Home Health & Hospice

Is CMS' Mistake Coming Back to Haunt Homecare Providers?

Homecare Insider, August 2, 2010

You know that feeling.  You just hit “send” on an e-mail and then realized it’s going to the wrong person.  You try to recall it but once it’s out in cyberspace, it’s there forever.  In February 2009, the Centers for Medicare and Medicaid Services (CMS) released some erroneous guidance.  It posted a correction on its website.  However, like an e-mail, the bad guidance is still out there and now it appears to be the justification for a payment reduction.

The proposed rule to update the Prospective Payment System (PPS) for 2011 includes a lengthy discussion on the substantial increase in the case-mix weight  over the last few years.  CMS believes this increase is due to changes in coding practices and documentation rather than to the treatment of more resource intensive patients.  In response, CMS plans to increase the reduction in the market basket update from 2.71 percent in 2011 to 3.79 percent for the next two years to address this “case-mix creep.”

One contributing factor cited in the proposed rule was the use of secondary diagnosis fields.  CMS noted a substantial increase in the percentage of episodes with a reported diagnosis code in M0240, other diagnoses (now M1022).  Because of the expanded case-mix diagnosis list in the revised PPS, CMS believes “the incentives to report more comorbidities under the refined case-mix system, and not the actual disease burden of home health patients” are behind this increase.  As justification, CMS notes, “Longstanding OASIS manual language instructs providers to encode diagnoses on the OASIS only when the condition is unresolved and only when the condition has an impact on the home health care.” 

This so-called longstanding language first appeared in December 2008 when CMS updated Attachment D.  It created such a furor that, in February 2009, CMS posted notification of the errors on its website.  It also restored the definition that first appeared in 2003 and the basis of the instructions for completion of the diagnosis data elements in the current OASIS-C Guidance Manual.  Comorbidity is any condition with an impact on the patient’s rehabilitative prognosis and response to treatment, even if not addressed in the plan of care. 

Download the proposed rule at — http://edocket.access.gpo.gov/2010/pdf/2010-17753.pdf.  Beacon Health’s audio conference on August 10 will discuss this issue.  Find more information at — http://www.beaconhealth.org/cgi-bin/ccp51/cp-app.cgi?pg=prod&ref=J081010A.