I

t has been almost four years since home healthcare agencies (HHAs) began electronically submitting Outcome and Assessment Information Set (OASIS) data for each patient as part of the Centers for Medicare and Medicaid Services (CMS) requirement for all certified agencies. CMS continues to refine how it monitors this data to improve accuracy and control costs.
       A good example is the new edit CMS has created to monitor how HHAs complete OASIS question M0175 (From which {if any} inpatient facilities was a patient discharged in the 14 days preceding the home care admission?) during the admission. CMS is comparing the answer of this question to data submitted by hospitals and nursing homes to see if the patient had a stay in a facility within 14 days of the admission to home care. The purpose is to determine whether HHAs failed to identify inpatient hospital stays, because this error results in excess payments to the HHAs. Depending on how other OASIS questions in the service domain are answered and where the patient lives, M0175 can lead to overpayments of up to $500.
       When CMS identifies unreported hospital stays through this process, it either reduces the payment or rejects the entire claim, because payment to the HHA should be lower if the patient had a hospital stay along with a skilled nursing or rehabilitation facility stay prior to the HHA admission. Three answers to M0175 affect reimbursement:
• Option 1 (hospitalization)—When this response is not checked, one point is added to the service domain.
• Option 2 (rehabilitation facility) or Option 3 (skilled nursing facility)—when either of these items is checked, two points are added to the service domain.
       CMS will perform this evaluation three times:
• Request for Anticipated Payment (RAP) release: The HHA submits an admission or recertification OASIS for payment through a process called RAP release. At the time of RAP release, CMS will reject any RAP releases where this data is inconsistent.
• Claim release: After the end of each 60-day HHA episode, a final claim is submitted by the HHA for payment. At this time, the OASIS data is again compared to Medicare’s data base on inpatient activity. Where inconsistencies are found between the HHA’s OASIS and CMS’s database, the claim will be down coded.
• Annually: On an annual basis, there will be one additional verification for accuracy in M0175 completion, and claims will be down coded retroactively.
       What are the implications for HHAs? Savvy agencies are paying more attention to question M0175 to avoid these problems and are using any down codes or rejects to educate caregivers on completion of this OASIS question.
       When a new patient referral is received from a physician office, questions the HHA can ask include:
• Do you know if the patient has been in a facility in the last month? If the answer is yes, ask for dates of discharge and the name of the facility.
• Was this office visit a follow-up visit from a previous hospitalization or facility stay? If the answer is yes, ask for dates of discharge and the name of the facility.
• Does this patient have any other healthcare providers that you are aware of? If the answer is yes, ask for the names of the other providers, as you may need to contact them for information on this referral.
       If the new patient referral is coming from a hospital, getting the correct answer to M0175 is relatively easy. It is important to note that some hospitals have licensed skilled nursing facility and rehabilitation beds as well as acute care beds, and if this is the case, the HHA needs to clarify all the levels of care provided to the patient while in the facility. If the person giving the referral to the HHA is unsure of the levels of care for each unit, ask to speak to the social worker or business office to clarify what level of care was billed for the patient’s stay in the facility.
       Sometimes, of course, little information is provided to the HHA when a new patient referral is received. If the admitting nurse or therapist is meeting the patient for the first time and has none of the above information, a little detective work may help answer to M0175 correctly:
• When looking at the medications, are the fill dates all the same? This would suggest an inpatient stay that ended at that time.
• Are there items in the home with the names/logos of healthcare facilities?
• Are there indications of recent needle punctures? These may indicate recent blood work or intravenous therapies.
       It’s also a good idea to review the details of exactly how the days should be counted to avoid errors due to a day or two difference between the HHA and CMS’s calculations. When the admitting nurse or therapist is answering M0175, he or she should count 1 for the day before the start of care or resumption of care, back to 14 (if today is the 17th, count the 16th as 1, the 15th as 2, etc.).
       In summary, reviewing the new patient referral when it is being received as well as effective interviewing at the time of admission can help HHAs complete M0175 accurately and avoid payment delays or reductions when the OASIS data is submitted to CMS for processing and payment.

Frequently Asked Questions
       Question: How should I answer M0540 (bowel incontinence) for a patient who is learning a bowel program?
       Answer: While this patient may have more bowel incontinence, the fact that the patient is on a bowel program does not indicate incontinence by itself. The evaluation should not be different because the patient is on a bowel program. Assess if the program with the use of timing and procedures eliminates any bowel incontinence.
       Question: How do I respond to M0670 (bathing) if the patient’s tub is not safe for him to use?
       Answer: The patient’s environment can affect the patient’s ability to complete his activities of daily living (ADLs). If the patient is not able to use the tub or shower, response 4 or 5 would be appropriate depending on his ability to assist in the bathing process.
       Question: How do I respond to M0700 (ambulation) when the patient is on restricted weight bearing but is able to ambulate?
       Answer: When answering M0700, take into consideration any restrictions currently ordered for the patient. This addresses what the patient is able to safely accomplish at the time the assessment is completed.
       If you have a question that you would like addressed in “OASIS: More Than Just an Assessment,” e-mail it to Renee Olszewski, Managing Editor, at rolszewski@hmpcommunications.com and we will address it in a future issue.