OASIS Alert

Published on Fri Feb 20, 2004 PDF

It may seem like too much trouble, but checking the common working file could make a $200 to $600 difference in an episode payment.

Besides asking patients, caregivers, referral sources and providers for information to pinpoint prior facility stays (see "Profit and Comply - Use These 4 Tips For M0175 Success"), home health agencies should query the CWF, experts suggest. Adding this resource to your other information sources gives you the best chance of accurately answering M0175 - and receiving the payment you deserve.

What you need to know: M0175 asks if the patient has been discharged from a hospital, skilled nursing facility or rehab facility within 14 days of home health admission. Referral sources, patients and caregivers often are unsure about the type of facility or the timing of the stay, so relying on their recollection can cost you hundreds of dollars. Regional home health intermediary edits will catch the errors in Medicare's favor, but it's up to you to catch the ones that will put money in your pocket.

RHHI edits taking effect April 1 will check for prior stays when the agency files a request for anticipated payment, when an agency files a final claim and again annually - because hospitals have up to 27 months to submit and be paid for their claims.

Agencies should create their own systems for checking on prior stays, says consultant M. Aaron Little with BKD in Springfield, MO. Check the CWF on admission, along with the other intake procedures, he recommends. Besides possibly showing prior stay information, it can confirm the validity of the patient's Medicare number, show if another insurer is primary and tell you if another agency is already seeing the patient, Little explains.

Check the CWF again before locking the OASIS to see if an inpatient stay shows up yet, Little says. Then check once more before your last opportunity to file or correct the claim - which will be from 15 to 27 months after the episode ends. For example, claims for episodes that ended from 10/1/2002 to 9/30/2003 can be corrected only prior to 1/1/2005. Claims for episodes that ended from 10/1/2003 to 9/30/2004 must be corrected before 1/1/2006, Little explains.

Using the HIQA query screen for the CWF means HHAs won't have to rely solely on hearsay for information on patients' prior inpatient stays, a Centers for Medicare & Medicaid Services official tells Eli. If you know where to look, the CWF can tell you lots about a patient's history of inpatient stays.

Heads up: You could wait for CMS' educational material, but many agencies want to start now.

Checking the CWF through HIQA should be an important part of ensuring M0175 accuracy, but it "can require detective work to decipher," Little says.

Protect yourself: Follow these steps from Little to make the most of your CWF access:

1. Locate HIQA Page 1. You can access all the prior stay information on this page.

2. Look under the "CURRENT" line. There you should see two columns: "FULL-SNF" and "CO-SNF." The "FULL-SNF" column represents the first 20 days of a Medicare SNF stay, which are fully covered by the program. The "CO-SNF" column represents the last 80 days of a Medicare SNF stay, which are only partially covered and require coinsurance.

3. Determine how many days are under each SNF column. If the days are to their limit - 20 and 80 respectively - then the patient didn't have a SNF stay and you can stop. If the days are under the 20/80 limit, then a SNF stay most likely occurred and you should proceed to Step 4.

"If you see SNF days of less than 100 (the SNF benefit limit), then the discharge date will typically be discharge from the SNF," agrees the CMS official.

4. Check the discharge date. Even if there was a hospital and/or SNF stay, it affects M0175 and billing only if the stay was within 14 days of home health admission. To check the discharge date, locate the "DOEBA" and "DOLBA" columns under the "CURRENT" line. "DOEBA," the "date of earliest billing action," normally represents the date the patient entered an acute hospital stay. "DOLBA," the "date of latest billing action," represents the discharge date of either an acute hospital stay or a SNF stay, if the number of days left for SNF coverage are fewer than 20/80.

5. Compare the dates. Compare the date under "DOLBA" to the home health admission date to see if it falls within 14 days of admission and therefore affects M0175 and related billing.