To file or not to file: SCIC is hard to define

Evaluate claims on financial and clinical basis

Most home health workers have heard the definitions of Medicare’s significant change in condition (SCIC). Simply stated, it is any unexpected improvement or decline in the patient’s condition, or a change in the treatment plan. But identifying a SCIC situation and deciding whether to submit a SCIC adjustment for reimbursement is not a simple process, say experts interviewed by Hospital Home Health.

Home health agency staffs are confused about whether or not to file SCICs because there are no clear definitions of what "significant" means, says Mary St. Pierre, BSN, vice president of regulatory affairs and membership services for National Association for Home Care (NAHC) in Washington, DC. "If you look at the situation logically, any change in the treatment plan is unexpected, so that would make it significant," she explains.

Because there is no standard definition for a significant change and the reassessment that must occur, it is left up to each agency to define the situations in which a patient must be reevaluated, says Judy Adams, RN, BSN, consultant with Larson Allen Health Consulting in Charlotte, NC. Because assessments are conducted at the initiation of service, transfer to hospitals, transfer back to home health, and every 60 days for recertification, home health staff members have trouble keeping up with extra assessments, she says.

"Agencies wrote policies that specify the addition of a therapy service, the development of a new wound, or a combination of Outcome and Assessment Information Set (OASIS) factors to define a decline in condition," Adams explains. The problem with identifying a wide range of factors that initiate a SCIC assessment is that it becomes too difficult for staff members to follow, so the policy isn’t followed, she adds. "It’s better for an agency to write a simple policy that is easy to follow so you don’t get into accreditation or regulatory trouble for not following policies," she says.

Basically, if there is a change in the OASIS score that was not anticipated at the beginning of care, if new physician orders that alter treatment were not anticipated and if the new OASIS code changes the grouper code, you can qualify for a SCIC claim, Adams says. Even if you can file a SCIC claim, the real issue is whether you want to file the claim, she adds.

Filing a SCIC claim isn’t mandatory if the patient’s condition declines, Adams points out.

It is mandatory if the patient’s condition improves and the home health agency is using fewer resources for the patient’s care, she says.

Why wouldn’t an agency file for a payment adjustment if more resources are required to care for the patient? To understand, it’s important to think about how the payment is calculated, St. Pierre says.

For example, you may have a diabetic patient that you have planned to see for 10 visits over 20 days. You see the patient for the initial assessment and a second visit at five days. On the third visit, at the 10-day point, the patient’s blood pressure is out of control and requires a change in medication by the physician. An adjusted payment would be calculated as payment for five days of service in the original grouper, no payment for days six through nine because there were no visits, and payment for days 10-20 in the new grouper, St. Pierre explains.

Because Medicare payments are based on 60-day episodes, you would receive a total of 5/60 of the payment on the first grouper and 11/60 of the payment on the second grouper. Financially, this may not be as much as the payment you would have received if you just filed the entire episode under the first grouper, she explains.

The key to determining if it is financially feasible to file a SCIC claim is to look at when the change in condition occurred and what extra resources are needed, Adams says. "Ninety-five percent of the changes in condition occur as a result of a hospital admission. This means that the home health agency will not receive any payment for those days and that may be a significant enough drop in payment that it is better to file the claim with the original grouper," she says.

The best way to evaluate whether or not you should file a SCIC is to review changes in OASIS status from both a clinical and financial perspective, Adams says.

"Some billing software programs automatically file the SCIC if there is a change in condition without giving the agency a chance to decide if SCIC is the best way to proceed," she says. For this reason, you need to make sure you can override the automatic adjustment feature if necessary, she adds.

Adams recommends that one or two people with a combination of clinical and financial expertise be responsible for reviewing all charts in which there is a change in OASIS codes before claims are filed. "By using software such as CMS [the Centers for Medicare & Medicaid Services] Pricer Software, which can be downloaded from the CMS web site for free, the reimbursement for both codes can be evaluated, and an informed decision can be made as to whether . . . to file a SCIC," she says.

[For more information about SCIC claims, contact:

Mary St. Pierre, BSN, National Association for Home Care 228 Seventh St., S.E., Washington, DC 20003. Telephone: (202) 547-7424. Fax: (202) 547-3540. E-mail: mts@nahc.org.

Judy Adams, RN, BSN, Consultant, Larson Allen Healthcare Consulting, 525 N. Tryon St., Suite 1200, Charlotte, NC 28202. Telephone: (919) 960-6739. E-mail: jadams@larsonallen.com

For additional resources, visit these web sites:

www.hcfa.gov/medicare/nm75ght/pricdnld.htm. CMS publishes a PC version of the Pricer software that calculates claim payments under the home health prospective payment system. The free software is available via download at this site. CMS updates the download file of the current year PC Pricer quarterly to reflect the most current changes.

www.hcfa.gov/medicare/hhqanda.htm. The web site, sponsored by CMS, answers frequently asked questions and groups answers by topic. Go to web site and choose SCIC for answers to questions related to significant change in condition.]