Knowledge Base Article #904:

M0825 = NO but patient has more than 10 visits, do we perform SCIC assessment?

Q: When a patient exceeds the 10-therapy visit threshold, but was not expected to, our agency performs a SCIC adjustment to correct the HHRG. I am confused with this practice, because it does not seem to meet the SCIC criteria, since the patient's status is not really changing. Is this an appropriate practice?

A: If you answer "no" to M0825, and then reach the 10-therapy visit threshold, and the patient has not experienced a major decline or improvement in status, then you are entitled to adjust the payment to more accurately reflect the services the patient is receiving. In order to receive an adjustment, your agency must do something: either cancel and resubmit the RAP, or apply for a SCIC adjustment. Applying for the SCIC adjustment is the least attractive option for at least three reasons. 1) Calculation of a SCIC adjustment includes potentially receiving NO reimbursement for "lost days" at the beginning, middle and end of the episode; 2) the SCIC adjustment requires an update to the comprehensive assessment - including OASIS collection, and 3) reimbursement at the higher rate only applies from the span of billable visit dates after the new OASIS is completed. When the underestimation was due only to clinician misjudgment, and not to an actually change in the patient's status, canceling and resubmitting the RAP will allow your agency to receive payment at the higher HHRG amount, applied to the entire episode (unless an intervening event occurs triggering a PEP, etc.).

Keywords: careportal, OASIS, M0825, therapy
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