in the APP DATE field you can access prior eligibility information" for hospital and SNF stays via the ELGAscreen, the RHHI explains.

Here's how it works: Page 1 of the ELGA screen displays hospital and SNF stay information. (See OASIS Alert, Vol. 5, No. 6. for instructions on how to decipher hospital stays from the information on the ELGA screen).

When you enter the patient information on the ELGA inquiry screen but leave the "APP DATE" field blank, ELGA gives you the most recent stay information, Cahaba says. To look up stays from previous time periods, simply enter a date in the APP DATE field and it will search for stays after that date.

Having the APP DATE function available for hospital and SNF stays "will be beneficial not only to home health agencies, but to hospitals and SNFs as well," cheers consultant M. Aaron Little with BKD in Springfield, MO. "The APP DATE will be very helpful when agencies are researching M0175 takebacks to identify whether the takeback was appropriate," Little says.

"Using the APP DATE field is important when prior beneficiary eligibility information is needed," Cahaba notes.

Caution: Of course, there are limits to the CWF's usefulness in researching prior inpatient stays. The data displayed "is only as good as the last bill" submitted by the hospital or SNF, warns Lynda Dilts-Benson with Rein-gruber & Co. in St. Petersburg, FL.

"If a hospital/SNF has not yet billed its claims, ELGA will not be updated with the current inpatient stay information," Little cautions.

But looking up stays from years ago, after the hospitals' 27-month billing window has closed, is likely to garner more useful information than using ELGA only a few days after the patient has been discharged from the hospital.

Dilts-Benson recommends using CWF data in conjunction with the "tried-and-true" methods of M0175 research -- questioning patients, their families, referral sources and hospital case managers and discharge planners.

ELGH and ELGA both display patients' home health stays, Cahaba explains in its June newsletter to providers.

When you fill in the patient information in the ELGH/ELGA inquiry screen and leave the "APP DATE" field blank, the most recent HHA episode information will appear on p. 3 of ELGH and p. 4 of ELGA, Cahaba says. The screens show the episodes'start and end dates, among other information.

Try this: To look up prior home health episodes, type a date into the APP DATE field and ELGH/ELGA will show you episodes before that date. Determining patients' current and prior home health stays may help with billing problems such as partial episode payment (PEP) adjustments for overlapping episodes and transfer patients.

Editor's Note: Cahaba's newsletter is available online at www.iamedicare.com/Provider/newsroom/newslines/060104.pdf