Presented by Selman-Holman & Associates, LLC · 2019. 12. 17. · OASIS C‐1/ICD‐10 Presented by...

OASISC‐1/ICD‐10

Presented by Selman-Holman & Associates, LLCTeresa Northcutt, BSN, RN, HCS-D, COS-C

1 Selman‐Holman&Associates,LLC2

Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-CHome Health Insight—Consulting, Education and Products

CoDR—Coding Done RightCodeProUniversity

606 N. Bell Ave.Denton, Texas 76209

214.550.1477972.692.5908 fax

[email protected]@selmanholman.comwww.selmanholmanblog.com

www.selmanholman.comwww.CodeProU.com

www.codingdoneright.com

PurposesofOASIS3

RiskAdjustedEndResultOutcomeMeasures

Improvement in Stabilization

GroomingDyspneaBathing Bed transferringToilet transferringToilet hygieneEatingSpeech and language

Management of Oral MedsConfusion FrequencyUTIsBowel incontinenceAmbulation/locomotionStatus of surgical woundsBehavior problem frequencyPain interfering w/activity

Upper body dressingLower body dressingLight meal prepPhone useAnxiety level

GroomingBathing Bed transferringLight meal prepPhone UseManagement of Oral MedsSpeech and LanguageCognitive FunctioningAnxiety levelToilet transferringToilet hygiene

4

Risk‐AdjustedUtilizationOutcomeMeasures

Discharged to community

[OASIS based]Acute care hospitalization (ACH)[Claims based]ACH during 1st 60 days of HHRehospitalizationduring 1st 30 days of HH

[OASIS based]ED use w hospitalization[Claims based]ED use w/o hospitalizationED use without hospital readmission during 1st 30 days of HHED use w/o hospitalization during 1st 30 days of HH

5

OASISTimepoints

SOC -------------- DCSOC -------------- TransferROC -------------- DCROC -------------- TransferThe Definition of an Episode Can Be

D I f f e r e n t

And the definition of ‘short term episode’…And why is that important? Home Health Compare

6

Ramifications

Resumption of Care is as important as SOC Discharge is as important as SOC or ROC

Unplanned discharges without a visit to the home for assessment can be disastrous to your outcomes

SOC, FU, FU, FU, FU, DC—not good for your Home Health Compare outcomes

7

Outcomes

Outcomes are health status changes between two or more time points, where the term “health status” encompasses physiologic, functional, cognitive, emotional, and behavioral health.

Outcomes are changes that are intrinsic to the patient.

Outcomes are changes that result from care provided, or natural progression of disease and disability, or both.

Outcomes are positive, negative, or neutral changes in health status.

8

Outcomes

OASIS data items are arranged from least impaired or independent, to most impaired or dependent.

The answer at SOC/ROC is compared to the answer at Transfer/DC to determine if there has been improvement, decline or stabilization on that particular outcome.

9

Example—AtSOC,Mr.Brownwasmarkedasa3.

X

10

AtDC,Mr.Brownwasmarkedasa2ashehadbeentrainedbytherapytousea2handeddevice,buthe

stillneededoccasionalassistance.

X

11

5StarRatings

Home Health Compare information can be overwhelming to consumers27 outcome and process measures provide

information on provider quality to allow informed choice of a HH agency

Consumers are accustomed to using a “star” rating system to compare and choose products and servicesHH Star Ratings offer a simple tool to aid

consumers’ health care decision making

12

MeasuresIncludedinStarRating

Outcome Measures: Improvement in Ambulation Improvement in Bed Transferring Improvement in Bathing Improvement in Pain Interfering with Activity Improvement in Shortness of BreathAcute Care Hospitalization

13

MeasuresIncludedinStarRating

Process Measures:Timely Initiation of CareDrug Education on all Medications Provided to

Patient/Caregiver Influenza Immunization Received for Current

Flu SeasonPneumococcal Vaccine Ever Received

HHCAHPS measures pending

14

CriteriaforMeasureSelection

Measure applies to substantial portion of home health patients and has sufficient data to report for a majority of home health agencies

Measure should show some variation between agencies and agencies should be able to show improvement in performance for the measure

Measure should be clinically relevant Measure should be relatively stable and should

not show substantial random variation over time

15

HowareStarRatingsCalculated?

Specific methodology for calculating and reporting the Star Rating Eligible episodes must have discharge date

within the 12 month reporting period All Medicare-certified home health agencies will

be eligible to receive a Star Rating; must have reported data for at least 6 of the 10 measures

16

EpisodesExcludedfromOutcomeEpisodes

Those episodes that score a zero at SOC / ROCFor example patient is scored a zero on

transferring—transferring will not be evaluated on that particular patient for the rest of his stay

Those episodes that don’t change either up or down (unless there is a stabilization outcome for that particular measure)

Episodes longer than one year

17

RiskAdjustment

The challenge in outcome analysis is to attempt to somehow separate changes due to care from those due to natural progression.

Statistical risk adjustment refers to a collection of analytic methods designed to separate the relationships of outcomes with care provided from the relationship of outcomes with natural progression of disease and disability.

One of the major purposes of OASIS is to provide data items needed for risk adjustment. General intent of risk adjustment is to compensate or

adjust for differences in case mix or risk factors (between agency and a comparison sample) that should be taken into consideration if outcomes are to be compared validly.

Risk adjustment compensates or controls for the potential influence of case mix variables (i.e., risk factors) that can affect outcomes.

18

ProcessMeasures

Processes that promote good outcomes—known as best practices Some require standardized validated tools

DomainsTimely care care coordination patient assessment care planning care plan implementation education prevention

19

StateSpecificScoresAvailable

Timely Care •Start of Care Visit Occurs in a Timely Manner

Assessment

•Patients Assessed for Signs of Depression•Patients Assessed for Risk of Falling•Patients Assessed for Pain•Patients Assessed for Risk of Getting Pressure Sores

Care Planning •Plan of Care Includes Steps to Prevent Pressure Sores

Care Plan Implementation

•Diabetic Patients Receive Foot Care and Education•Heart Failure Symptoms Addressed Appropriately•Patients Get Care to Help Deal with Pain

Education •Patients Get Education on All Their Medications

Prevention•Staff Make Sure Patient Gets Flu Shot•Staff Make Sure Patient Has Had Pneumonia Shot•Steps to Prevent Pressure Sores are Implemented

20

StandardizedandValidatedTools

A standardized and validated tool is one that 1) has been scientifically tested on a population

with characteristics similar to that of the patient being assessed and shown to be effective in identifying ((the problem)); and

2) includes a standard response scale (e.g., a scale where patients rate pain from 0-10).

The standardized tool must be appropriately administered as indicated in the instructions and must be relevant for the patient's ability to respond.

CMS does not endorse a specific tool.

21

StandardizedToolsIntegrated?

There is no Medicare requirement that standardized assessment tools be embedded in agency’s comprehensive assessment (except PHQ-2 in M1730).

It is acceptable for clinician to supplement agency’s comprehensive assessment with additional standardized assessment forms to meet the criteria for OASIS best practice items.

Include form in medical record with comprehensive assessment.

Q&A#1 April 2013

22

PotentiallyAvoidableEventsEmergent Care for Injury Caused by Fall

Discharged to community needing wound care or medication assistance

Substantial Decline in 3 or more Activities of Daily Living

Development of Urinary Tract Infection

Emergent Care for Wound Infections, Deteriorating Wound Status

Discharged to community with behavioral problems

Substantial Declinein Mngt of Oral Medications

Increase in Number of Pressure Ulcers

Emergent Care for Improper Medication Administration, Medication Side Effects

Discharged to the community needing toileting assistance

Emergent Care for Hypo/Hyperglycemia

Discharged to the community with a unhealed Stage II pressure ulcer23

HomeHealthResourceGroup

OASIS is the basis for payment HHRG produced through grouper software

Determined through 25 OASIS responsesThree domainsClinical SeverityFunctional StatusService utilization

45 HHRGs; 153 case mix weightsC1F1S1 to C3F3S5 for four different

equations (five different groupings)(five different C1F1S1s)

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CLINICAL DIMENSION

Episode number within sequence of adjacent episodes 1 or 2 1 or 2 3+ 3+Therapy Visits 0‐13 14+ 0‐13 14+EQUATION 1 2 3 4

1 Primary or Other Diagnosis =Blindness/Low Vision2 Primary or Other Diagnosis= Blood disorders 6 33 Primary or Other Diagnosis = Cancer, selected benign neoplasms 8 84 Primary Diagnosis = Diabetes 8 75 Other Diagnosis = Diabetes 16 Primary or Other Diagnosis = Dysphagia AND Primary or Other Diagnosis

= Neuro 3 ‐Stroke 2 16 1 97 Primary or Other Diagnosis = Dysphagia AND M1030 (Therapy at home) =

3 (Enteral) 2 7 78 Primary or Other Diagnosis = Gastrointestinal disorders

9 Primary or Other Diagnosis = Gastrointestinal disorders ANDM1630(ostomy)= 1 or 2 6

10 Primary or Other Diagnosis = Gastrointestinal disorders AND Primaryor Other Diagnosis = Neuro 1 ‐ Brain disorders and paralysis, ORNeuro 2 ‐ Peripheral neurological disorders, OR Neuro 3 ‐ Stroke, OR Neuro 4‐Multiple Sclerosis

11 Primary or Other Diagnosis=Heart Disease OR Hypertension 112 Primary Diagnosis=Neuro 1 ‐ Brain disorders and paralysis 3 11 6 1113 Primary or Other Diagnosis = Neuro 1 ‐ Brain disorders and paralysis

ANDM1840 (Toilet transfer)= 2 or more14 Primary or Other Diagnosis = Neuro 1 ‐ Brain disorders and paralysis

OR Neuro 2 ‐Peripheral neurological disorders ANDM1810 or M1820 (Dressing upper or lower body)=1, 2, or 3

2 7 1 7

15 Primary or Other Diagnosis = Neuro 3 ‐ Stroke 3 10 2

M0110EpisodeTiming

Timepoints: SOC, ROC, F/U Placement of the current Medicare PPS payment

episode in the patient’s current sequence of adjacent Medicare PPS payment episodes

26

M0110EpisodeTiming

A “sequence of adjacent Medicare home health payment episodes” is a continuous series of Medicare PPS payment episodes, regardless of whether the same home health agency provided care for the entire series. Low utilization payment adjustment (LUPA ) episodes (less than

5 total visits) are counted. “Adjacent” means that there was no gap between Medicare-

covered episodes of more than 60 days. 60-day gap is counted from the end of the Medicare payment

episode, not from the date of the last visit or discharge, which can occur earlier.

(If the episode is ended by an intervening event that causes it to be paid as a partial episode payment [PEP] adjustment, then the last visit date is the end of the episode).

Periods of time when the patient is "outside" a Medicare payment episode but on service with a different payer - such as HMO, Medicaid, or private pay - are counted as gap days when counting the sequence of Medicare payment episodes.

27

M0110EpisodeTiming

“Early” includes the only PPS episode in a single episode case OR the first or second PPS episode in a sequence of adjacent PPS episodes.

“Later” means the third or later PPS episode in a sequence of adjacent episodes.

“UK - Unknown” response means placement of this PPS payment episode in the sequence of adjacent episodes is unknown. (will have the same effect as selecting the “Early” response)

Enter “NA” if no Medicare case mix group is to be defined for this episode.

If the patient needs a case mix code for billing purposes (a HIPPS code), a response other than “NA” is required to generate the code. Some payment sources that are not Medicare-fee-for-service payers will use this information in setting an episode payment rate.

28

EpisodeTiming

ExampleEnd of episode date is March 1. Any new

episode within 60 days of March 1 will be a subsequent episode.

You check the CWF and another agency had the patient for two episodes ending March 1. Your SOC is April 2. Early or Later?

Same example but during that period with the other agency, it shows the patient’s payor source was a Medicare HMO. Early or Later?

29

CLINICAL DIMENSION










2 7 1 7

15 Primary or Other Diagnosis = Neuro 3 ‐ Stroke 3 10 2

M2200TherapyNeed31

M2200TherapyNeed

Timepoints SOC ROC Follow-up Therapy visits must

Relate directly and specifically to a treatment regimen ordered by physician

Be reasonable and necessary to the treatment of the patient’s illness or injury

Answer “000” if no therapy services are needed Answer NA when this assessment will not be used

to determine a case mix group for Medicare, or other payers using a Medicare PPS-like model

32

M2200TherapyNeed

How many combined therapy visits? Social work does not count as a therapy If therapy services are ordered, how many total

visits are indicated over the 60-day payment episode?

If number is uncertain, provide best estimate.

33

M2200TherapyNeed

Medicare will adjust both up and down based on the actual number of visits provided.

ExampleYou believe patient needs 6 therapy visits at

the beginning of episode. You are paid RAP based on 6 therapy visits. Patient falls in episode and ends up with 16 visits. You will be paid final claim based on 16 visits.

34

HowtoAnsweratROC

ROC in the last 5 days of the episode Answer based on estimated need for therapy in

the next episode. ROC any other time in the episode

Answer any way you’d like (doesn’t impact payment).Number of therapy visits in episodeNumber of therapy visits left to do NA—No HHRG is needed (dependent on

software)000

4b-Q171.10

35

WhatifM0110andM2200arewrong?

No action required. May correct M0110 by a narrative. 4b-23.18

Claims will automatically be adjusted so CMS expects no extraordinary efforts to be taken after SOC, ROC or Follow up to ensure M0110 or M2200 is correct.

Other Follow-up assessment is only required if your policy requires (Is it a major decline or improvement in the patient’s condition?)

4b-Q23.18

36

Example Patient in early episode with 12 therapy visits

with CHF, diabetes (takes insulin), blindness and is recovering from gall bladder surgery (no full epithelialization yet) has the following scores on OASIS data items

M1810/1820 = 1 M1242 = 2 M1830 = 2 M1342 = 3 M1840 = 2 M1400 = 2 M1850 = 2

M1860 = 2

37

Aftercareforgallbladdersurgery,diabetes,blindnessandCHF

M0230/M0240 M0246(3) (4)(1) (2) M1024 (3)

M1020(a) AC following surgery GI system

Z48.815

M1022(b) Acute Systolic Heart Failure

I50.21 (1pt)

M1022(c) Diabetes E11.9 (1pt)

M1022(d) Blindness H54.0M1022(e) Insulin use Z79.4M1022(f)

OPDx

38

CLINICAL DIMENSION










2 7 1 7

15 Primary or Other Diagnosis = Neuro 3 ‐ Stroke 3 10 2 40

28 Primary or Other Diagnosis = Skin 2 ‐ Ulcers and other skinconditions

2 17 8 17

29 Primary or Other Diagnosis = Tracheostomy 4 19 4 1130 Primary or Other Diagnosis = Urostomy/Cystostomy 19 1431 M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) 18 6 1832 M1030 (Therapy at home) = 3 (Enteral) 15 733 M1200 (Vision)= 1 or more34 M1242 (Pain)= 3 or 4 2 135 M1308 =Two or more pressure ulcers at stage 3 or 4 4 5 4 1336 M1324 (Most problematic pressure ulcer stage)= 1 or2 3 19 7 1637 M1324 (Most problematic pressure ulcer stage)= 3 or4 8 33 12 2638 M1334 (Stasis ulcer status)= 2 4 13 8 2239 M1334 (Stasis ulcer status)= 3 7 18 10 1840 M1342 (Surgical wound status)= 2 1 7 6 1441 M1342 (Surgical wound status)= 3 6 5 1142 M1400 (Dyspnea)= 2, 3, or4 2 343 M1620 (Bowel Incontinence)= 2 to 5 4 344 M1630 (Ostomy)= 1 or 2 4 11 3 1145 M2030 (Injectable Drug Use)= 0, 1, 2, or 3

2 Clinical points

41

FUNCTIONAL DIMENSION

46 M1810 orM1820 (Dressing upper or lower body)=1, 2, or3 2 2

47 M1830 (Bathing)= 2 or more 6 3 5

48 M1840 (Toilet transferring)= 2 or more 1 3 3

49 M1850 (Transferring)= 2 or more 3 4 2 1

50 M1860 (Ambulation) = 1, 2 or 3 7 3

51 M1860 (Ambulation) = 4 or more 7 8 6 8

19 functional points42

CY 2015 Clinical and Functional Thresholds

1st and 2nd Episodes 3rd+ episodes All episodes

0‐13 therapy visits




20+ therapy visits

Grouping Step: 1 2 3 4 5

Clinical

Functional

Service

C1C2C3F1F2F3S1S2S3S4S5

0 to 12 to 34+0 to 141516+0‐567‐91011‐13

0 to 12 to 78+0 to 34 to 1314+14‐1516‐1718‐19

012+0 to 91011+0‐567‐91011‐13

0 to 56 to 1213+01 to 78+14‐1516‐1718‐19

0 to 34 to 1617+0 to 23 to 56+20+

Non‐routinesupplies(NRS)

Gets its own points system based on certain OASIS questions and diagnoses

6 non-routine supply levelsS-X supplies provided1-6 supplies not provided

Are required to bill suppliesRevenue code 0270 or 0623Charges, not cost

43

PaymentisBasedOnPoints44

45

Assessment Data Collection

TheHow,Who,What&WhenofOASIS‐C1:thePatients,

theCoPs,theTimepoints andtheConventions

Patients

OASIS data are collected for Medicare and Medicaid patients, 18 years and older, receiving skilled services, with the exception of patients receiving services for pre- or postnatal conditions.

Patients receiving only personal care, homemaker, or chore services are excluded since these are not considered skilled services.

47

IfOASISisnotrequired:

HHAs must provide each patient, regardless of payment source, with a patient-specific comprehensive assessment that accurately reflects the patient’s current health status. The comprehensive assessment must also identify the patient’s continuing need for home care, medical, nursing, rehab, social and discharge planning needs. Only exception is housekeeping and chore services

Comprehensive assessment includes drug regimen review.

HHAs may continue to collect OASIS data on non-Medicare/non-Medicaid patients for agency use, BUT do not transmit the info.

48

WhocancollectOASISdata?

Qualified clinicians RN PT ST OT (but not on SOC)

Who CANNOT collect OASIS? SW LVN/LPN PTA OTA HHAides

49

TheConditionsofParticipation42CFR484.55

50

TheCoPs—ComprehensiveAssessment

42 CFR 484.55 CoPs OASIS

Initial assessment visit Completion of the comprehensive assessment Drug regimen review Update of the comprehensive assessment Incorporation of the OASIS data set

51

OASISdataitemsarenotmeanttobeacomprehensiveassessment

Not meant to be a complete assessment by themselves

Integrate the OASIS data items into your own comprehensive assessment and throw the redundancy out

52

DrugRegimenReview

Required at every comprehensive assessment M2000 Drug Regimen Review SOC/ROC M2002 Medication Follow-up TRN/DC M2010 Medication Intervention SOC/ROC M2015 Patient Caregiver Drug Education Intervention

TRN/DC A review of ALL medications the pt is currently using in

order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

This requirement applies to all pts being serviced by the HHA, regardless of whether the specific requirements of OASIS apply.

53

InitialAssessment

Initial means FIRST visit Determines immediate care needs and

homebound status Must be conducted either

Within 48 hours of referralWithin 48 hours of return homePhysician-ordered SOC date

54

InitialAssessment

Must be conducted by RN, unless therapy only case

If therapy only Appropriate therapist may perform initial

assessment OT may only complete initial assessment if

need for OT establishes program eligibility (cannot perform a SOC on a Medicare patient)

55

ComprehensiveAssessment

Completed in timely manner Consistent with patient’s immediate needs No later than 5 days after SOC (SOC is day 0) May NOT be started prior to SOC (first billable

visit) RN only, unless therapy only case May perform initial assessment and comprehensive

assessment on same visit or on different visits If no skilled service is delivered, the visit is not the

SOC or reimbursable (will not be accepted by HAVEN as SOC)

56

SOCDeterminationformulti‐disciplinarycases

A reimbursable service must be delivered to be considered the start of care for Medicare patients.

For Medicare reimbursement (42CFR409.46), a physician must specifically order that a particular skilled service be furnished during the evaluation in which the agency accepts the beneficiary for treatment and all other coverage criteria must be met for this visit to be billable as a skilled nursing visit.

57

42CFR409.46

Services that are allowable as administrative costs but are not separately billable include, but are not limited to, the following:

(a) Registered nurse initial evaluation visits. Initial evaluation visits by a registered nurse for the purpose of assessing a beneficiary’s health needs, determining if the agency can meet those health needs, and formulating a plan of care for the beneficiary are allowable administrative costs. If a physician specifically orders that a particular skilled service be furnished during the evaluation in which the agency accepts the beneficiary for treatment and all other coverage criteria are met, the visit is billable as a skilled nursing visit. Otherwise it is considered to be an administrative cost.

58

RequirementsforTherapyatSOC

For skilled PT or SLP to perform the SOC visit for Medicare patient: the HHA is expected to have orders from the patient’s

physician indicating the need for physical therapy or SLP prior to the initial assessment visit;

no orders are present for nursing at the start of care; a reimbursable service must be provided; and the need for this service establishes program eligibility

for the Medicare home health benefit (42 CFR 484.55(a)(2).

Occupational therapy does not establish program eligibility for Medicare home health benefit

59

60

If the agency chooses to have an RN conduct the comprehensive assessment for therapy only cases, the RN should perform the assessment on the same day or within 5 days after the therapist’s SOC date. 2-Q12-12.1

Any comprehensive assessment info collected prior to the SOC date may not contribute to the SOC comprehensive assessment. 2-Q36.1

Whatmakesavisitskilledorbillable?

Therapy—the evaluation itself is billable Nursing—the assessment is not billable What makes nursing skilled?

Intermittent—medically recurring need What’s the fix?

Therapy does the initial assessment prior to, or on the same day as, the nurse completes OASIS.

If therapy does initial assessment, must get consent signed

Nursing established the start of care with a truly billable visit.

61

OneNon‐billableNursingVisit

We received an order for nursing and PT. The nurse conducted the initial assessment visit and determined that the patient did not have any justifiable nursing need, but did have a need for PT services. Because there was an order for nursing present with the original orders, is the RN required to complete the SOC comprehensive assessment? Or since nursing services are not necessary, can the PT complete the SOC comprehensive assessment on or within 5 days after the PT establishes the start of care?

62

OneNon‐billableNursingVisit

Since an order for nursing existed at the time of the initial referral, the RN must complete the initial assessment visit. If it is determined during the initial assessment visit, that the patient either did not have a need for nursing services and/or the patient declined all nursing services, the SOC will not be established by that visit. The RN can notify the physician that nursing will not be involved in the patient’s care, and either continue on to complete the SOC comprehensive assessment (if the PT will be establishing the SOC that day), OR have the PT complete the SOC comprehensive assessment on or within 5 days after the PT establishes the start of care. 3rd Q 2014

63

Whocanconducttheassessment?

If the RN’s entry in the case is known at SOC (i.e. the nursing is scheduled even if only for one visit) then the case is NOT therapy-only, and the RN

should conduct the SOC assessment. If the order for the RN is not known at SOC and

originates from a verbal order after SOC, then the case is therapy only at SOC, and the

therapist can perform the SOC comprehensive assessment.

2-Q10

64

TimingofInitialandComprehensiveAssessments

Nursing and PT ordered RN must do the initial assessment and must

also complete the comprehensive assessment. This does not necessarily mean that the SOC

comprehensive assessment must be completed by the RN on the SOC date or that the initiation of therapy must be delayed until the RN completes the comprehensive assessment. 2-Q51

65

NoLaterthan5daysaftertheSOC

Polly Perfect, RN admits the patient to home care on 3/7 with a skilled visit. She calls the physician about a suspicious area on the patient’s hip on 3/8. The therapist completes his eval on 3/9 and the answer to M2200 is determined, and the physician’s office calls back on 3/10 with info regarding the confirmed closed stage 3 ulcer on the hip.

What is the M0090 date on the SOC assessment?

66

Whocanconducttheassessment?

If therapy and aides are ordered:Because this is considered a therapy-only

case (i.e. therapy is the only skilled service), the PT or ST could perform the comprehensive assessment and all subsequent assessments

RN supervisory visits are not billable visits2-Q11

67

WhoCanStartFirst?

If PT and HHA are ordered—who can start first? The aide’s visit is a reimbursable visit. Registered nurse does a non-billable initial

assessment visit to establish needs and eligibility for a therapy only patient and sets up the aide care plan.

The aide visits the same day as the RN. Do we now have a SOC date?

2-Q48

68

M0030SOCDate

Date that the first reimbursable service is delivered

A physician must specifically order that a particular covered service be furnished on the SOC date. All other coverage criteria must be met for this initial service to be billable and to establish the start of care.

69

Comprehensiveassessmentmustbeupdatedandrevised

Not less frequently than the last 5 days of every 60 day episode beginning with the SOC date (days 56-60) (Follow-Up)

Major decline or improvement in condition (Other Follow-Up)

Within 48 hours of patient’s return home from an inpatient facility admission of 24 hours or more for reasons other than diagnostic tests (ROC)

At discharge (DC)

70

UpdateoftheComprehensiveAssessment

Any “qualified skilled” discipline may perform the updates, e.g. the nurse does not have to perform the recert and the discharge just because the RN had to do the admission.

RN, PT and OT are ordered at SOC PT and OT are continuing into the next episode OT continuing into the next episode What about SLP? 2-Q12.2

71

M0100RFA72

SOCRFA1

SOC = first billable visit date POC established Discipline starting care may differ for different

payors

This is the appropriate response any time an initial HIPPS code (for a Home Health Resource Group) is required, whether or not the patient will be receiving ongoing services.

73

SingleVisitsandPayment

Per the CMS payment regulations as of January 2010, you must submit an OASIS assessment in order to be paid for a final claim under the Medicare PPS system.

If you choose NOT TO BE PAID, there is no requirement to collect and transmit OASIS data if there has been only one visit. 2-Q42.2

The discharge OASIS is never mandated in situations of single visits in a quality episode (SOC/ROC to TRF/DC) 2-Q42.2

74

Whatifjustonevisit?

The patient is admitted to home care (single visit is made) and then the patient refuses any further visits, is an OASIS required?

The agency is not required to assess the OASIS items, nor encode and submit their assessment (as of 12/2003). The comprehensive assessment would be placed in the medical record.

HOWEVER, you cannot bill without an HHRG. If you want to be paid for that single visit, you must

collect, encode and submit the assessment.

75

Whatifjustonevisit?

What if you’ve already completed OASIS (SOC or ROC), encoded and/or transmitted, and then no further visits are made?

Conduct no further assessments. Document that no further visits occurred. Patient’s name will appear on data system for 6

months If patient is readmitted, there will be a warning that

OASIS is out of sequence but will not prevent OASIS from being transmitted 4b-Q21

76

Whathappensif…..

During the SOC assessment the patient has dyspnea and has to be transferred to the hospital before the entire admission process is completed? If skilled care was provided and eligibility was

established and the patient is not admitted to the facility, then the clinician still has five days after the SOC to complete the assessment. Has to be the same clinician.

Answers can be changed after the patient returns from the facility to reflect new condition

2-Q17.1

77

Whathappensif…

The patient is admitted to the facility after ONE visit?

You have two options: Readmit the patient when the patient is

discharged with a new SOC assessment.Place the first one in the medical record with

explanation.The first SOC can only be billed if the OASIS

was completed and transmitted. Transfer and then Resume care when

discharged. 2-Q46.2

78

ExampleandRamifications

SOC completed and then patient transferred into hospital.Readmit.No acute hospitalization Start new with a new HHRG.

Transfer and ROCAcute hospitalization when you didn’t have a

chance to even try to prevent hospitalization.Stuck with the original HHRG after the

hospitalization (no opportunity for billing a SCIC)

This is only true if ONE visit is made!

79

Whatif…

An initial assessment with skilled service Start of Care (SOC) was performed on 1/24/14 (the SOC comprehensive assessment with OASIS was begun, but not completed). Later in the day, the patient was admitted to the hospital and returned home on 1/26. The comprehensive assessment with OASIS data collection was completed on 1/26, within the 5 day window. Since the comprehensive assessment was completed after the hospital admission, we did not do a Transfer or ROC. Was this correct?

80

No…

In order to bill for the 1/24 visit, the SOC assessment should be completed within 5 days after the SOC date

Transfer and Resumption of Care assessments (ROC) should be completed within 2 days after knowledge of a qualifying stay in the inpatient facility.

At SOC, you may take up to 5 days after the SOC date to complete the SOC comprehensive assessment, noting that it must be completed by one clinician. When the patient returned to your care on 1/26 which was within the allowed 5 day assessment time frame, the same assessing clinician could complete the SOC comprehensive assessment that was begun on the first visit, updating previously completed items as necessary and completing the rest of the items. M0030, Start of Care Date, remains the date of the first billable visit. M0090, Date Assessment Completed, is the actual date the single clinician completed the assessment.

81

So…

If the original assessing clinician could not complete the SOC comprehensive assessment that he/she began on the first visit, another qualified clinician would have to visit and complete a new SOC comprehensive assessment from beginning to end, within 5 days after the SOC date.

Unless it had already been completed by someone else, the clinician who completes the SOC assessment on 1/26 may also complete the RFA 6-Transfer. The ROC assessment must be completed with 2 calendar days of the patient’s inpatient facility discharge, and may also be completed on the 1/26 visit, by the same clinician who completes the SOC assessment and the OASIS Transfer data collection. July 2014

82

EvenNon‐BillableVisitCounts

If nursing performs a non-billable admit for a PT only case, the PT goes the same day completing an evaluation only, and there is no further need for therapy, are we required to complete the RFA 9 OASIS Discharge?

For skilled Medicare and skilled Medicaid patients, OASIS data collection is required if more than one visit was made in a quality episode. In your scenario, the nurse made one visit and the PT made one visit. Therefore both the SOC (RFA 1) and DC (RFA 9) comprehensive assessments are required. This is true even if one of the visits was non-billable.

2-Q42.1-42.1.1

83

M0032ResumptionofCareDate

Specifies the date of the first visit following an inpatient stay by a patient receiving service from the home health agency (ROC date not necessarily the date assessment is done.

Following an inpatient stay of 24 hours or longerFor reasons other than diagnostic tests

Need to update the Patient Tracking Sheet for the most recent ROC date

84

ROCClarification—NoOrdertoReturntoHomeisRequired

CMS advised that when the patient returns home:

Home health services are resumed; The patient is reassessed; The orders for services are reviewed and

reestablished from that point forward; and A verbal order updating the orders for services

and frequency of services must be obtained. NAHC Report Nov 12, 2009

2-Q18

85

RFA3ResumptionofCare

If the patient returns home from an inpatient stay during the last 5 days of the episodeComplete ROC, not Follow-UpROC OASIS will determine the case mix for

the subsequent episode so answer M2200 and M0110 accordingly

Returns home on day 54…what now?3-Q5

86

87

My patient was released from the hospital and needed an injection that evening (Feb 26). The case manager was unavailable and planned to do the ROC assessment the following day (Feb 27). Could the on call nurse visit and give the injection before the resumption of care assessment is done? Is there a time frame in which care (by an LPN or others) can be provided prior to the completion of the ROC assessment?

ROC date M0032 is __________.M0090 date on ROC assessment is _________.Can the LPN do the ROC visit? The assessment?There is no requirement that the ROC assessment be

on the first visit. 2-Q15.1-15.1.1 4bQ23.3—Didn’t know the pt was in the hospital

ResumptionofCare

Can the RN do the ROC on a therapy only case before the therapist visits?

The ROC assessment must be performed within 48 hours of the patient’s return home after an inpatient facility stay (or within 48 hours of knowledge).

Before or after the therapist visit. 4b-Q23.9 ROC date (M0032) is the first visit, regardless

who makes it, or whether or not it is billable. 2-Q51.2

88

ResumptionofCare

Clarified again 07/13 and 01/14: No flexibility in performing ROC outside of timeframe

Within 48 hours of return home from an inpatient stay or within 48 hours of knowledge of inpatient stay

If the standardized assessment is performed outside of those timeframes, you must answer ‘No’ to M1240, M1300, M1730 and M1910.

You must answer ‘No’ to M2250 unless ‘NA’ is the appropriate answer.

89

BestPracticesatROC‐‐NewestUpdate

If the ROC assessment is late, "Yes" may still be selected for the best practices in M2250, Plan of Care Synopsis, if the relevant orders were present within the 48 hour ROC time frame. Likewise,

M1240, Pain Assessment, M1300, Pressure Ulcer Risk Assessment, M1730, Depression Screening, and/or M1910, Falls Risk Assessment may also be reported with "Yes" responses, if the relevant standardized, validated assessments were conducted by the assessing clinician within the 48 hour time frame, even if the ROC comprehensive assessment was completed after the 48 hour time frame.

When the assessing clinician takes credit on M1240, M1300, M1730 and/or M1910 for standardized, validated assessments completed within the 48 hour time frame and the M0090 date indicates that the ROC comprehensive assessment was completed late (beyond the 48 hour time frame), clarifying documentation to support the reported OASIS responses is expected.

If the relevant standardized, validated assessment was completed greater than 48 hours after inpatient facility discharge or greater than 48 hours after gaining knowledge of a qualifying stay in an inpatient facility, M1240, M1300, M1730 and M1910 must be answered "No".

90

LateTransferandROC

The patient had a qualifying stay in an inpatient facility, but the Transfer OASIS and the ROC assessments were not done when the RN made a routine visit following the patient’s discharge home. The patient has since been recertified and continues as a current patient. How do we proceed?

When the agency becomes aware of a qualifying stay in an inpatient facility, a Transfer OASIS and Resumption of Care (ROC) assessment must be completed within 2 days of gaining the knowledge. In your situation, assuming the Recertification assessment had been performed during the last five days of the prior certification period, the agency would still need to complete a Transfer and send a qualified clinician to the home to perform the missing ROC assessment. You will receive a notice that the assessments have been submitted out of sequence. April 2014

91

ROCSituation

The RN visits the patient after his discharge from the hospital. She finds him in acute distress. She calls his doctor who directs the nurse to call 911. The patient is admitted back into the hospital.

There is no requirement to collect OASIS data. Why? No requirement to collect OASIS data on

one visit episodes (this is considered a quality episode) 2-Q19,23

92

OneMoreROCSituation

The patient is admitted to the hospital during the episode. When making the ROC visit, the patient refuses further visits.

If the visit is made, there is no requirement to collect OASIS data.

Why? No requirement to collect OASIS data on one visit episodes (this is considered a quality episode)

2-Q19,23

93

Quiz

Patient returns home from hospital after transfer and needs PT visit for eval of equip, etc. PT determines no further visits are required.

Is ROC assessment required? Is DC OASIS required? Is a DC summary required? 2-Q54.2

94

M0100RFA4Recertification&RFA5OtherFollow‐Up

Days 56-60 (Follow Up aka Recertification) Due to a major decline or improvement in

patient condition (Other Follow-Up)Updates the patient’s plan of careYour policy dictates when you have to do

another assessmentHas the patient improved or deteriorated

beyond your expectations?Must be completed within 2 days of identifying

major improvement or decline.

95

M0100RFA4Recertification

If Days 56-60 are missed, do not DC and readmit. M0090 is the date assessment is done Include in clinical documentation reason lateWill get a warning message

Legal considerations!! Example: Start of episode is October 15. Recert

should have been done Oct 10-14, but due to error was not performed until October 18. M0090 is 10-18, but SOE is still October 15.

3-Q11

96

LateRecertification

We missed completing a recertification assessment on a patient between days 56-60. During the first visit in the new episode, the patient was transferred to the emergency room before the Recertification comprehensive assessment could be completed. The patient had a qualifying stay in an inpatient bed. What OASIS is due when we resume care of the patient?

97

Answer

Do not discharge the patient. A Transfer assessment (RFA 6) should be completed. If the patient returns to the HHA, a Resumption of Care (ROC) comprehensive assessment should be completed. The ROC will serve as both the Resumption of Care and the Recertification, establishing the PPS payment code for the next certification period. This demonstrates non-compliance with the Medicare comprehensive assessment update standard of the Conditions of Participation, but is the only option available due to the missed recertification. Care should be taken to monitor recertification dates to avoid this situation in the future. 3-11.3

Don’t change your episode dates.

98

Situation

The patient is admitted to the hospital before or during the recert window, in an inpatient bed more than 24 hours but only for diagnostic purposes, then comes home on day 61…

Treat this situation as a missed recertification, and complete the Recert asap. 3-Q11.4

Other situations in OASIS Considerations for PPS

99

MissedtheRecertandDecidedtoDC

If there was a need for continuing services into the next certification period, but the clinician missed completing the recertification assessment between day 56-60 and on the first visit in the new episode it was determined the patient had reached goals and needed to be discharged, do I have to complete both the Recert and the Discharge OASIS?

Yes. When a Recertification assessment is missed it should be completed as soon as possible.

If the clinician determined the patient was ready for discharge on the first visit in the new episode, the Discharge comprehensive assessment is also required. The discharge is the endpoint of the quality episode, which is not captured with a recertification assessment. 3Q11.1

100

M0100RFA4Recertification

What if done too early?Do it over within the right time points.Even if into the next episode when you

figure it out. 3-Q11.2, 4b-Q23.5 A clinician may start the comprehensive

assessment on day 56 and complete it on any day on or before day 60. Only one clinician may complete though, so if Nurse A begins, then Nurse A must complete. 3-Q5.1

101

RFA6TransfertoInpatientFacility–NotDischarged

Inpatient admission of 24 hours or longer

Reasons other than diagnostic tests

Patient expected to resume care

Does not require a home visit

If patient does not return, a DC visit/OASIS is not required (a DC summary is required)

102

RFA7TransfertoInpatientFacility–Discharged

Inpatient admission of 24 hours or longer

Reasons other than diagnostic tests

Is not expected to return to home care or does not return by the end of the episode

Does not require a home visit

103

RFA6vs.RFA7

If the HHA plans on the patient returning after their inpatient stay, the RFA 6 should be completed.

There will be times when the RFA7 is necessary to use, but only when the HHA does NOT anticipate the patient will be returning to care. 2-Q3

Providers should not discharge (use RFA 7) when goals have not been met at transfer. 2-Q3

What if we complete a 6 and the patient does not return?

No need to cancel—will be on data system for 6 months.

104

RFA6vs.RFA7

Medicare Claims Processing Manual, CMS Publication 100-4, Chapter 10, reads, “A beneficiary does not have to be discharged from home care because of an inpatient admission. If an agency chooses not to discharge and the patient returns to the agency in the same 60-day period, the same episode continues. However, if an agency chooses to discharge, based on an expectation that the beneficiary will not return, the agency should recognize that if the beneficiary does return to them in the same 60-day period, the discharge is not recognized for Medicare payment purposes. All the home health services provided in the complete 60-day episode, both before and after the inpatient stay, should be billed on one claim."

105

WhatifaMedicaidpatient?

Do I have to follow this guidance for Medicaid patients? In my state, our Medicaid program instructs us to discharge when a patient is transferred into the inpatient setting.

The instructions [on the previous slide] only apply to Medicare Traditional fee-for-service patients. Follow your payer's guidance.

106

Whatisconsideredadiagnostictest?

Tests, scans and procedures utilized to yield a diagnosisX-rays, UGI, CT scansCardiac catheterization?

Requires that each case be considered individually

107

Whatisanadmission?

In order to qualify for the Transfer to Inpatient Facility OASIS assessment timepoint, the patient must meet 3 criteria:

1) Be admitted to the inpatient facility (not the ER, not an observation bed in the ER)2) Reside as an inpatient for 24 hours or longer (does not include time spent in the ER)3) Be admitted for reasons other than diagnostic testing onlyAn admission to an inpatient facility for observation is not an admission for diagnostic testing only. This is considered a hospitalization. 4-Q23.7

108

InpatientTimeCumulative?

If the patient was admitted to one inpatient facility bed then transferred to another, the Transfer OASIS would be required once a total of 24 hours have been spent as an inpatient, under an inpatient billing status. 4-Q23.01

109

Isthisanadmission?

A patient is held for several days in an observation bed (referred to as a “Patient Observation” or “PO” bed) in the emergency or other outpatient department of a hospital to determine if the patient will be admitted to the hospital or sent back home. While under observation, the hospital did not admit the patient as an inpatient, but billed as an outpatient under Medicare Part B.

Is this Emergent Care? With or without hospitalization?

Should we complete a transfer, discharge the patient, or keep the patient?

Inpatient vs outpatient observation

110

Quiz

Patient is transported to hospital and is placed on observation on June 26. On June 28, he is admitted as an inpatient. What is the transfer date? What is the M0090 date on the transfer?

June 28 is transfer date (M0906) M0090 date is June 29 or within 48 hours of

transfer date

111

Quiz

You make a routine visit and discover the patient was in the hospital for two days earlier in the week. You find that it was a qualifying stay in an inpatient facility.

Within 2 calendar days of knowledge of transferComplete the RFA 6 (TRN) and the RFA 3

(ROC) True or False? 4b-Q23.3

112

M0100RFA8Deathathome

Complete Death at home while still under the care of the agency At home At church While in route to or before treatment in an ER Before inpatient admission (pronounced DOA)

Exception--Complete transfer assessment INSTEAD, if Death while under care of facility (in ER) Regardless of length of time in the facility 2-Q22

113

TransferorDeathatHome?

My patient died during outpatient surgery. Should I complete a transfer or a death at home?

Complete a transfer. My patient died in the recovery room after

outpatient surgery. Should I complete a transfer or a death at home?

Complete a transfer.

2-Q22.1-22.2

114

115

Since the Transfer and Death at Home OASIS time points require data collection and not actual pt assessment findings, any RN, PT, OT or SLP may collect the data, as directed by agency policy. Not assessments and do not require the clinician to

be in the physical presence of the pt. May be completed by chart review and telephone.

It is not required that the clinician completing the data collection must have previously visited the pt.

Any RN, PT, OT or SLP familiar with OASIS data collection practices.

This guidance applies only to the Transfer and Death time points, as a visit is required to complete the comprehensive assessments and OASIS data collection at the Start of Care, Resumption of Care, Recertification, Other Follow-up and Discharge.

2-Q15.6, 4b-Q13.2

M0100RFA9Discharge

Not due to an inpatient facility admission Not due to death at home Visit is required to complete the assessment

Except in cases of unexpected discharge Unplanned or unexpected discharges

Assessment must report patient status at an actual visitLast visit conducted by a qualified clinician

2-Q37 with 7 different unplanned dc scenarios

116

UnplannedorUnexpectedDischarges

Who can complete the DC OASIS? Last qualified clinician (Not a LPN/LVN) that

visited the patient should complete the DC comprehensive assessmentHow do you show that you completed the

OASIS without a visit? (“based on visit of mm/dd/yyyy”)

Complete the OASIS based on information available at the last qualified clinician’s visit

117


What if the last qualified clinician is no longer available?DC matches the SOC or…Do not complete the DC OASIS (CoP

problem) A supervisor in the office cannot create an

assessment as if it were fact without seeing the patient. 2-Q37

118


Do not include any events that occurred after the last qualified clinician’s visit. Include the ER visit that occurred after the last

qualified clinician’s visit??Consider that all the teaching about heart

failure symptoms occurred since the last qualified clinician’s visit??

119

Exception:UnplannedDischarge

In situations of unplanned or unexpected discharges, when completing the discharge assessment, base the OASIS responses on the patient’s status at the time of the visit by the last qualified clinician.

Do not include the reporting of any health status changes or service utilization that occurred after the date of the last qualified clinician’s visit EXCEPT for completion of M2400 Intervention Synopsis, where the discharge OASIS can report any ordered interventions that were implemented up until the time of discharge (the M0906 date). This includes taking credit for education provided at a home visit by an LPN or therapy assistant. April 2014

120

Example121

Discharge M0090

LastQualifiedClinician’s

VisitEvents past this

point are not included in DC

assessment, but visits are still

billable. Past 14 days starts here.

ERtrip

TeachingRe:

Heart Failure by LPN

Teaching and

Interven-tions

included in M2400

Count as a

Yes on M2400

UnplannedorUnexpectedDischarge

M0090 Date assessment completedActual date agency completed assessment

M0903 Date of the last (most recent) home visitDate of the most recent visit by agency staffLast visit by any agency staff even if visit was

not included on the POC M0906 Discharge date

Determined by agency policyCan’t be before last visit

122

Quiz:Whichsequencesofassessmentsarecorrect?

SOC, with only one visit performed SOC, FU, Transfer, Discharge SOC, FU, FU, FU, DC SOC, FU, Transfer SOC, ROC, FU, DC

123

OneClinicianRule

Collaboration is allowed on selected items, however only one clinician may complete the assessment

If two clinicians are seeing the patient at the same time:May confer about interpretation of the

assessment dataClinician performing the assessment follows

up on any observations of patient status reported by other staff

Clerical staff may complete demographic and agency ID items—assessing clinician verifies

124

Conventions

Understand the time period under consideration for each item. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.

For OASIS purposes, a care episode (also referred to as a quality episode) must have a beginning (that is, an SOC or ROC assessment) and a conclusion (that is, a Transfer or Discharge assessment) to be considered a complete care episode.

125

Conventions

If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual status” or what is true greater than 50% of the assessment time frame, unless the item specifies differently (for example, for M2020 Management of Oral Medications, M2030 Management of InjectableMedications, and M2100e Management of Equipment, instead of “usual status” or “greater than 50% of the time,” consider the medication or equipment for which the most assistance is needed).

Minimize the use of NA and Unknown responses.

126

Conventions

Responses to items documenting a patient’s current status should be based on independent observation of the patient’s condition and ability at the time of the assessment without referring back to prior assessments. Several process items require documentation of prior care, at the time of or since the time of the most recent SOC, ROC, or FU OASIS assessment. These instructions are included in item guidance for the relevant OASIS questions.

Combine observation, interview, and other relevant strategies to complete OASIS data items as needed (for example, it is acceptable to review the hospital discharge summary to identify inpatient procedures and diagnoses at Start of Care, or to examine the care notes to determine if a physician ordered intervention was implemented at Transfer or Discharge). However, when assessing physiologic or functional health status, direct observation is the preferred strategy.

127

Conventions

Complete OASIS items accurately and comprehensively, and adhere to skip patterns.

Understand the definitions of words as used in the OASIS.

Follow rules included in the Item Specific Guidance

Stay current with evolving CMS OASIS guidance updates. CMS may post updates up to twice per year, in June and December, and quarterly Q&A’s

128

Conventions

“Same day” means by the end of the same day. When the OASIS item includes language

specifying “one calendar day” (for example, M2002 Medication Follow-up), this means until the end of the next calendar day.

When an OASIS item refers to assistance, this means assistance from another person unless otherwise specified within the item. Assistance is not limited to physical contact and includes both verbal cues and supervision.

129

PatientTracking130

AgencyIdentification131

PatientIdentification

Agency assigned

As it appears on Medicare card

If the patient has a #

Even if Medicaid is not a payer

Unknown acceptable

132

PatientIdentification133

M0150CurrentPaymentSources134

1‐4RequiresOASIS

OASIS is collected and transmitted for all adult Medicare or Medicaid patients (age 18 or over) receiving skilled health services from the HHA, except for patients receiving care for pre- and post-partum conditions.

1-Q1

135

M0150

Identifying payers to which any services provided during this home care episode and included on the Plan of Care will be billed by your home health agency. No pending payers

Do not consider any equipment, medications, or supplies being paid for by the patient, in part or in full.

136

M0080DisciplineofPerson

Specifies the discipline of the clinician completing the comprehensive assessment during an actual visit to the patient’s home at the specified OASIS time point or the clinician reporting the transfer to an inpatient facility or death at home.

137

M0080DisciplineofPerson

Only one individual completes the comprehensive assessment. Even if two disciplines are seeing the patient at the time a comprehensive assessment is due, while care coordination and consultation are needed, only one individual actually completes and records the assessment. “One clinician rule”

According to the comprehensive assessment regulation, when both the RN and PT/SLP are ordered on the initial referral, the RN must perform the SOC comprehensive assessment. An RN, PT, SLP, or OT may perform subsequent assessments.

LPNs, PTAs, COTAs, MSWs, and home health aides do not meet the requirements specified in the comprehensive assessment regulation for disciplines authorized to complete the comprehensive assessment or collect OASIS data.

When both the RN and qualified therapist are scheduled to conduct discharge visits on the same day, the last qualified clinician to see the patient is responsible for conducting the discharge comprehensive assessment.

138

M0090DateAssessmentCompleted

If agency policy allows assessments to be performed over more than one visit date, the last date (when the final assessment data are collected) is the appropriate date to record.

For the following OASIS time points, Transfer to Inpatient Facility – patient not discharged from agency; Transfer to Inpatient Facility – patient discharged from agency or Death at Home, record the date the agency completes the data collection after learning of the event, as a visit is not necessarily associated with these events.

139

M0102DateofPhysician‐orderedSOC(ROC)

Timepoints: Start of care, Resumption of care

Specifies the date that home care services are ordered to begin, if the date was specified by the physician. The item refers to the order to start home care services (that is, provide the first covered service), regardless of the type of services ordered (for example, therapy only).

140

M0102DateofPhysician‐orderedSOC(ROC)

If the originally ordered start of care is delayed due to the patient’s condition or physician request (for example, extended hospitalization), then the date specified on the updated/revised order to start home care services would be considered the date of physician-ordered start of care (resumption of care).

Because the State Operations Manual requires a visit within 48 hours of resumption of care following hospitalization, mark "N/A" if the physician orders a ROC date that extends beyond 2 calendar days of the inpatient facility discharge.

In order to be considered a physician-ordered SOC date, the physician must give a specific date to initiate care, not a range of dates. If a single date to initiate services is not provided, the initial assessment visit must be conducted within 48 hours of the referral or within 48 hours of the patient's return home from the inpatient facility.

141

M0104DateofReferral

Timepoints: SOC, ROCSpecifies the referral date, which is the most recent date that verbal, written, or electronic authorization to begin home care was received by the home health agency.

142

M0104DateofReferral

If start of care is delayed due to the patient’s condition or physician request (for example, extended hospitalization), then the date the agency received updated/revised referral information for home care services to begin would be considered the date of referral.

This does not refer to calls or documentation from others such as assisted living facility staff or family who contact the agency to prepare the agency for possible admission.

The date authorization was received from the patient's payer is NOT the date of the referral (for example, the date the Medicare Advantage case manager authorized service is not considered a referral date).

143

M0104DateofReferral

When an agency receives an initial "referral" or contact about a patient who needs service, the HHA must ensure this physician, or another physician will provide for the plan of care and ongoing orders.

If a physician is willing to follow the patient, and provides adequate information (name, address/contact info, and diagnosis and/or general home care needs) regarding the patient, this is considered a valid referral.

In cases where the referring physician is not going to provide orders and follow the patient, this is not a valid “referral" for M0104. 3rd Q 2014

144

M0104DateofReferral

In the example of a hospitalist who will not be providing an ongoing plan of care for the patient, the HHA must contact an alternate, or attending physician, and upon agreement from this following physician, for referral and/or further orders, the HHA will note this as the Referral date in M0104 (unless referral details are later updated or revised).

If a general order to “Evaluate for Home Care services” (no discipline(s) specified) is received from a physician who will be following the patient, this constitutes a valid order, and per CoPs §484.55 the RN must conduct the initial assessment visit to determine immediate care and support needs and eligibility for the Home Health benefit for Medicare patients. 3rd Q 2014

145

M1000InpatientFacilities146

‘During’ in

OASIS C

M1000InpatientFacilities

Timepoints: SOC ROC and added FU to the OASIS-C1/ICD-10

The term “past 14 days” is the two-week period immediately preceding the start/resumption of care. This means that for purposes of counting the 14-day period, the date of admission is day 0 and the day immediately prior to the date of admission is day 1. Discharges on Day 0 should be included.

Consider any inpatient stays with discharge dates within the 2 week period.

Skilled nursing facility means (a) Medicare certified nursing facility where the patient received a skilled level of care under the Medicare Part A benefit or (b) transitional care unit (TCU) within a Medicare-certified nursing facility.

Short-stay acute hospital applies to most hospitalizations.

147

M1000InpatientFacilities

Long-term care hospital, applies to a hospital that has an average inpatient length of stay of greater than 25 days.

Inpatient rehabilitation hospital or unit (IRF) means a freestanding rehab hospital or a rehabilitation bed in a rehabilitation distinct part unit of a general acute care hospital.

Intermediate care facilities for individuals with intellectual disabilities (ICF/IID) should be considered Response 7 –Other.

If patient has been discharged from a swing-bed hospital, it is necessary to determine whether the patient was occupying a designated hospital bed (Response 3), a skilled nursing bed under Medicare Part A (Response 2), or a nursing bed at a lower level of care (Response 1). The referring hospital can answer this question regarding the bed status.

148

M1011InpatientDiagnosis

List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those conditions actively treated during an inpatient stay having a discharge date within the last 14 days (no V,W,X,Y or Z codes or surgical codes):

149

M1011InpatientDiagnosis

Timepoints: SOC ROC and added FU to OASIS-C1/ICD-10

Include only those diagnoses that required active treatment during the inpatient stay

“Actively treated” should be defined as receiving something more than the regularly scheduled medications and treatments necessary to maintain or treat an existing condition.

May or may not correspond with the hospital admitting diagnosis

No V,W,X,Y or Z codes, no surgical codes—list underlying diagnosis.

150

M1017DiagnosesRequiringChange

Timepoints: SOC ROC

151


Identifies if any change has occurred to the patient’s treatment regimen, health care services, or medications within the past 14 days. Identify the patient’s recent history by identifying

new diagnoses or diagnoses that have exacerbated over the past 2 weeks.New onset of CHF 12 days ago, improved with

treatment Mark "NA" if changes in the medical or treatment

regimen were made because a diagnosis improved. UTI diagnosed 3 weeks ago, treated, improved

and resolved

152


The intent of the item is not to identify diagnoses where all medical or treatment regimen changes in the last 14 days were related to improvement in a condition. If at any time in the last 14 days the patient requires a medical or treatment regimen change due to development of a new condition or lack of improvement or worsening of an existing condition, the diagnosis should be reported in M1017, even if the condition also showed improvement or stabilization during that time, or is improved at the time of SOC/ROC. 4bQ41.1

153

M1021/1023/1025Diagnoses154

1. Complete assessment2. Plan Care

3. Describe pt with diagnoses in column 1

4. Codes added in column 2

M1021/1023/1025Diagnoses

Timepoints: SOC ROC F/U M1021: Primary Diagnosis - accurately report and code the

patient’s primary home health diagnosis and document the degree of symptom control for that diagnosis. Chief reason the patient is receiving home care and the

diagnosis most related to the current home health Plan of Care.

M1023: Other Diagnoses - accurately report and code the patient’s secondary home health diagnoses and document the degree of symptom control for each diagnosis. Comorbid conditions that exist at the time of the

assessment, that are actively addressed in the patient’s Plan of Care, or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis.

155

1025OptionalDiagnoses

M1025 Optional Diagnosis - OPTIONAL: the intent of this item is to provide the agency with the option of documenting a resolved underlying condition in Columns 3 and 4, if a Z-code is reported as a primary or secondary diagnosis in Columns 1 and 2, and the underlying condition is no longer active.

NOT FOR PAYMENT CMS says it may be used for risk adjustment,

but not currently part of the risk adjustment models for any outcome measures.

156

M1021/1023Diagnoses

The assessing clinician is expected to complete the patient’s comprehensive assessment and understand the patient’s overall medical condition and care needs before selecting and assigning diagnoses.

The determination of the patient’s primary and secondary home health diagnoses must be made by the assessing clinician based on the findings of the assessment, information in the medical record, and input from the physician.

The primary diagnosis may or may not relate to the patient’s most recent hospital stay, but must relate to the skilled services (skilled nursing, physical therapy, occupational therapy, and speech language pathology) rendered by the HHA.

157

M1021/1023Diagnoses

The secondary diagnoses include coexisting conditions actively addressed in the patient’s Plan of Care, and any comorbid conditions having the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis, even if the condition is not the focus of any home health treatment itself. The secondary diagnoses may or may not be related to a patient’s recent hospital stay, but must have the potential to impact the skilled services provided by the HHA.

Only current medical diagnoses should be reported as primary or secondary diagnoses in M1021 and M1023. Diagnoses should be excluded if they are resolved or do not have the potential to impact the skilled services provided by the HHA. An example of a resolved condition is cholecystitis following a cholecystectomy.

158

M1021/1023Diagnoses

Diagnoses may change during the course of the home health stay due to a change in the patient’s health status or a change in the focus of home health care. At each required OASIS time point, the clinician must assess the patient’s clinical status and determine the primary and secondary diagnoses based on patient status and treatment plan at the time of the assessment.

All diagnoses on the Plan of Care must be documented in the medical record or verified with the physician; document this confirmation.

Diagnoses are selected utilizing current code set, conventions, and guidelines as well as Medicare coverage rules.

159

M1021/1023Diagnoses

The order that secondary diagnoses are listed should be determined by the degree that they impact the patient’s health and need for home health care, rather than the degree of symptom control. For example, if a patient is receiving home health care for Type 2 diabetes that is “controlled with difficulty,” this diagnosis would be listed above a diagnosis of a fungal infection of a toenail that is receiving treatment, even if the fungal infection is “poorly controlled.”

A coding specialist in the agency may enter the actual numeric ICD-10-CM codes in Column 2, as long as the assessing clinician has determined the primary and secondary diagnoses in Column 1.

160

M1021/M1023SymptomControl

Do not assign symptom control ratings for V,W,X,Y or Z codes.

Assessing degree of symptom control includes: review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care provider.

Inquire about the degree to which each condition limits daily activities. Assess the patient to determine if symptoms are controlled by current treatments. Clarify which diagnoses/symptoms have been poorly controlled in the recent past.

161

DataSources

Patient/caregiver interview Physician Physician orders Referral information Current medication list Effective October 1, 2015 the current ICD-10-CM

List of Codes and Descriptions and the ICD-10-CM Official Guidelines for Coding and Reporting should be the source for coding (see Chapter 5 for link).

For degree of symptom control, data sources may include patient/caregiver interview, physician, physical assessment, and review of past health history.

162

M1030Therapies

Identifies whether the patient is receiving intravenous, parenteral nutrition, or enteral nutrition therapy at home, whether or not the home health agency is administering the therapy. This item is not intended to identify therapies administered in outpatient facilities or by any provider outside the home setting.

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M1030Therapies

Timepoints: SOC ROC F/U If the patient will receive such therapy as a result of this

SOC/ROC or follow-up assessment (for example, the IV will be started at this visit or a specified subsequent visit; the physician will be contacted for an enteral nutrition order; etc.), mark the applicable therapy.

Response 1 intermittent medications or fluids via an IV line (including heparin or saline flushes).

IV catheter is present but not active (for example, site is observed only or dressing changes are provided), do not mark Response 1.

Response 1 if ongoing infusion therapy is being administered at home via central line, subcutaneous infusion, epidural infusion, intrathecal infusion, or insulin pump.

Response 1 if the patient receives hemodialysis or peritoneal dialysis in the home.

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M1030Therapies

Do not select Response 1 if there are orders for an IV infusion to be given when specific parameters are present (for example, weight gain), but those parameters are not met on the day of the assessment.

An irrigation or infusion of the bladder is not included when completing M1030

Response 3 if any enteral nutrition is provided. Not currently used for nutrition, Response 3 does not

apply. A water, medications or flush of a feeding tube does not provide nutrition.

Triple lumen with TPN/lipids infusing in one port and flushing other – Responses 1 and 2

Single lumen utilized for TPN with pre and post flush –Response 2 only

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M1033RiskforHospitalization

Timepoints: SOC ROC

166

No fraility

Exhaustion

Removed professional judgment

M1033RiskforHospitalization

Objective with specific timeframes in order longest to shortest

Response 1 includes witnessed and reported (unwitnessed) falls.

Response 5, decline in mental, emotional, or behavioral status refers to significant changes occurring within the past 3 months that may impact the patient’s ability to remain safely in the home and increase the likelihood of hospitalization.

Response 7, medications includes OTC medications. Response 9 - Other risk(s), may be selected if the

assessing clinician finds characteristics other than those listed in Responses 1-8 that may indicate risk for hospitalization (for example, slower movements during sit to stand and walking).

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M1034OverallStatus

Use information from other providers and clinical judgment to select the response that best identifies the patient’s status. ● Consider current health status, medical diagnoses, and information from the physician and patient/family on expectations for recovery or life expectancy. ● A “Do Not Resuscitate” order does not need to be in place for Responses 2 or 3.

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M1036RiskFactors

Timepoints: SOC ROC

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M1036RiskFactors

Identifies specific factors that may exert a substantial impact on the patient’s health status, response to medical treatment, and ability to recover from current illnesses, in the care provider’s professional judgment.

No specific definitions. Amount and length of exposure should be considered

when responding (for example, smoking one cigarette a month may not be considered a risk factor).

Care providers should use judgment in evaluating risks to current health conditions from behaviors that were stopped in the past.

For determination of obesity, consider using Body Mass Index guidelines.

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M1041InfluenzaVaccine

A care episode is one that includes both SOC/ROC and Transfer/Discharge.If no part of the care episode (from SOC/ROC to Transfer or Discharge) occurred during the time period from October 1 and March 31, mark “No.”Identifies whether the patient was receiving services from the home health agency during the time period for which influenza vaccine data are collected (October 1 and March 31).

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M1046InfluenzaVaccineReceived

Timepoints: TRN DC

172


For a patient with any part of the home health episode (SOC/ROC to Transfer/Discharge) occurring between October 1 and March 31, identifies whether the patient received an influenza vaccine for this year’s flu season, and if not, the reason why. This item meets National Quality Forum (NQF) standards for harmonization of influenza measures across care settings.

Response 1 if your agency provided the influenza vaccine to the patient during this episode of care (SOC/ROC to Transfer/Discharge).

Response 2 -your agency provided the flu vaccine for this year’s flu season prior to this home health episode

Response 2 if a current patient was given a flu vaccine by your agency during a previous roster billing situation during this year’s flu season.

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Response 3 if the patient or caregiver reports (or there is documentation in the clinical record) that the patient received the influenza vaccine for the current flu season from another provider. The provider can be the patient’s physician, a clinic, or health fair providing influenza vaccines, etc.

Responses 1 or 2 or 3 may be selected even if the flu vaccine for this year’s influenza season was provided prior to October 1 (that is, flu vaccine was made available early).

Response 4 if the patient and/or healthcare proxy (for example, someone with power of attorney) refused the vaccine. Note: It is not required that the agency offered the vaccine.

Select Response 4 only if the patient was offered the vaccine and he/she refused.

Response 5 if the influenza vaccine is contraindicated for medical reasons. Medical contraindications include anaphylactic hypersensitivity to eggs or other component(s) of the vaccine, history of Guillain-Barre Syndrome within 6 weeks after a previous influenza vaccination, or bone marrow transplant within 6 months or other physician medical restriction.

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Response 6 if age/condition guidelines indicate that influenza vaccine is not indicated for this patient. Age/condition guidelines are updated as needed by the CDC. Detailed information regarding current influenza age/condition guidelines is posted to the CDC website (see link in Chapter 5). It is the agency’s responsibility to make current guidelines available to clinicians.

Response 7 only in the event that the vaccine is unavailable due to a CDC-declared shortage.

Response 8 only if the patient did not receive the vaccine due to a reason other than Responses 4-7.

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Example

• Patient admitted to HH on Sept 13 and given the vaccine on September 17. You are now discharging on December 10.

Admit Sept 13

Vaccine DC—Dec 10

October 1

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Example

Patient admitted to home care on January 2. The flu season is bad this year and is lingering on. He is given the flu vaccine on April 2. You are discharging in July. Answer?

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AdmitJan 2

M1051Pneumococcalvaccine

Timepoints: TRN DC

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M1056ReasonPneumococcalVaccineNotReceived

Timepoints: TRN DC

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M1056ReasonPneumococcalVaccineNotReceived

Response 1 -if the patient and/or healthcare proxy (for example, someone with power of attorney) refused the vaccine.

Response 2 -if pneumococcal vaccine administration is medically contraindicated for this patient. Medical contraindications include anaphylactic hypersensitivity to component(s) of the vaccine, acute febrile illness, bone marrow transplant within past 12 months, or receiving course of chemotherapy or radiation therapy within past 2 weeks.

Response 3 if CDC age/condition guidelines indicate that pneumococcal vaccination is not indicated for this patient. Age/condition guidelines are updated as needed by the CDC. It is the agency’s responsibility to make current guidelines available to clinicians.

Response 4 -if the patient was not provided the vaccine due to a reason other than Responses 1 - 3.

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M1100PatientLivingSituation

Timepoints: SOC ROC

181


Using the care provider’s professional judgment, determine:

First, determine living arrangement – whether the patient lives alone, in a home with others, or in a congregate setting (usual status).

Second, determine availability of assistance – how frequently caregiver(s) are in the home and available to provide assistance if needed.

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Row a -- the patient lives alone in an independent (non-assisted) setting. For example, the patient lives alone in a home, in their own apartment, or in their own room at a boarding house. A patient with only live-in paid help is considered

to be living alone. A patient who normally lives alone but temporarily

has a caregiver staying in the home to provide assistance is considered to be living alone.

A patient who lives alone but can obtain emergency help by phone or life-line, is still living alone.

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Row b -- the patient lives with others in an independent (non-assisted) setting. For example, the patient lives with a spouse, family member or another significant other in an independent (non-assisted) setting. A patient who normally lives with others but is

occasionally alone because caregiver(s) are traveling out of town is still considered to be living with others.

Lives with family paid to provide care

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Row c -- the patient lives in an “assisted living” setting (assistance, supervision and/or oversight are provided as part of the living arrangement). For example, the patient lives alone or with a spouse or partner in an apartment or room that is part of an assisted living facility, residential care home, or personal care home.

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If the patient has recently changed their living arrangement due to their condition, report the usual living arrangement prior to the illness, injury or exacerbation for which the patient is receiving careunless the new living arrangement is expected

to be permanent.

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Around the clock means there is someone available in the home to provide assistance to the patient 24 hours a day.

Regular daytime means someone is in the home and available to provide assistance during daytime hours every day with infrequent exceptions.

Regular nighttime means someone is in the home and available to provide assistance during nighttime hours every night with infrequent exceptions.

Occasional/short-term assistance means someone is available to provide in-person assistance only for a few hours a day or on an irregular basis, or may be only able to help occasionally.

No assistance available means there is no one available to provide any in-person assistance.

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Availability of assistance refers to in-person assistance provided in the home of the patient. Includes any type of in-person assistance, including but not

limited to ADLs and IADLs. If a person is in an assisted living or congregate setting

with a call-bell that summons help, this is considered in-person assistance.

The caregiver(s) need not live in the home with the patient, but assistance via telephone is not included in this question.

Use your professional judgment to determine if someone will be available to provide any assistance to the patient. If a person is living in the patient’s home but is completely unable to or unwilling to provide any assistance to the patient, do not count them as a caregiver.

Availability of assistance refers to the expected availability and willingness of caregiver(s) for this upcoming care episode.

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M1100Examples

Patient lives alone in her own apartment. Since her discharge from the hospital, her two daughters alternate staying with her during the day and night so that one of them is always there, except for the times when one goes out to run an errand or pick up a child at day care. Response = 01 (Patient still considered to be living alone,

since daughters are only staying there temporarily. Daughters are providing round-the-clock care, even if one occasionally needs to be out of the house for brief periods.)

Patient lives alone in her home but her son and daughter-in-law live across the street. They bring the patient dinner every night and are available around the clock by telephone. Response = 04 (Son and daughter-in-law are not there to

provide in-person assistance consistently, day or evening, even if they live across the street and are available by phone.)

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M1100Examples

Patient lives with her daughter who works during the day but is home every evening and sleeps there every night. A paid aide comes in 3 days a week to assist with ADLs. Daughter has back problems that prevent her from lifting patient, but she assists the patient with dressing every morning and takes the patient to doctor’s appointments. Response = 08 (Patient lives in a home with others who are available every night to offer in-person assistance. Even if the daughter can’t meet all of patient’s needs, she is available all night.)

Patient lives with her husband who has significant cognitive and functional impairments, is wheelchair bound, and is unable to provide the patient with any assistance. A member of the church comes by one evening a week and brings groceries. Response = 09 (Patient lives in a home with another person who is there 24 hours but is unavailable to provide assistance. Caregiver from church provides occasional assistance.)

Patient lives alone in an apartment that is part of an ALF. The apartment does not have a call-bell but her contract with the ALF includes having a home health aide assist her with ADLs 2 hours every morning. Her son also comes over occasionally to assist with bills, groceries, and errands. Response = 14 (Patient is living in a congregate setting; one caregiver is available to assist for some part of every day on a regular basis, but not all day, another caregiver offers occasional assistance.)

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M1200Vision

Timepoints: SOC ROC F/U

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M1200Vision

“Nonresponsive” means that the patient is not able to respond.

A magnifying glass (as might be used to read newsprint) is not an example of corrective lenses. Neither is an adaptive reader.

Reading glasses (including "grocery store" reading glasses) are considered to be corrective lenses.

Assessment strategies: In the health history interview, ask the patient about vision problems (for example, cataracts) and whether or not the patient uses glasses. Observe ability to locate signature line on consent form, to count fingers at arm’s length and ability to differentiate between medications, especially if medications are self-administered.

Be sensitive to requests to read, as patient may not be able to read though vision is adequate.

Hard cervical collar; orbital swelling; blind in one eye 4bA64.1.

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July2015Q&A#2

Q2: Is a person with severe kyphosis or limited neck mobility who cannot adequately see objects in their path creating a safety issue on ambulation but can read med labels and newsprint considered to have partially (1) or severely (2) impaired vision?

A2: When selecting the correct response for M1200 Vision, the clinician is assessing the patient’s functional vision, not conducting a formal vision acuity screen or distance vision exam to determine if the patient has 20/20 vision. Therefore physical deficits or impairments that limit the patient’s ability to use their existing vision in a functional way would be considered. If physical deficit/impairments (like limited neck range of motion) prevent a patient from seeing objects in his path, affecting safe function in his environment, M1200 should be 2 – severely impaired vision.

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M1210AbilitytoHear

Timepoints: SOC ROC

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M1210AbilitytoHear

Hearing spoken language and other sounds, e.g. alarms

Hearing is evaluated with the patient wearing hearing aids or devices if he/she usually uses them. If evaluating ability to hear with hearing aids, be

sure that the devices are in place, turned on, and that the hearing aids are working (for example, batteries are functional).

“UK” response if the patient is not able to respond or if the patient’s condition makes it impossible to assess hearing (for example, severe dementia, schizophrenia, unconscious).

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M1220UnderstandingofVerbalContent

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M1220UnderstandingofVerbalContent

Identifies the patient’s functional ability to comprehend spoken words and instructions in the patient’s primary language. Both hearing and cognitive abilities may impact a patient's ability to understand verbal content.

The “UK” response should be selected if the patient is not able to respond or if it is otherwise impossible to assess understanding of spoken words.

For patients whose primary language differs from the clinician’s, an interpreter may be necessary.

If a patient can comprehend lip reading, they have the ability to understand verbal content, even if they are deaf.

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M1230SpeechandOral(Verbal)ExpressionofLanguage

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M1230SpeechandOral(Verbal)ExpressionofLanguage

Identifies the patient’s physical and cognitive ability to communicate with words in the patient’s primary language.

Does not address communicating in sign language, in writing, or by any nonverbal means.

Augmented speech (for example, a trained esophageal speaker, use of an electrolarynx) is considered verbal expression of language.

Presence of a tracheostomy requires further evaluation of the patient’s ability to speak. Can the trach be covered to allow speech? If so, to what extent can the patient express him/herself?

Response 5 for a patient who communicates entirely nonverbally (for example, by sign language or writing) or is unable to speak.

“Nonresponsive” means that the patient is not able to respond.

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PainProcessMeasure200

SOC/ ROC Assessment

SOC/ROC Plan

Transfer/ DCImplementation

M1240FormalPainAssessment201

M1240FormalPainAssessment

If the standardized, validated tool does not define levels of "severe" pain, then the agency or care provider should use the level(s) of pain identified in the tool that best reflect the concept of "severe."

Response 0 if such a tool was not used to assess pain. Response 1 or 2 based on the pain reported at the time

the standardized, validated tool was administered, per the tool’s instructions.

Response 1 or 2, the pain assessment must be conducted by the clinician responsible for completing the comprehensive assessment during the allowed time frame (that is, within five days of SOC and within two days of discharge from the inpatient facility at ROC).

202

M1240Timeframe

Timeframe is determined by the administration protocols associated with the exact standardized, validated tool that the clinician uses to assess pain. Examples of time frames stated in protocols include “at the present time”, and “at its worst during the past 24 hours”. If the tool selected has multiple sets of validated administration protocols, in order to standardize data collection agency policy may state which protocol the agency prefers the clinicians use.

203

Example

The patient’s present pain level is 3 but reports that this morning when she had to climb the stairs it was an 8.

The agency’s standardized, validated pain assessment tool rates the highest level in the past 24 hours. What is the response?

204

M1242FrequencyofPainInterferingwithMovement

205


Pain interferes with activity when the pain results: in the activity being performed less often than otherwise

desired, requires the patient to have additional assistance in

performing the activity, or causes the activity to take longer to complete.

Include all activities (for example, sleeping, recreational activities, watching television), not just ADLs.

When reviewing patient’s medications, the presence of medication for pain or joint disease provides an opportunity to explore the presence of pain, when the pain is the most severe, activities with which the pain interferes, and the frequency of this interference with activity or movement. Be careful not to overlook seemingly unimportant activities (for example, the patient says she/he sits in the chair all day and puts off going to the bathroom, because it hurts so much to get up from the chair or to walk).

206


Evaluating the patient’s ability to perform ADLs and IADLs can provide additional information about such pain. Assessing pain in a nonverbal patient involves observation of facial expression (for example, frowning, gritting teeth), monitoring heart rate, respiratory rate, perspiration, pallor, pupil size, irritability, or use of visual pain scales (for example, FACES).

The patient’s treatment for pain (whether pharmacologic or nonpharmacologic) must be considered when evaluating whether pain interferes with activity or movement. Pain that is well controlled with treatment may not interfere with activity or movement at all.

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4‐‐AlloftheTime

"At all times" means constantly throughout the day and night with little or no relief. Pain is also considered to be interfering if a patient stops performing an activity in order to avoid the pain. For the pain to be interfering "all the time" the frequency of the activity that was stopped in order to avoid pain must collectively represent all the hours of the day/night. Pain must wake them frequently at night. The clinician must use judgment based on observation and patient interview to determine if pain is interfering all the time. July 2013

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Example

Your patient reports that her pain doesn’t bother her as long as she moves slowly and doesn’t sit in the same position for long. Once she takes her sleeping medication at night, she rests well.

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M1400ShortofBreath210

M1400WhenisthepatientdyspneicornoticeablyShortofBreath?

Timepoints SOC/ROC/FU/Discharge How to assess?

If patient uses oxygen continuouslyAssess with oxygen in use

If the patient uses oxygen intermittentlyAssess without the use of oxygen

If oxygen used at night due to positional dyspnea, report level of exertion that causes dyspnea w/o O2

Sleep apnea ≠ dyspnea

211


Chairfast or bedbound patient:Evaluate the level of exertion required to

produce shortness of breathThe chairfast patient can be assessed for

level of dyspnea while performing ADLs or at rest • Response 0 Patient has not been short of breath

during the day of assessment

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Chairfast or bedbound patient:• Response 1 (When walking more than 20 feet…)

• Appropriate if demanding bed-mobility activities produce dyspnea in the bedbound patient (or physically demanding transfer activities produce dyspnea in the chairfast patient).

Responses 2, 3, and 4 for assessment examples for these patients as well as ambulatory patients.

213

M1400

Assess and report what caused the patient to experience dyspnea on the day of the assessment.

The examples included in Responses 2 and 3 are used to illustrate the degree of effort represented by the terms moderate and minimal.

Response 3 - With minimal exertion or agitation includes the examples of eating, talking or performing other ADLs. The reference to other ADLs means activities of daily living that only take minimal effort to perform like grooming.

214

Quiz

Dyspneic only in supine position Patient sleeps with 2 pillows or in recliner and

currently not short of breath at rest and otherwise not SOB

Environmental modifications: If the patient restricts an activity to remain free of dyspnea, they can be a “0”

Go up stairs 2 steps at a time to avoid dyspnea can still be a 0

215

M1410RespiratoryTreatments

Timepoints SOC/ROCNo longer answered at DCExcludes any respiratory treatments that are not listed in the item

Does not include nebulizers, inhalers

Option 3 reflects both CPAP and BiPAP.

216

CardiacStatusM1500s217

HeartFailureProcessMeasure218

TRN/ DCIdentification

TRN/DC Implementation

M1500SymptomsinHeartFailurePatients

Select 0,1, 2 if the patient has a diagnosis of heart failure

219


Identifies if patient has experienced signs/ symptoms of heart failure at time of most recent OASIS assessment or since that time

If the patient had symptoms and was transferred without our knowledge, the answer is “yes”

220


Consider New or ongoing heart failure symptoms since

previous OASIS Review clinical record

physical assessment data weight trends clinical notes

Dyspnea is a symptom of heart failure and while it may also be a symptom of another co-existing disease process, such as pneumonia, it would still be reported in M1500 and M1510, Heart Failure Follow-up, if the patient has a diagnosis of heart failure.

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NotAssessed

"Not assessed" means the patient with a diagnosis of heart failure was not assessed for symptoms of heart failure at the time of or at any time since the previous OASIS assessment.

Assessing clinician is completing a Transfer OASIS on a heart failure patient shortly after recertification, where CHF was not the focus of care, and there is no evidence in the clinical record that an assessment of lung sounds, weight gain, dyspnea, orthopnea or lower extremity edema was performed at the time of or since the recertification.

A patient with CHF is admitted to the hospital and discharged with a new diagnosis such as hip fracture. The ROC visit and next visit focused on interventions related to the hip fracture, and no documentation of the heart failure assessment. Patient is unable to remain in the home and is transferred to a SNF. No CHF assessment between ROC and Transfer would mean that M1500 at Transfer would be "2-Not assessed".

222

M1510HeartFailureFollow‐up

Timepoints: TRN DCBest practice

223


Include any actions that were taken at least one time at the time of the last OASIS assessment or since that time.

Response 0 - No action takenInterventions are not completed as outlined in

this item Document the rationale in clinical record

If Response 0 is selected, none of the other responses should be selected.

224

SameDay?

When completing M1510 - Heart Failure Follow-up, Response 1 is an appropriate response only if a physician responds to the agency communication with acknowledgment of receipt of information and/or further advice or instructions on the same day.

Same day in this item means by the end of this calendar day, and is not the same as "within one calendar day", which is defined in M2002, Medication Follow-up as "until the end of the next calendar day".

4b-Q116.2

What if we left a message for the physician on the same day and the physician calls the patient on the same day but not us??

Response 1 cannot be marked. Has to be communication to the agency. 4b-116.2.3

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Response 3 Either the home care clinician reminds the patient to

implement physician-established parameters for treatmentor is aware that the patient is following physician-

established parameters for treatment, e.g., took extra diuretic 4b-Q116.2.1

Teaching must be in response to symptoms—notpreventive teaching

Telehealth and interventions by telephone do count. Therapists providing written materials without

assessment of understanding is not an educational intervention. 4b-Q116.2.2

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ExampleofNotAssessed

Patient returns from hospital after fracture to hip. First 2 visits by therapist and care is directed to fracture. Patient returns to hospital with heart failure symptoms without being assessed.

M1500—2—Not Assessed4b-Q116.1

Not assessed—has diagnosis of heart failure and was never assessed for symptoms of heart failure at any point at or since the previous assessment

227

M1500;M1510

The nurse is notified by family that her patient, who has a diagnosis of heart failure, was admitted to the hospital due to increased shortness of breath due to CHF. Record review revealed that the patient experienced SOB which resulted in a qualifying hospitalization since the previous OASIS assessment. Since the family chose not to call the agency, no visit was made to assess the patient for s/s of CHF on the day he went in the hospital. How do we answer M1500, Heart Failure Symptoms and M1510, Heart Failure Followup in this situation?

228

M1500;M1510

“1-Yes” is the appropriate response if the patient had a diagnosis of heart failure and exhibited symptoms of heart failure at or since the previous OASIS assessment. In your scenario, the patient had a diagnosis of heart failure and the record review revealed that the patient experienced SOB which resulted in a qualifying hospitalization since the previous OASIS assessment. When completing the Transfer OASIS, the clinician would answer M1500

“1-Yes”, even though the agency did not have the opportunity to assess the symptoms during a visit.

4b-Q116.1.5

x

229

When answering M1510, Heart Failure Follow-up, you report the actions your agency took in response to the heart failure symptoms and if none were taken, Response “0-No action taken” would be appropriate. Include an explanation of the "No" in the clinical record. 4b-Q116.1.5

x

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July2015Q&A#7

Q7: If a patient does not have a diagnosis of heart failure when admitted for home health, but is first diagnosed with heart failure when transferred to the hospital from your agency, how should M1500 and M1510 be answered on the transfer OASIS?

A7: If the patient has a physician-confirmed diagnosis of heart failure at the time of the transfer to the inpatient facility, the clinician completing the transfer data collection would consider the patient as having the diagnosis of heart failure, and for M1500 select a response reflecting whether symptoms of heart failure were exhibited since the previous OASIS assessment. In M1510, the clinician would report all actions taken by the agency in response to heart failure symptoms, at the time of or any time since the previous OASIS assessment.

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EliminationStatusM1600s232

M1600UrinaryTractInfection233

M1600HasthispatientbeentreatedforaUrinaryTractInfectioninthepast14days?

Timepoints SOC ROC Discharge Response 0-No Patient has not been treated for a UTI within

the past two weeksPatient may have had symptoms of a UTI or a

positive culture for which the physician did not prescribe treatment

Or treatment ended more than 14 days ago

234

M1600HasthispatientbeentreatedforaUrinaryTractInfectioninthepast14days?

Response 1-YesPatient has been prescribed an antibiotic within

the past 14 days specifically for a confirmed or suspected UTI.

Patient is on prophylactic treatment and develops a UTI.

Response NAPatient is on prophylactic treatment to prevent

UTIs. UK not an option at discharge from agency

235

M1600

My patient has an order for Sulfa BID x5 days, during the first five days of every month. Upon my SOC assessment on 11/1, the patient complained of s/s of UTI. The physician was notified, but no order was obtained for a urinalysis since the patient was just beginning her prophylactic treatment that day. How should I answer M1600?

If the patient was on antibiotics and developed a UTI, the answer would be ‘Yes”, HOWEVER

The physician must diagnose a UTI to answer ‘yes’ so the answer is NA.

4b-Q116.6

236

M1610UrinaryIncontinenceorUrinaryCatheterPresence

237


Timepoints SOC/ROC/DC Response 0-No incontinence or anuria

Patient has anuria or an ostomy for urinary drainage (e.g., an ileal conduit)

Patient has a urinary diversion that is pouched (ileal conduit, urostomy, ureterostomy, nephrostomy), with or without a stoma

238


Response 1-Patient is incontinent If patient is incontinent AT ALL (i.e.,

“occasionally,” “only when I sneeze,” “sometimes I leak a little bit,” etc.)

Patient is incontinent or is dependent on a timed-voiding programTimed voiding is defined as scheduled

toileting assistance or prompted voiding to manage incontinence based on identified patterns. Time voiding is a compensatory strategy; it does not cure incontinence.

239


Response 2 Pt requires urinary catheterCatheter or tube is utilized for urinary drainage

(even if catheterizations are intermittent). Patient requires the use of a urinary catheter for

any reason (e.g., retention, postsurgery, incontinence, continent urinary diversions). Xceptions—inserting catheter to irrigate bladder

with antibiotic and capped tube with no plan to use for draining urine

Select Response 2 and follow the skip pattern if the patient is both incontinent and requires a urinary catheter.

240


What if the catheter was removed or inserted during the comprehensive assessment? Day of assessment doesn’t apply If inserted, select response 2 If removed, select response 0 or 1

This refers to an indwelling catheter, not intermittent. 4b-Q119.2.1

241


Does the patient admit having difficulty controlling the urine?

Do you have orders to change a catheter? Is your stroke patient using an external catheter? Any odors? Consider

Physiologic reasonsCognitive impairmentsMobility problems

242

July2015Q&A#8

Q8: My patient has an order for a nurse to perform a straight catheterization to obtain a urine specimen for C&S because my patient has symptoms of a UTI. There are no other orders for urinary catheterization. Would this be considered a “condition” requiring catheterization as noted in the item intent for M1610? Or does catheterization in M1610 relate to catheterization for urinary drainage only?

A8: A patient requiring a one-time catheterization for the sole purpose of obtaining urine for laboratory testing or other diagnostic procedure would not be considered having a “catheter for urinary drainage” when responding to M1610 Urinary Incontinence or Urinary Catheter Presence. Response 0 or 1 would be appropriate depending on whether or not the patient is continent.

243

M1615WhendoesUrinaryIncontinenceoccur?

Other types of

incontinence

244


Timepoints SOC ROC Discharge Response 0 Timed-voiding defers incontinence

Timed voiding determines the patient’s pattern for voiding and schedules toileting to prevent episodes of leaking. The patient can self-schedule toileting or the caregiver can prompt or bring the patient to the toilet. Time voiding is a compensatory strategy; it does not cure incontinence. If timed voiding does not defer incontinence, do not select Response 0. If timed voiding defers incontinence, but there’s an occasional accident, up to clinician to determine if in relevant past or if timed voiding is 100% effective. 4b-Q121.1

245


Response 1 Occasional stress incontinence Patient is unable to prevent escape of

relatively small amounts of urine when coughing, sneezing, laughing, lifting, moving from sitting to standing position, or other activities (stress), which increase abdominal pressure.

246


Response 2,3,or 4Urinary incontinence regularly Determine when the incontinence usually occursMay be secondary to a symptom not listed

Response 2 ‘During the night only’ Response 3 ‘During the day only’

Includes incontinence during daytime naps. Response 4 ‘During the day and night’

When the patient is incontinent when sleeping at night and up/awake during the day.

247

M1620BowelIncontinenceFrequency

248


Timepoints SOC ROC F/U Discharge Response 4 ‘On a daily basis’

Indicates that the patient experiences bowel incontinence once per day.

Response NAPatient has an ostomy for bowel elimination.

UnknownNot an option at follow-up or discharge

Bowel program—no assumed incontinence 4b-Q122

249

TimeFrameforBowelIncontinence

The timeframe under consideration is day of assessment and relevant past. This timeframe is directed by Response options "0-Very rarely or never has bowel incontinence" and "1-Less than once weekly."

Considering these two options, the assessing clinician would need to consider bowel incontinence that was experienced beyond the past 7 days. The assessing clinician must use clinical judgment to determine how far into the past would be relevant to this home care admission.

The assessing clinician may elect to re-assess bowel incontinence within the allowed timeframe and change her/his original response as well as M0090, Date Assessment Completed. 4bQ122.1.

250


Review the bowel elimination pattern Difficulty controlling stools Diarrhea

Note cleanliness Around the toilet Clothing At F/U may ask the aide

Consider Physiologic reasons Cognitive impairments Mobility problems

251

M1630OstomyforBowelElimination

252

M1630Ostomy forBowelElimination

Timepoints SOC ROC FU Addresses bowel ostomies ONLY

Applies to any type of ostomy for bowel elimination (e.g., colostomy, ileostomy)

If an ostomy has been reversed, then the patient does not have an ostomy at the time of assessment

Antegrade Colonic Enema therapy is provided by a catheter through an ostomy, but is not considered a "bowel elimination ostomy". (Could be considered under M1350) 3rdQ2014

253

M1700s

Neuro/Emotional/Behavioral254

M1700CognitiveFunctioning255

M1700CognitiveFunctioning

Timepoints SOC ROC Discharge Consider:

Patient’s signs/symptoms of cognitive dysfunction over the past 24 hours.

Amount of supervision and care the patient has required due to cognitive deficits

Level of cognitive functioning- includingalertnessorientationcomprehensionconcentration immediate memory for simple commands

256

M1700CognitiveFunctioning

Patients with diagnoses such as dementia, delirium, development delay disorders, mental retardation, etc., will have various degrees of cognitive dysfunction.

Patients with neurological deficits related to stroke, mood/anxiety disorders, or who receive opioid therapy may have cognitive deficits.

257

M1710WhenConfused258

M1710WhenConfused(ReportedorObservedWithintheLast14Days)

Timepoints SOC ROC Discharge May not relate directly to Item M1700 Assess specifically for confusion in the past 14

days. If it is reported that the patient is “occasionally”

confused, identify the situation(s) in which confusion has occurred within the last 14 days, if at all.

Report any episodes of confusion that occurred during the past 14 days, without regard to the cause of potential relevance of the confusion to this episode of care

259

WhatisthedifferenceinwhatismeasuredinM1700– CognitiveFunctioningandM1710‐

WhenConfused?

M1700--Level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands on the day of assessment (at the time of the assessment and in the preceding 24 hours).

M1710, When Confused, is intended to identify the time of day or situations when the patient experienced confusion, if at all, during the past 14 days (Day of assessment and prior 14 days). 4b-Q123.9

260

M1700– CognitiveFunctioningandM1710‐WhenConfused

If a patient is demonstrating confusion on the day of the assessment, it would be reported both in M1700 and M1710. If a patient was NOT confused on the day of assessment, but had experienced confusion during the prior 14 days, it would only be reported in M1710.

If a patient has a cognitive impairment on the day of the assessment, that does NOT result in confusion, e.g.; forgetfulness, learning disabilities, concentration difficulties, decreased intelligence, it would only be reported in M1700.

4b-Q123.9

261

M1720WhenAnxious262

M1720WhenAnxious

Timepoints SOC ROC Discharge Anxiety includes:

Worry that interferes with learning and normal activities

Feelings of being overwhelmed and having difficulty coping

Symptoms of anxiety disorders

263

NonresponsiveM1710/M1720

“Nonresponsive” means that the patient is unable to respond or the patient responds in a way that you can’t make a clinical judgment about the patient’s level of orientation. Examples at 4b-Q124.1

Can still report confusion or anxiety during the past 14 days—ask the caregiver or other source

Nonresponsive pulls the patient from 30+ measures because may not expect to improve. If not expected to improve, NR is a good response.

264

DepressionProcessMeasure265

M2250

M2400

M1730DepressionScreening266

M1730DepressionScreening

Identifies if the home health agency screened the patient for depression using a standardized, validated depression screening tool.

Response 0 if a standardized, validated depression screening was not conducted. If the clinician chooses not to assess the patient

(because there is no appropriate depression screening tool available or for any other reason), Response 0 – No should be selected.

Response 1 if the PHQ-2© is completed, and mark the appropriate responses in rows a and b. Please note that the PHQ-2© instructions indicate that the patient is interviewed, not family or others. If the patient scores three points or more on the PHQ-2©, then further depression screening is indicated.

267


When evaluating the patient, the clinician must first assess whether the PHQ-2 is the appropriate depression screening tool. If the PHQ-2 is appropriate (the patient appears to be cognitively and physically able to respond), then the instrument may be used.

If, however, the patient is unable to answer the specific PHQ-2 questions when asked by the assessing clinician, e.g. the patient can't quantify how many days they have experienced the problems, the clinician can report in M1730 that the PHQ-2 was administered (Response 1), and select N/A - Unable to respond.

Response 1-Yes may NOT be selected if the patient refuses to hear the questions or states they are too personal.

268


If the PHQ-2© is not used to assess the patient, you may choose to administer a different standardized, validated depression screening tool with instructions that may allow for information to be gathered by observation and caregiver interview as well as self-report. In this case, the clinician would select Response 2 or 3 for M1730, depending on the outcome of the assessment.

Response 2 if the patient is screened with a different standardized, validated assessment AND the tool indicated the need for further evaluation.

Response 3 if the patient is screened with a different standardized, validated assessment BUT the tool indicates no need for further evaluation.

269

M1740Cognitive,behavioral,andpsychiatricsymptoms

270


Timepoints SOC ROC Discharge Behaviors can be observed by the clinician or

reported by the patient, family, or others

Consider problematic behaviorsSevere enough to make the patient unsafe

OR cause considerable stress to caregivers OR require supervision or intervention

Consider frequency of behaviors

271


The time frame under consideration for M1740, Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week, is defined in the wording of the item - "at least once a week". The phrase "at least once a week" means that a behavior was demonstrated multiple times in the recent, relevant past and the frequency of the occurrence was at least one time a week prior to and including the day of assessment. The assessing clinician will determine "recent, relevant past" based on the patient/caregiver interview, referral information, assessment findings, diagnoses and recent history of medical treatment and its effectiveness. 4b-Q124.5.6

272

M1740

If a patient is alert and oriented, but decides not to use their cane because they think they don’t need it (they are unsafe without it) or they decide they aren’t going to take their diuretic because they are going to the doctor and don’t want to have any accident, would you select Response “2 – Impaired decision-making”?

4b-Q124.5.5

273

M1740

The intent of M1740, Cognitive, behavioral, and psychiatric symptoms, is to capture specific behaviors that are a result of significant neurological, cognitive, behavioral, developmental or psychiatric limitations or conditions. It is not the intent of M1740 to report noncompliance or risky choices made by cognitively intact patients who are free of the aforementioned conditions. The assessing clinician will have to determine if the patient has a disorder that is causing her non-compliance or is the patient making a choice not to comply completely with physician's orders, cognizant of the implications of that choice.

274

M1745FrequencyofDisruptiveBehaviorSymptoms

275

M1745FrequencyofDisruptiveBehaviorSymptoms

Consider if the patient has any problematic behaviors – not just the behaviors listed in M1740 – which jeopardize or could jeopardize the safety and well-being of the patient or caregiver. Then consider how frequently these behaviors occur.

Include behaviors considered symptomatic of neurological, cognitive, behavioral, developmental, or psychiatric disorders. Use clinical judgment to determine if the degree of the behavior is disruptive or dangerous to the patient or caregiver.

Disruptive/dangerous behaviors Sleeplessness “Sun-downing” Agitation Wandering Aggression Combativeness Getting lost in familiar places, etc.

276

Is M1745 - Frequency of Disruptive Behavior Symptoms, only based on disruptive behavior: physical, verbal or other disruptive/dangerous symptoms? Or is this item based on behaviors listed in M1740?

M1740 - Cognitive, behavioral, and psychiatric symptoms, and M1745 – Frequency of Disruptive Behavior Symptoms are not directly linked to one another.

There may be behaviors reported in M1740 that are not reported in M1745 and vice versa.

For example, a patient may express excessive profanity or sexual references that cause considerable stress to the caregivers and be reported in M1740, but in the clinician's judgment, the behavior does not jeopardize the safety and well-being of the patient or caregiver, therefore is not reported in M1745.277

Answer each question individually. M1740 contains a list of specific behaviors associated with significant neurological, developmental, behavioral or psychiatric disorders and asks if they are demonstrated by the patient at least once a week. M1745 is not reporting on a specific list of behaviors, but rather any behaviors that are disruptive or dangerous to the patient or the caregivers.

278

M1750PsychiatricNursingServices

279

M1750PsychiatricNursingServices

M1750, Psychiatric Nursing Services, reports if the patient is receiving psychiatric nursing services in the home at the time of the SOC/ROC assessment. This is referring to qualified personnel of the home health agency, per physician orders, specifically for the assessment and treatment of psychiatric conditions. When completing the SOC/ROC comprehensive assessment, if an order exists on the plan of care for the agency to provide psychiatric services, then respond "Yes" to M1750. 4bQ126.2

280

IntegumentaryM1300s281

PressureUlcerDefined

A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. NPUAP

Does not include mucosal pressure ulcers 4bQ98.2.2.

282

BasicsRegardingPressureUlcers

In 2004, based on advances in wound care research and the opinion of the National Pressure Ulcer Advisory Panel (NPUAP), it was determined that Stage I and Stage II (partial thickness) pressure ulcers can heal through the process of regeneration of the epidermis across a wound surface, known as epithelialization.

Stage III and IV (full thickness) pressure ulcers heal through a process of contraction, granulation, and epithelialization. They can never be considered "fully healed" but they can be considered closed when they are fully granulated and the wound surface is covered with new epithelial tissue.

283

StageIPressureUlcer

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area

284

StageIPressureUlcer285

StageIIPressureUlcer

Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

286

StageIIPressureUlcer

A Stage II ulcer also may present as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. * Bruising indicates suspected deep tissue injury.

287

StageIIIPressureUlcer

Full thickness tissue loss. Sub-q fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

288

StageIIIPressureUlcer

The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; Stage III ulcers in these locations can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

289

StageIIIonAnkle290

StageIVPressureUlcer

Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

291

StageIVPressureUlcer

The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; Stage IV ulcers in these locations can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule); osteomyelitis is possible. Exposed bone/tendon is visible or directly palpable.

292

Unstageable

Known or likely but not stageable due to non-removable dressing or device Includes those that are sutured Includes those with skin grafts that edges haven’t

healed yet Known or likely but not stageable due to coverage

of wound bed by slough and/or eschar. (New language regarding Stage IV structures) Scab obscuring tissue loss. July 2013

Suspected deep tissue injury in evolution.

293

Unstageable (#d2)294

SuspectedDeepTissueInjury

Suspected deep tissue injury in evolution, which is defined by the NPUAP as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

295

SuspectedDTI296

“Healing”

Stage I and II heal.Healed stage I not at risk for future PU

developmentHealed stage II at minimal risk for future ulcer

formation Stage III and IV close; they do not heal.

They never fully heal and will always remain at risk

OASIS-C1 status—newly epithelialized Reverse staging NEVER appropriate

297

DoStageIIIandIVpressureulcersevergoaway?

If muscle flap, skin advancement flap or rotational flap procedure performed—no longer a pressure ulcer If a pressure ulcer is closed with a muscle flap, and

before the muscle flap suture line heals completely, pressure causes new breakdown within the flap area (not along the suture line), this would be considered a new pressure ulcer, and until the muscle flap suture site is completely epithelialized for approximately 30 days, the flap site would remain a surgical wound. In this scenario, the patient would have both a new pressure ulcer and a surgical wound simultaneously. 3rd Q2014

If limb amputated If entire pressure ulcer is surgically excised 4bQ94.1

298

M1300PressureUlcerAssessment/M1302Risk

Timepoints: SOC ROCBest practice M1300 includes an exception to the use of a standardized validated tool.

299

M1300PressureUlcerAssessment

In order to select Response 1 or 2, the pressure ulcer risk assessment must be conducted by the clinician responsible for completing the comprehensive assessment during the time frame specified by CMS for completion of the assessment.

If the evaluation was based on clinical factors (without a validated standardized screening tool), then the agency or care provider may define what constitutes risk.

If both a standardized, validated screening tool and an evaluation of clinical factors are utilized, select Response 2.

300

M1302RiskforPressureUlcers

If both a standardized, validated screening tool and an evaluation of clinical factors are utilized, select Response 1-Yes, if either assessment is positive for risk.

301

M1306UnhealedPressureUlceratStageIIorHigher

Timepoints: SOC ROC F/U DC

302

OASIS C-1

M1306UnhealedPressureUlceratStageIIorHigher

Response 1: Pressure ulcers that are known to be present or that the

care provider suspects may be present based on clinical assessment findings (for example, patient report of discomfort, past history of skin breakdown in the same area), but that are unobservable due to dressings or devices (for example, casts) that cannot be removed to assess the skin underneath.

Pressure ulcers that the care provider suspects may be present based on clinical assessment, but that cannot be staged because no bone, muscle, tendon, or joint capsule (Stage IV structures) are visible, and some degree of necrotic tissue (eschar or slough) or scabbing is present that the clinician believes may be obscuring the visualization of Stage IV structures.

Suspected deep tissue injury in evolution

303

M1307TheOldestStageIIPressureUlcer

304

T

The term “non-epithelialized” was eliminated from the item stem and the NA response to improve clarity and be consistent with the OASIS-C1 Guidance manual.Added exclusion of healed Stage II ulcers.Changed references to “fully epithelialized”Stage II pressure ulcers to “healed” Stage IIpressure ulcers.


Response 1 if the oldest Stage II pressure ulcer was already present when the SOC/ROC assessment was completed.

Response 2 if the oldest Stage II pressure ulcer was first identified since the most recent SOC/ROC visit (that is, since the last time the patient was admitted to home care or had a resumption of care after an inpatient stay). Enter onset date

305


Response “NA” if the patient has no Stage II pressure ulcers at the time of discharge, or all Stage II pressure ulcers have healed.

An ulcer that is suspected of being a Stage II, but is Unstageable, should not be identified as the “oldest Stage II pressure ulcer.” For this item, Unstageable refers to pressure ulcers that are known to be present or that the care provider suspects may be present based on clinical assessment findings (for example, patient report of discomfort, past history of skin breakdown in the same area), but that are unobservable due to dressings or devices (for example, casts) that cannot be removed to assess the skin underneath.

306

M1308CurrentNumberofUnhealedPressureUlcers

Took out “nonepithelialized”

307


Timepoints: SOC ROC F/U DC Stage II ulcers

Stage II ulcers that have healed are not reported in this item.

Stage II pressure ulcers are described as “partial thickness” ulcers.

Once epithelialized, considered healed.

308


Stage III and IV ulcers A closed Stage III or Stage IV pressure ulcer should be

reported as a pressure ulcer at its worst stage. Reverse staging of granulating Stage III and Stage IV pressure ulcers is NOT an appropriate clinical practice according to the NPUAP. For example, if a pressure ulcer is Stage III at SOC and is granulating at the follow-up visit, the ulcer remains a Stage III ulcer.

A previously closed Stage III or Stage IV pressure ulcer that is currently open again should also be reported at its worst stage.

If the patient has been in an inpatient setting for some time, it is conceivable that the wound has already started to granulate, thus making it challenging to know the stage of the wound at its worst. The clinician should make every effort to contact previous providers (including patient’s physician) to determine the stage of the wound at its worst.

309


Stage III and IV ulcers If the assessing clinician becomes aware that the

patient had a full-thickness (Stage III or IV) pressure ulcer in the past that is now closed, but is unable to determine the stage at its worst, it should be reported in the OASIS pressure ulcer items as a Stage III. 4bA89.5.

An ulcer's stage can worsen, and this item should be answered appropriately if this occurs.

A pressure ulcer that has been surgically debrided remains a pressure ulcer and should not be reported as a surgical wound on M1342.

310

SkinGrafts

A pressure ulcer treated with a skin graft (defined as transplantation of skin to another site) remains a pressure ulcer and should not be reported as a surgical wound on M1342. Graft edges not healed--the grafted pressure

ulcer should be reported on M1308 as d.1 (Unstageable) pressure ulcer.

Graft edges healed, the closed Stage III or Stage IV pressure ulcer would continue to be regarded as a pressure ulcer at its worst stage.

311


Unstageable d.1--Known to be present or that the care provider suspects may be present based on clinical assessment findings (for example, patient report of discomfort, past history of skin breakdown in the same area), but that are Unstageable due to dressings or devices (for example, casts) that cannot be removed to assess the skin underneath.

Unstageable d.2 refers to pressure ulcers that the care provider suspects may be present based on clinical assessment findings, but that cannot be staged because no bone, muscle, tendon, or joint capsule (Stage IV structures) are visible, and some degree of necrotic tissue (eschar or slough) or scabbing is present that the clinician believes may be obscuring the visualization of Stage IV structures.

Unstageable d.3--suspected deep tissue injury in evolution

312

M1309WorseninginPressureUlcerStatus

Timepoint: DC

313


Compare the current stage of the pressure ulcer to the stage of that ulcer at the most recent SOC/ROC to determine whether the pressure ulcer currently present is new or worsened when compared to the presence or stage of that pressure ulcer at the most recent SOC/ROC.

For pressure ulcers that are currently Stage II, III or IV, “worsening” refers to a pressure ulcer that has progressed to a deeper level of tissue damage and is therefore staged at a higher number using a numerical scale of I-IV (the NPUAP staging system) at the time of discharge in comparison to the most recent SOC/ROC assessment.

314


For row a: Stage II. Enter the number of current pressure ulcers at discharge, whose deepest anatomical stage is Stage II, that were not present or were a Stage I at most recent SOC/ROC. Enter “0” if there are no current Stage II pressure ulcers or no Stage II pressure ulcers that have worsened since most recent SOC/ROC.

For row b: Stage III. Enter the number of current pressure ulcers at discharge whose deepest anatomical stage is Stage III, that were not present or were a Stage I or II at the most recent SOC/ROC. Enter “0” if there are no current Stage III pressure ulcers or no Stage III pressure ulcers that have worsened since most recent SOC/ROC.

For row c: Stage IV. Enter the number of current pressure ulcers at discharge whose deepest anatomical stage is Stage IV, that were not present or were at Stage I, II, or III at the most recent SOC/ROC. Enter “0” if there are no current Stage IV pressure ulcers or no Stage IV pressure ulcers that have worsened since most recent SOC/ROC.

315

M1309Unstageable duetosloughoreschar

Unstageable due to slough or eschar are those in which the wound bed is not visible due to some degree of necrotic tissue or scabbing that the clinician believes may be obscuring the visualization of bone, muscle, tendon or joint capsule (Stage IV structures). Note that if a Stage IV structure is visible, the pressure ulcer is not considered Unstageable – it is a Stage IV even if slough or eschar is present. “Worsening” refers to a pressure ulcer that was either

not present or was a Stage I or II pressure ulcer at the most recent SOC/ROC and is now Unstageable due to slough or eschar.

Pressure ulcers that are currently Unstageable due to presence of slough or eschar and were Stage III or IV at the most recent SOC/ROC are not considered worsened.

316

M1309Unstageable‐NOTIncluded

Pressure ulcers that were Unstageable for any reason at the most recent SOC/ROC cannot be reported as new or worsened.

Pressure ulcers that are Unstageable at discharge due to dressings or devices (for example, casts) that cannot be removed to assess the skin underneath cannot be reported as new or worsened.

Suspected deep tissue injuries in evolution that are present at SOC/ROC or discharge cannot be reported as new or worsened.

317

M1309Algorithm318

Example

Stage IV on the coccyx at SOC and a stage II on the elbow. Stage IV underwent a skin rotational flap. Stage II now a Stage III

319

Example

Stage II at ROC. At DC it is 80% covered with slough—no stage IV structures visible. New stage II at different location.

320

M1309Quiz

Scenario 1: You are completing Mrs. Sanchez’s discharge comprehensive assessment. While assessing her skin, you determine she has two pressure ulcers. One is a Stage IV on her left buttock, and is 50 percent covered in slough, with observable muscle. The other is on her left elbow and is completely covered with eschar. You review her chart and find that at SOC the left elbow was a Stage II and the buttock ulcer was a Stage III.

How would you respond to M1309 — Worsening in Pressure Ulcer Status since SOC/ROC?

321

M1309Quiz

Scenario 2: You are completing Mr. Stone’s discharge comprehensive assessment. When assessing his skin, you discover a Stage II pressure ulcer on his right heel and a suspected deep tissue injury on his left heel. When you review the chart, you discover that he had no pressure ulcers at SOC.

How would you respond to M1309 — Worsening in Pressure Ulcer Status since SOC/ROC?

322

M1320StatusofMostProblematicPressureUlcer

323

M1320StatusofMostProblematicPressureUlcer

Determine which pressure ulcer(s) are observable: Includes all Stage II or higher pressure ulcers that

are not covered with a non-removable dressing or device, even if Unstageable

When determining the healing status of a pressure ulcer for answering M1320, the presence of necrotic tissue does NOT make the pressure ulcer “NA – No observable pressure ulcer.”

A pressure ulcer with necrotic tissue (eschar/slough) obscuring the wound base cannot be staged, but its healing status is either Response 2 – Early/Partial Granulation if necrotic or avascular tissue covers <25% of the wound bed, or Response 3 - Not Healing, if the wound has ≥25% necrotic or avascular tissue.

324

HealingStatus

Response 0 – Newly Epithelialized: wound bed completely covered with new epithelium, no exudate, no avascular tissue (eschar and/or slough); no signs or symptoms of infection.

Response 1 – Fully Granulating: wound bed filled with granulation tissue to the level of the surrounding skin or new epithelium; no dead space, no avascular tissue (eschar and/or slough); no signs or symptoms of infection; wound edges are open

325

HealingStatus

Response 2 – Early/Partial Granulation: wound with ≥25% of the wound bed covered with granulation tissue; <25% of the wound bed covered with avascular tissue (eschar and/or slough); may have dead space; no signs or symptoms of infection; wound edges open.

Response 3 – Not Healing: wound with ≥25% avascular tissue (eschar and/or slough) OR signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound edges OR persistent failure to improve despite appropriate comprehensive wound management. Stage II and suspected deep tissue injury are not

healing Hypergranulation 3rd Q 2014

326

M1322CurrentNumberofStage1PressureUlcers

327

M1324StageofMostProblematicPressureUlcer

328


If a pressure ulcer is Stage IV at SOC and is granulating at the follow-up visit, the ulcer remains a Stage IV ulcer.

A closed Stage III or Stage IV pressure ulcer continues to be regarded as a pressure ulcer at its worst stage. However, an unhealed active ulcer at a lower stage may be the most problematic ulcer.

A previously closed Stage III or Stage IV pressure ulcer that breaks down again should be staged at its worst stage.

329


In order to stage the pressure ulcer as a Stage IV, bone, muscle, tendon, or joint capsule (Stage IV structures) must be visible. A pressure ulcer that has some degree of necrotic tissue (eschar or slough) or scabbing present that the clinician believes may be obscuring the visualization of Stage IV structures cannot be staged, even if it previously stageable.

330


If the assessing clinician becomes aware that the patient had a full-thickness (Stage III or IV) pressure ulcer in the past that is now closed, but is unable to determine the stage at its worst, it should be reported in the OASIS pressure ulcer items as a Stage III. Although the assessing clinician can report the observed, closed ulcer on the OASIS without physician confirmation, collaboration with the physician would be required in order to receive related orders and/or provide physician-ordered care related to the pressure ulcer.

331

CoveredwithEschar;NowGranulated

If a patient has an unstageable pressure ulcer due to black stable eschar at SOC and during the episode it peels off and leaves an area of newly epithelialized tissue, how should this be staged at Discharge on M1308?

If unable to obtain any documentation that would support the most advanced stage, an assumption would be allowed that this wound is at least a Stage III, and reported in M1308 as such. Stage I and II ulcers do not form eschar or slough. Due to the presence of this avascular tissue, the assumption is allowed for the less advanced stage of a Stage III. See CMS Q&A Category 4b, Q 89.5 for additional detail. 3rd Q 2014

332


We are recertifying a patient who had a Stage II pressure ulcer at SOC that is now closed and only red. We understand not to “back-stage” but when a Stage II pressure ulcer closes and is only red, is it now considered a Stage I pressure ulcer? Or is it considered healed and gone in which we would no longer score it on OASIS?

When a Stage II ulcer re-epithelializes, it is considered "healed" and no longer reported in the OASIS data set. If you are describing a patient who now has non-blanchable redness at the same site where the Stage II ulcer healed, then this would now be considered a new Stage I, as it has been caused by new pressure at the same site, and is not reversing the staging of a healed Stage II ulcer.

333

M1324MuscleFlap

If a pressure ulcer is closed with a muscle flap (defined as full thickness skin and subcutaneous tissue partially attached to the body by a narrow strip of tissue so that it retains its blood supply), the new tissue completely replaces the pressure ulcer. In this scenario, the pressure ulcer "goes away" and is replaced by a surgical wound. If the muscle flap healed completely, but then began to break down due to pressure, it would be considered a new pressure ulcer. If the flap had never healed completely, it would be considered a non-healing surgical wound. 4bQ94

334

SuturedClosed

A pressure ulcer that is sutured closed (without a flap procedure) would still be reported as a pressure ulcer.

For M1308 – Current Number of Unhealed Pressure Ulcers at Each Stage or Unstageable, it would be reported in row d.1 as Unstageabledue to non-removable dressing or device.

M1309—not reported M1320—NA M1324—NA

335

Example

Stage III on the left hip now fully granulating. Small pressure ulcer on elbow that is covered with slough. Patient keeps on removing dressing.

336

M1330DoesthispatienthaveaStasisUlcer?


337

M1330DoesthispatienthaveaStasisUlcer?

Identifies patients with ulcers caused by inadequate venous circulation in the area affected (usually lower legs). This lesion is often associated with stasis dermatitis.

Stasis ulcers DO NOT include arterial lesions or arterial ulcers.

Response 3--Information may be obtained from the physician or patient/caregiver regarding the presence of a stasis ulcer underneath the cast or dressing.

338

M1332CurrentNumberofStasisUlcers


339

Current number of observable stasis ulcer

CountingStasisUlcers

If areas of venous stasis ulceration are contiguous and developed at the same time, the entire area would be counted as one stasis ulcer. If the patient had a venous stasis ulcer and then later developed another venous stasis ulcer, and eventually the wound margins met, it would be counted as two ulcers, as long as it remains possible to differentiate one ulcer from another based on wound margins. Depending on the timing and progression, it may be difficult for the clinician to know that a current ulcer was once two ulcers, and/or where one ulcer ends and another begins for assessment/reporting purposes. It would be up the assessing clinician to determine the number of stasis ulcers in situations where multiple ulcers may have merged together.

340

MixedArterialandVenousDisease

341

Venous stasisdisease

Arterial origin

TraumaWoundorStasisUlcer?

Our patient’s lower extremity wound originated as a trauma wound due to a fall. The patient also has diagnoses of venous insufficiency and stasis dermatitis. The physician stated the wound is not healing due to the venous insufficiency. Is there a point in time when the wound is no longer classified as a traumatic wound and considered a stasis ulcer for M1330?

Ulcers caused by inadequate circulation in the area affected. The healing process of other types of wounds, e.g. traumatic wounds, surgical wounds, burns, etc., may be impacted by the venous insufficiency, but it would not change the traumatic or surgical wound into a venous stasis ulcer.

4bQ100.01.

342

M1334StatusofMostProblematicStasisUlcer

343

What’s missing from OASIS-C responses?1. Determine which stasis ulcers are observable2. Determine which stasis ulcer is most problematic, then3. Determine and report healing status

M1334StatusofMostProblematicStasisUlcer

Response 1 – Fully Granulating: Mark 1 when a stasis ulcer has a wound bed filled with granulation tissue to the level of the surrounding skin or new epithelium; no dead space, no avascular tissue; no signs or symptoms of infection; wound edges are open

Response 2 – Early/Partial Granulation: Mark 2 when ≥ 25% of the wound bed is covered with granulation tissue; there is minimal avascular tissue (that is, <25% of the wound bed is covered with avascular tissue); may have dead space; no signs or symptoms of infection; wound edges open.

Response 3 – Not Healing: Mark 3 when wound has ≥25% avascular tissue OR signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratoticwound edges OR persistent failure to improve despite appropriate comprehensive wound management.

344

M1340SurgicalWound


345

M1340SurgicalWound

Old surgical wounds that have resulted in scar or keloid formation are not considered current surgical wounds and should not be included in this item.

If the patient has both an observable and an unobservable wound, the best response is 1 – Yes, patient has at least one observable surgical wound.

Response 2 if the only surgical wound(s) is/are not observable. A wound is considered not observable if it is covered by a dressing/device (such as a cast) which is not to be removed per physician order.

A surgical site closed primarily (with sutures, staples, or a chemical bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has been present for approximately 30 days, unless it dehisces or presents signs of infection. After 30 days, it is generally described as a scar and should not be included in this item.

346

SurgicalWounds4b‐Q102‐106

Pressure ulcers with muscle flaps (breaks down after healing—non healing surgical wound

Excised pressure ulcers Q94.1

Dialysis cath exit sites (AV fistulas, AV shunts)*

Pressure ulcers with skin grafts

Pressure ulcers sutured closed

Paracentesis 4b-Q105.6

Surgical Wounds Not Surgical Wounds347

SurgicalWounds

Implanted infusion devices*

ON-Q catheter sites Implanted pumps* Cardiac cath by cutdown VANTAS implanted

device* electrodessication and

curettage MammoSite® breast

brachytherapy

PICC line (tunneled and non-tunneled) Unless inserted centrally

Cardiac cath by needle puncture

Toenail removal

Surgical WoundsNot surgical wounds

348

*As long as present in body, regardless whether functional

SurgicalWounds

I&D with drain Excision Wound with drain

even after drain pulled

Shave, punch or excisional biopsy

Repair of a internal trauma

Take down of ostomy

I&D without drain Removal of a callus Repair of a traumatic

laceration Burn with a skin graft Thoracotomy or any

wound ending is otomy(ostomy) Surgical incision to

insert chest tube Ostomy allowed to close

on its own


SurgicalWounds

Pacemakers and internal defibrillators until epithelialized for 30 days

LVAD (as long as present)

VP shunt Donor site for grafts Arthroscopy Kyphoplasty by open

approach

Pacemakers and internal defibrillators once epithelialized for 30 days

Retention sutures, staple sites

Kyphoplasty by percutaneous approach

Cataract surgery Gynecological surgery via

vaginal approach Mucous membranes

(dental)


July2015Q&A#3and4

Are these surgical wounds? Diabetic foot ulcer that had I&D of foot and bone

biopsy to rule out osteomyelitis – is it a surgical wound after the biopsy? No, still a diabetic ulcer

Burr holes in head following evacuation of a subdural hematoma with tightly adhered scabs? Burr holes are surgically placed in skull and are considered current surgical wounds until site is completely epithelialized for 30 days.

351

July2015Q&A#5and6

Are these surgical wounds? Wound from an abdominal laparoscopy surgery, if

no drain was placed? Yes, an incision created for laparoscopic surgery, arthroscopy, and other minimally invasive surgery/procedure would be considered a surgical wound.

Wound lesions resulting from freezing with liquid nitrogen? No, a lesion resultant from cryosurgery is not considered a surgical wound for OASIS item M1340. It would be reported in M1350 if the lesion requires assessment or intervention from agency.

352

SurgicalWounds

Central venous catheters or central lines are those with the catheter tip located in the superior vena cava. Central lines can be peripherally inserted (i.e., basilic or cephalic vein in upper arm, or femoral vein in the groin) or centrally inserted (i.e., internal jugular vein in the neck, or subclavian or axillary vein in the chest).

Central lines that are centrally inserted (as in the internal jugular example) ARE considered surgical wounds for M1340 because of the central insertion, even if the type of catheter inserted into the central vein was intended to be inserted peripherally.

Central lines that are peripherally inserted are not considered surgical wounds.

4bQ105.9.1.

353

Howmanysurgicalwounds?354

M1342StatusofMostProblematicSurgicalWound

355

1. Determine which surgical wounds are observable2. Determine which observable surgical wound ismost problematic, then3. Determine and report healing status

PrimaryIntention

The clinician must first assess if the wound is healing entirely by primary intention (well-approximated with no dehiscence), or if there is a portion healing by secondary intention, (due to dehiscence, interruption of the incision, or intentional secondary healing).

Surgical wounds healing by primary intention (approximated incisions) do not granulate, therefore the only appropriate responses would be Response 0 - Newly epithelialized or Response 3 - Not healing.

If the wound is healing solely by primary intention, observe if the incision line has re-epithelialized. Epithelialization is regeneration of the epidermis across a wound surface. (If there is no interruption in the healing process, this generally takes within a matter of hours to three days post-operatively.) If there is not full epithelial resurfacing such as in the case of a scab adhering to underlying tissue, the correct response would be "Not healing" for the wound healing exclusively by primary intention.

356

HealingbyPrimaryIntention357

SecondaryIntention358

SecondaryIntention359

Healing by primary intention

Healing by secondary intention

SecondaryIntention

If it is determined that there is incisional separation, healing will be by secondary intention. Surgical incisions healing by secondary intention do granulate, therefore may be reported as "Not healing," "Early/partial granulation," "Fully granulating," and eventually "Newly epithelialized.”

Response 0 – Newly epithelialized: Select 0 when the wound bed has completely covered with new epithelium; no exudate; no avascular tissue (eschar and/or slough); no signs or symptoms or infection. Epithelialization is characterized by "Epidermal resurfacing" and means the opening created during the surgery is covered by epithelial cells. If epidermal resurfacing has occurred completely, the correct response in the OASIS would be "Newly epithelialized" until 30 days have passed without complication, at which time it is no longer a reportable surgical wound.

Response 0 – Newly epithelialized for implanted venous access devices and infusion devices when the insertion site is healed and without signs and symptoms of infection.

360

Newlyepithelialized

wound bed completely covered with new epithelium

no exudate no avascular tissue

(eschar and/or slough) no signs or symptoms of

infection (Newly epithelialized for

30 days when closed by primary intention)

361

FullyGranulating

wound bed filled with granulation tissue to the level of the surrounding skin

no dead space no avascular tissue

(eschar and/or slough) no signs or symptoms

of infection wound edges are

open

362

Early/PartialGranulation

≥ 25% of the wound bed is covered with granulation tissue

< 25% of the wound bed is covered with avascular tissue (eschar and/or slough)

no signs or symptoms of infection wound edges open

363

NotHealing

≥ 25% avascular tissue OR

S/S of infection OR Clean but non

granulating wound bed OR

Closed/hyperkeratoticwound edges OR

Persistent failure to improve despite appropriate comprehensive wound management

364

HealingStatus—VenousAccessDevices

When a needle is inserted and removed from an implanted venous access device, it is possible that the skin that was pierced by the needle could have a resulting wound that would heal by secondary intention. Usually, with good access technique and current needle technology there will be no perceptible wound.

Occasionally, if there was an extremely large bore needle or traumatic entry or removal, there may be a resulting wound that heals by secondary intention. In this situation, the accessing clinician would rely on the WOCN's OASIS Wound Guidance document to determine the healing status. Note that a scab is a crust of dried blood and serum and should not be equated to either avascular or necrotic tissue when applying the WOCN guidelines. Therefore while the presence of a scab does indicate that full epithelialization has not occurred in the scabbed area, the presence of a scab does not meet the WOCN criteria for reporting the wound status as "Not healing". 4bQ112.6.

Some sites, because they are being held open by a line or needle, cannot fully granulate and may remain "non-healing" while the line or needle is in place. 4bQ112.6.1.

365

M1350SkinLesionorOpenWound

Timepoints: SOC ROC NO LONGER answeredAt FU or DC

366

Added some punctuation

M1350SkinLesionorOpenWound—Notincluded

Bowel ostomies (which are reported in OASIS item M1630) *ileostomies are considered bowel ostomies 3rdQ2014

Wounds resulting from cataract surgery, surgery to mucosal membranes, or gynecological surgical procedures by a vaginal approach

Tattoos, piercings, and other skin alterations without ongoing assessment and/or clinical intervention by the home health agency as a part of the planned/provided care

Any other skin lesions or open wounds that are notreceiving clinical intervention

367

M1350SkinLesionorOpenWound‐‐Included

A lesion is a broad term used to describe an area of pathologically altered tissue. All alterations in skin integrity are considered to be lesions.

Examples of lesions include but are not limited to sores, skin tears, burns, ulcers, rashes, edema, burns, diabetic ulcers, cellulitis, abscesses and wounds caused by trauma of various kinds.

PICC line and peripheral IV sites (not inserted centrally)

Primary lesions, secondary lesions, changes in shape (edema), texture, color, breaks in skin and vascular lesions

4b-Q112.7

368

Included

Non-bowel ostomies (for example, tracheostomies, thoracostomies, urostomies, jejunostomies, gastrostomies)

Gastrostomies and jejunostomies are not considered bowel ostomies. (G tubes and J tubes are reported in M1350)

• 4b-Q112.10.1

369

ClinicalInterventionsareNecessary

If clinical interventions (for example, cleansing, dressing changes, ongoing assessment) are being provided by the home health agency during the care episode

370

ADLs/IADLs371

ConventionsSpecifictoADLs/IADLs

Identify the patient’s ABILITY, not necessarily actual performance. "Willingness" and "adherence" are not the focus of these items.

The level of ability refers to the patient’s ability to safely complete specified activities.

While the presence or absence of a caregiver may impact actual performance of activities, it does not impact the patient’s ability to perform a task.

Consider medical restrictions when determining ability. For example, if the physician has ordered activity restrictions, consider this when selecting the best response to functional items related to ambulation, transferring, bathing, etc.

372


The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to do on the day of the assessment. If ability varies over time, choose the response describing the patient’s ability more than 50% of the time period under consideration.

Understand what tasks are included and excluded in each item and select the OASIS response based only on included tasks.

If the patient’s ability varies between the different tasks included in a multi-task item, report what is true in a majority of the included tasks, giving more weight to tasks that are more frequently performed.

373


Ability can be temporarily or permanently limited by: physical impairments (for example, limited range of

motion, impaired balance) emotional/cognitive/behavioral impairments (for

example, memory deficits, impaired judgment, fear) sensory impairments, (for example, impaired vision or

pain) environmental barriers (for example, accessing

grooming aids, mirror and sink, stairs, narrow doorways, location where dressing items are stored).Environmental barriers may be different dependent

on the tasks.

374


Response scales present the most optimal (independent) level first, then proceed to less optimal (most dependent) levels.

Assessment Strategies Observation/demonstration is the preferred method Patient/caregiver interview Physical assessment Nutritional assessment Physician orders Plan of Care Referral information Review of past health history

Service animals are considered “devices,” not “assistance” “Assistance of another person" includes those patients, actively

participating in performing a task, needing assistance of one or more person(s) to safely complete included tasks.

375

ThingstoRemember

What is the difference between “willingness” and “adherence” (which do not impact OASIS scoring) and “cognitive/mental/emotional/behavioral impairment” (which may impact OASIS scoring)?

In absence of pathology, patients may make decisions about how and when they perform their activities of daily living that may differ from what the clinician determines to be acceptable. A patient may choose to shave and brush his teeth infrequently because he doesn’t value doing it at a frequency that the clinician deems as socially appropriate. There are differences in the frequency at which grooming or bathing is performed, or expected to be performed based on age, religion, culture and familial practices, and this is not necessarily indicative of pathology.

376

ThingstoRemember

A patient may demonstrate that they can safely ambulate while using a walker, but then as a matter of choice, decide to walk without it. Another patient may demonstrate that they can safely ambulate while using a walker, but then consistently walk without it, forgetting that they have a walker. For the purposes of OASIS scoring, non-conformity or non-adherence should not automatically be considered indicative of a deeper psychological impairment. The assessing clinician will have to use clinical judgment to determine if the patient’s actions are more likely related to impairment, or to personal choice made in awareness of the potential related risk.

377

BedfastDefined

"Bedfast refers to being confined to the bed, either per physician restriction or due to a patient's inability to tolerate being out of the bed." If the patient can tolerate being out of bed, they are not bedfast unless they are medically restricted to the bed. The patient is not required to be out of bed for any specific length of time.

The assessing clinician will have to use her/his judgment when determining whether or not a patient can tolerate being out of bed. For example, a severely deconditioned patient may only be able to sit in the chair for a few minutes and is not considered bedfast as she/he is able to tolerate being out of bed. A patient with Multiple System Atrophy becomes severely hypotensive within a minute of moving from the supine to sitting position and is considered bedfast due to the neurological condition which prevents him from tolerating the sitting position.

378

AccessisExcluded

Patient’s ability to access needed items and/or location where the task occurs is INCLUDED, unless specifically excluded in guidance

M1845 Toileting hygiene—excludes getting to the location where the toileting occurs

M1870 Feeding/Eating—Excludes getting to location where meal is consumed and excludes transporting food to the table

M1880 Planning and Preparing Light meals—excludes getting to location where meal prepared

M1890 Telephone use—Excludes getting to the location where the telephone is stored

379

M1800Grooming380

Excluding bathing, shampooing hair, and toileting hygiene. Timepoints: SOC ROC DC

M1800Grooming

Patient's ability to safely perform grooming, given the current physical and mental/emotional/cognitive status, activities permitted, and environment.

Select the response that best describes the patient’s level of ability to perform the majority of grooming tasks.

Patients able to do more frequently performed activities (for example, washing hands and face) but unable to do less frequently performed activities (trimming fingernails) should be considered to have more ability in grooming.

381

M1810DressUpperBody382

Timepoints: SOC ROC FU DC

M1820DressLowerBody383

Timepoints: SOC ROC FU DC

M1810/M1820Dressing

Ability to obtain, put on, and remove upper body and lower body clothing.

Assess ability to put on whatever clothing is routinely worn. Specifically includes the ability to manage zippers, buttons, and

snaps if these are routinely worn. Prosthetic, orthotic, or other support devices applied to the upper

body (for example, upper extremity prosthesis, cervical collar, or arm sling) and/or lower body (for example, lower extremity prosthesis, ankle-foot orthosis [AFO], or TED hose) should be considered as dressing items. Note that elastic bandages, including ACE Wrap brand, worn for

support and compression should be considered as a lower body dressing item, but wraps utilized solely to secure a wound dressing would not be considered a dressing (clothing) item for M1810 or M1820.

Answer based on majority of tasks (items). Do NOT consider the importance of one item over another. 4b132.2.

384

M1810/M1820Dressing

If a patient modifies the clothing they wear due to a physical impairment, the modified clothing selection will be considered routine if there is no reasonable expectation that the patient could return to their previous style of dressing. There is no specified timeframe at which the modified clothing style will become the routine clothing.

The clinician will need to determine which clothes should be considered routine. It will be considered routine because the clothing is what the patient usually wears and will continue to wear, or because the patient is making a change in clothing options to styles that are expected to become the patient's new routine clothing.

Patient must dress in stages due to shortness of breath – Still can be independent

385

M1810/M1820Dressing

Assessment strategies: A combined observation/interview approach with the patient or caregiver is helpful in determining the most accurate response for this item.

Ask the patient if he/she has difficulty dressing upper body. Observe the patient’s general appearance and clothing and

ask questions to determine if the patient has been able to dress independently and safely.

Opening and removing garments during the physical assessment of the heart and lung provides an excellent opportunity to evaluate the upper extremity range of motion, coordination, and manual dexterity needed for dressing.

Observe spinal flexion, joint range of motion, shoulder and upper arm strength, and manual dexterity during the assessment. The patient also can be asked to demonstrate the body motions involved in dressing.

386

M1810/M1820Dressing

How do you answer if a disabled person has everything in their home adapted for them; for instance, closet shelves & hanger racks have been lowered to be accessed from a wheelchair. Is the patient independent with dressing? Response 0

I have a patient who could not obtain his clothes, but could dress without assistance if clothes were laid out (Response 1). If the environment was adapted (a new “usual” storage place for clothing was selected) so that the patient could obtain, put on and remove the clothing without any assistance, would the patient then be considered independent in dressing? Answer based on what is true the day of

assessment.

387

EnvironmentModification

If the environment is modified (e.g., the patient decides to start storing clothing in the dresser instead of hanging in the closet), and the patient can now access clothes from a location without anyone’s help, then this new arrangement could now represent the patient's current status (e.g., clothing’s new “usual” storage area and patient's ability). The appropriate score would be a “0” if the patient was also able to put on and remove a majority of his clothing items safely. Temporary storage because of weakness—1

(Patient could then work to gain independence in accessing clothing from its usual storage location, or decide to make long-term environmental modifications, and possibly achieve improvement in the outcome if successful.)

Permanent storage—0

388

M1830Bathing389

#5 now includes

intermittent assistance

M1830Bathing

Timepoints: SOC ROC F/U DC Specifically excludes washing face and hands,

and shampooing hair. M1830, Bathing - The focus is on the patient's

ability to access the tub/shower, transfer in and out, and bathe the entire body once the needed items are within reach. The ability to access bathing supplies and prepare the water in the tub/shower are excluded from consideration when assessing the patient's bathing ability.

390

M1830Bathing

If the patient requires standby assistance to bathe safely in the tub or shower or requires verbal cueing/reminders, then select Response 2 or Response 3, depending on whether the assistance needed is intermittent (“2”) or continuous (“3”).

If the patient's ability to transfer into/out of the tub or shower is the only bathing task requiring human assistance, select Response 2. If a patient requires one, two, or all three of the types of assistance listed in Response 2 of M1830 but not the continuous presence of another person as noted in Response 3, then Response 2 is the best response.

391

M1830Bathing

The patient’s status should not be based on an assumption of a patient’s ability to perform a task with equipment they do not currently have.

If the patient does not have a tub or shower in the home, or if the tub/shower is nonfunctioning or not safe for patient use, the patient should be considered unable to bathe in the tub or shower. Responses 4, 5, or 6 would apply, depending on the patient's ability to participate in bathing activities.

392

M1830Bathing

Assessment strategies: A combined observation/interview approach with the patient or caregiver is helpful in determining the most accurate response for this item. Ask the patient what type of assistance is needed to wash entire body in tub or shower. Observe the patient’s general appearance in determining if the patient has been able to bathe self independently and safely. Observe patient actually stepping into shower or tub to determine how much assistance the patient needs to perform the activity safely. The patient who only performs a sponge bath may be able to bathe in the tub or shower with assistance and/or a device. Evaluate the amount of assistance needed for the patient to be able to safely bathe in tub or shower.

393

M1830Bathing

Given the following situations, what would be the appropriate responses to M1830? a) The patient's tub or shower is nonfunctioning or is not safe for use. b) The patient is on physician-ordered bed rest. c) The patient fell getting out of the shower on two previous occasions and is now afraid and unwilling to try again. If due to fear, she refuses to enter the shower even with the

assistance of another person; either Response 4, 5, or 6 would apply, depending on the patient’s ability at the time of assessment. If she is able to bathe in the shower when another person is present to provide required supervision/assistance, then Response 3 would describe her ability.

d) The patient chooses not to navigate the stairs to the tub/shower. If the patient chooses not to navigate the stairs, but is able to do so

with supervision, then her ability to bathe in the tub or shower is dependent on that supervision to allow her to get to the tub or shower. 4bQ134

394

M1830Bathing

My patient is allowed to bathe in the tub, but is medically restricted from getting the cast on his lower leg and foot wet. He is unable to put the water protection sleeve on, but once someone applies the protective sleeve for him, he can get into and out of the bathtub using a transfer bench and wash all of his body with a handheld shower. Does this medical restriction impact the patient's ability when scoring M1830, Bathing?

In the scenario above, Response 2 is appropriate since the patient needs intermittent human assistance. 4bQ134.1

395

M1840ToiletTransferring396

Timepoints:

M1840ToiletTransferring

Observe the patient during transfer and ambulation to determine if the patient has difficulty with balance, strength, dexterity, pain, etc. Determine the level of assistance needed by the patient to safely get on and off the toilet or commode. Tasks related to personal hygiene and management of clothing are not considered when responding to this item.

397

M1840ToiletTransferring

If the patient can get to and from the toilet during the day independently, but uses the commode at night for convenience, select Response 0.

If the patient requires standby assistance to get to and from the toilet safely or requires verbal cueing/reminders, select Response 1.

If the patient needs assistance getting to/from the toilet or with toileting transfer or both, then Response 1 is the best option.

If the patient can independently get to the toilet, but requires assistance to get on and off the toilet, select Response 1.

Response 1 requires patient participation (effectively participate by contributing effort toward the completion of some of the included tasks)

A patient who is unable to get to/from the toilet or bedside commode, but is able to place and remove a bedpan/urinal independently, should be marked Response 3. This is the best response whether or not a patient requires assistance to empty the bedpan/urinal. If the bedfast patient needs assistance to get on/off the bedpan, the

appropriate M1840 Response is "4-Is totally dependent in toileting" even if they can place and remove the urinal.

398

M1845ToiletingHygiene399

Timepoints: SOC ROC DC

M1845ToiletingHygiene

Toileting hygiene includes several activities, including pulling clothes up or down and adequately cleaning (wiping) the perineal area.

The focus is on the patient's ability to access needed supplies and implements, and manage hygiene and clothing once at the location where toileting occurs. The ability to access the toilet or bedside commode, transfer on and off the bedpan and to use the urinal are excluded from consideration when assessing the patient's toileting hygiene ability.

Toileting hygiene includes the patient’s ability to maintain hygiene related to catheter care and the ability to cleanse around all stomas that are used for urinary or bowel elimination (for example, urostomies, colostomies, ileostomies).

The word “assistance” in this question refers to assistance from another person by verbal cueing/reminders, supervision, and/or stand-by or hands-on assistance.

400

M1845ToiletingHygiene

Response 0 if the patient is independent in managing toileting hygiene and managing clothing.

Response 1 if the patient is able to manage toileting hygiene and manage clothing IF supplies are laid out for the patient.

If the patient can participate in hygiene and/or clothing management but needs some assistance with either or both activities, select Response 2. Includes standby assistance or verbal cueing.

401

M1850Transferring402


M1850Transferring

Identifies the patient’s ability to safely transfer from bed (current sleeping surface) to chair (and chair to bed), or position self in bed if bedfast.

For most patients, the transfer between bed and chair will include transferring from a supine position in bed to a sitting position at the bedside, then some type of standing, stand-pivot, or sliding board transfer to a chair, and back into bed from the chair or sitting surface. If there is no chair in the patient’s bedroom or the patient does

not routinely transfer from the bed directly into a chair in the bedroom, report the patient’s ability to move from a supine position in bed to a sitting position at the side of the bed, and then the ability to stand and then sit on whatever surface is applicable to the patient’s environment and need, (for example, a chair in another room, a bedside commode, the toilet, a bench, etc.). Include the ability to return back into bed from the sitting surface.

The need for assistance with gait may impact the Transferring score if the closest sitting surface applicable to the patient's environment is not next to the bed.

403

M1850Transferring

If your patient no longer sleeps in a bed (e.g. sleeps in a recliner or on a couch), you will assess the patient's ability to move from the supine position on their current sleeping surface to a sitting position and then transfer to another sitting surface, like a bedside commode, bench, or chair.

Taking extra time and pushing up with both arms can help ensure the patient's stability and safety during the transfer process but does not mean that the patient is dependent. If standby human assistance were necessary to assure safety, then a different response level would apply.

If they push up on tables, etc—is the table an assistive device?

404

M1850Transferring

If the patient transfers either with minimal human assistance (but not device), or with the use of a device (but no human assistance), select Response 1.

If the patient is able to transfer self from bed to chair, but requires standby assistance to transfer safely, or requires verbal cueing/reminders, select Response 1.

For Response 1, “minimal human assistance” could include any combination of verbal cueing, environmental set-up, and/or actual hands-on assistance.

405

M1850Transferring

Response 1 – Minimal human assistance could include any combination of verbal cueing, environmental set-up, and/or actual hands-on assistance, where the level of assistance required from someone else is equal to or less than 25% of the total effort to transfer and the patient is able to provide >75% of the total effort to complete the task. Examples of environmental set-up as it relates to transferring would be a patient who requires someone else to position the wheelchair by the bed and apply the wheelchair locks in order to safely transfer from the bed to the chair, or a patient who requires someone else to place the elevated commode seat over the toilet before the patient is able to safely transfer onto the commode.

406

M1850Transferring

If the patient requires more than minimal assistance or requires both minimal human assistance and an assistive device to be safe, the appropriate score would be a “2”.

If the patient can bear weight and pivot, but requires more than minimal human assist, Response 2 should be marked. Able to bear weight refers to the patient's ability to

support the majority of his/her body weight through any combination of weight-bearing extremities (for example, a patient with a weight-bearing restriction of one lower extremity may be able to support his/her entire weight through the other lower extremity and upper extremities).

407

M1850Transferring

The patient must be able to both bear weight and pivot for Response 2 to apply. If the patient is unable to do one or the other and is not bedfast, select Response 3.

If the patient is bedfast, select Response 4 or 5, depending on the patient’s ability to turn and position self in bed.

Bedfast refers to being confined to the bed, either per physician restriction or due to a patient’s inability to tolerate being out of the bed.

408

M1850Transferring

A patient who can tolerate being out of bed is not “bedfast.” If a patient is able to be transferred to a chair using a Hoyer lift, Response 3 is the option that most closely resembles the patient’s circumstance; the patient is unable to transfer and is unable to bear weight or pivot when transferred by another person. Because he is transferred to a chair, he would not be considered bedfast (“confined to the bed”) even though he cannot help with the transfer.

Responses 4 and 5 do not apply for the patient who is not bedfast. The frequency of the transfers does not change the response, only the patient’s ability to be transferred and tolerate being out of bed.

409

M1860Ambulation/Locomotion410

All kinds

of canes

M1860Ambulation/Locomotion

Timepoints: SOC ROC F/U DC Identifies the patient’s ability and the type of assistance

required to safely ambulate or propel self in a wheelchair over a variety of surfaces. Variety of surfaces refers to typical surfaces that the

patient would routinely encounter in his/her environment, and may vary based on the individual residence.

Regardless of the need for an assistive device, if the patient requires human assistance (hands on, supervision and/or verbal cueing) to safely ambulate, select Response 2 or Response 3, depending on whether the assistance required is intermittent (“2”) or continuous (“3”).

411


If the patient is safely able to ambulate without a device on a level surface, but requires minimal assistance on stairs, steps, and uneven surfaces, select Response 2 (requires human supervision or assistance to negotiate stairs or steps or uneven surfaces).

If a patient does not require human assistance, but safely ambulates with a walker in some areas of the home, and a cane in other areas (due to space limitations, distances, etc.), select the response that reflects the device that best supports safe ambulation on all surfaces the patient routinely encounters (for example, Response 2 is appropriate if a walker is required for safe ambulation in the hallway and living room, even if there are some situations in the home where a cane provides adequate support.)

412


If a patient does not have a walking device but is clearly not safe walking alone, select Response 3, able to walk only with the supervision or assistance should be reported, unless the patient is chairfast.

Responses 4 and 5 refer to a patient who is unable to ambulate, even with the use of assistive devices and/or continuous assistance. A patient who demonstrates or reports ability to

take one or two steps to complete a transfer, but is otherwise unable to ambulate should be considered chairfast, and would be scored 4 or 5, based on ability to wheel self.

Powered or manual version.

413


Note if the patient uses furniture or walls for support, or demonstrates loss of balance or other actions that suggest a need for additional support for safe ambulation.

Observe patient’s ability and safety on stairs. If a patient uses a wheelchair for 75% of their mobility

and walks for 25% of their mobility, then should they be scored based on their wheelchair status because that is their mode of mobility >50% of the time? Or should they be scored based on their ambulatory status, because they do not fit the definition of “chairfast?”

Item M1860 addresses the patient's ability to ambulate, so that is where the clinician's focus must be. Endurance is not included in this item. The clinician must determine the level of assistance is needed for the patient to ambulate and choose Response 0, 1, 2, or 3, whichever is the most appropriate.

414


My patient does not have a walking device but is clearly not safe walking alone. I evaluate him with a trial walker that I have brought with me to the assessment visit and while he still requires assistance and cueing, I believe he could eventually be safe using it with little to no human assistance. Currently his balance is so poor that ideally someone should be with him whenever he walks, even though he usually is just up stumbling around on his own. What score should I select for M1860?

It sounds as though your assessment findings cause you to believe the patient should have someone with them at all times when walking (Response “3”). When scoring M1860, clinicians should be careful not to assume that a patient, who is unsafe walking without a device, will suddenly (or ever) become able to safely walk with a device. Observation is the preferred method of data collection for the functional OASIS items, and the most accurate assessment will include observation of the patient using the device. Often safe use will require not only obtaining the device, but also appropriate selection of specific features, fitting of the device to the patient/environment and patient instruction in its use.

415


A patient is able to ambulate independently with a walker, but the patient chooses to not use the walker, therefore not being safe. Response #2, or Response #3?

The OASIS items should report the patient’s physical and cognitive ability, not their actual performance, adherence or willingness to perform an activity. You state the patient is able to ambulate independently with a walker, so we will assume you meant that the patient is able to ambulate without human assistance safely with the walker. This would be scored a “2” for M1860 Ambulation/Locomotion. You state the patient’s actual performance is that he is unsafe ambulating because he chooses not to use his walker. This patient would still be scored a “2” unless, as you pointed out, the clinician identified some other physical, cognitive or environmental barrier that prevents the patient from utilizing his walker to assist with ambulation, e.g. fear, memory impairment, undisclosed pain associated with walker use, or other emotional, behavioral or physical impairments. If there was a barrier preventing the patient from safely utilizing the walker during ambulation, the clinician would need to determine if the patient needed someone to assist at all times in order to ambulate safely and if so, the appropriate score for M1860 would be a “3”. If the patient only needed assistance intermittently, the correct response would be a “2”. 4bQ155.3.

416


Not safe even with assistance. “5-Chairfast, unable to ambulate and is unable to

wheel self”. Ambulates safely with a straight cane, but

requires a stair lift to get up and down stairs in her home?

If the patient requires no human assistance while ambulating and negotiating the stairs, but requires a stair lift to traverse the stairs safely, she would be scored a "2" for M1860 if she needs two hands to use the stair lift and a "1" if she only needs one hand to safely use the stair lift.

417


Our patient requires maximum assistance to ambulate (over 75% of the effort necessary for ambulation is contributed by someone other than the patient) and only ambulates with the therapist during gait training activities. The patient is extremely unsafe when attempting to ambulate without the therapist’s assistance.

Still ambulatory—Response 3 unless able to take only a few steps

Minimal assistance (like in transferring) vs maximum assistance doesn’t apply with ambulation

418

July2015Q&A#9

Q9: If a patient is safely using a knee scooter to facilitate non-weight bearing on one lower extremity, what response would be selected for M1860 -Ambulation?

A9: To determine the accurate response for M1860, the assessing clinician must determine if the knee scooter will be considered an assistive device for the purpose of ambulation. If the assessing clinician determines the knee scooter is an assistive device, then the clinician must determine if the patient is safe without the assistance of another person and assess the number of hands (one-hand or two-hands) the patient requires to safely use the device.

419

M1870FeedingorEating420

Timepoints: SOC ROC DC

M1870FeedingorEating

Excludes preparation of food items, and transport to the table.

Based on the assistance needed by the patient to feed himself once the food is placed in front of him.

Assistance means human assistance by verbal cueing/reminders, supervision, and/or stand-by or hands-on assistance.

Meal "set-up" (Response 1) includes activities such as mashing a potato, cutting up meat/vegetables when served, pouring milk on cereal, opening a milk carton, adding sugar to coffee or tea, arranging the food on the plate for ease of access, etc. -- all of which are special adaptations of the meal for the patient.

421


Response 2 if the patient is either unable to feed themselves and/or must be assisted or supervised while eating. (History of aspiration pneumonia and pockets food)

422


If a tube is being used to provide all or some nutrition, select Responses 3 or 4, depending on the patient’s ability to take in nutrients orally. If a patient is being weaned from tube feeding, Responses 3 or 4 will continue to apply until the patient no longer uses the tube for nutrition, at which time, select Responses 0, 1, or 2. This is true, even if the tube remains in place, unused for a period of time.

Responses 4 and 5 include non-oral intake. Response 5 is the best response for patients who are

not able to take in nutrients orally or by tube feeding. This may be the case for patients who receive all nutrition intravenously (such as TPN) or for patients who are receiving only intravenous hydration.

423

M1880CurrentAbilitytoPlanandPrepareLightMeals

424

Timepoints: SOC ROC DCAbility to plan and prepare meals once the patient is in the meal preparation location.


Identifies the patient’s physical, cognitive, and mental ability to plan and prepare meals, even if the patient does not routinely perform this task.

In cases where a patient’s ability is different for various light meal preparation tasks, pick the response that best describes the patient’s level of ability to perform the majority of light meal preparation tasks.

Day of assessment applies Response 0 (Able) indicates the patient has the consistent physical

and cognitive ability to plan and prepare meals. Response 1 (Unable on a regular basis) indicates the patient has

inconsistent ability to prepare light meals (for example, can’t prepare breakfast due to morning arthritic stiffness, but can prepare other meals throughout day). Also if the patient has a newly prescribed diet

Response 2 indicates patient does not have the ability to prepare light meals at any point during the day of assessment.

425


While nutritional appropriateness of the patient’s food selections is not the focus of this item, any prescribed diet requirements (and related planning/preparation) should be considered when selecting a response. When a patient’s prescribed diet consists either

partially or completely of enteral nutrition, the clinician must assess the patient’s ability to plan and prepare their prescribed diet, including their knowledge of the feeding amount and ability to prepare the enteral feeding, based on product used. (Not including management of equipment)

426


Mrs. DM is able to heat a frozen dinner in the microwave or make a sandwich but now has been placed on a diabetic diet. She is NOT able to plan and prepare a simple meal within the currently prescribed diet (until teaching has been accomplished for THAT diet, or until physical or cognitive deficits have been resolved), would Mrs DM be considered able or unable to plan and prepare light meals?

Response 1- until adequate teaching/learning has occurred for the special diet, or until related physical or cognitive barriers are addressed. If the patient with any prescribed diet requirements is unable to plan and prepare a meal that complies with their prescribed diet AND also is unable to plan and prepare “generic” light meals (e.g. heating a frozen dinner in the microwave or making a sandwich), Response 2 should be selected. This is a critical assessment strategy when considering the important relationship between this IADL and nutritional status. A poorly nourished patient with limited ability to prepare meals is at greater risk for further physical decline.

427

M1900PriorFunctioningADL/IADL

Timepoints: SOC ROC

Specifically tub, shower, commode, and bed to chair transfers

428

M1900PriorFunctioningADL/IADL

“Independent” means that the patient had the ability to complete the activity by him/herself (with or without assistive devices) without physical or verbal assistance from a helper.

“Needed some help” means that the patient contributed effort but required help from another person to accomplish the task/activity safely.

“Dependent” means that the patient was physically and/or cognitively unable to contribute effort toward completion of the task, and the helper must contribute all the effort.

Wheelchair (with or without assistance) would be reported as “Dependent” in Ambulation

If the patient was previously independent in some self-care tasks (or some transfers, or some household tasks), but needed help or was completely dependent in others, pick the response that best describes the patient’s level of ability to perform the majority of included tasks.

429

M1910FallsRiskAssessment

Timepoints: SOC ROCBest Practice itemMAHC-10 Fall Risk Assessment tool

430


For Responses 1 and 2, an agency may use a single comprehensive multi-factor falls risk assessment tool that meets the criteria as described in the item intent. Alternatively, an agency may incorporate several tools as long as one of them meets the criteria as described in the item intent.

Use the scoring parameters specified in the tool to identify if a patient is at risk for falls.

Response 1 if the standardized, validated response scale rates the patient as no-risk, low-risk, or minimal risk.

Response 2 if the standardized, validated response scale rates the patient as anything above low/minimal-risk. If the tool does not provide various levels, but simply has a single threshold separating those “at risk” from those “not at risk,” then the patient scoring “at risk” should be scored as Response 2.

431


In order to select Response 1 or 2, the falls risk assessment must be conducted by the clinician responsible for completing the comprehensive assessment during the time frame specified by CMS for completion of the assessment.

Select Response 0 if: a standardized, validated multi-factor falls risk screening

was NOT conducted by the home health agency, a standardized, validated multi-factor falls risk screening

was conducted by the home health agency but NOT during the required assessment time frame,

a standardized, validated multi-factor falls risk screening was conducted during the assessment time frame, but NOT by the assessing clinician.

the patient is not able to participate in tasks required to allow the completion and scoring of the standardized, validated assessment(s) that the agency chooses to utilize.

432


Missouri Alliance for Home Care’s Fall Risk Assessment Tool (MAHC-10) is a tool meeting criteria as a single standardized, validated, multifactor tool to meet the “Yes” response for M1910.

If the MAHC 10 (multifactor tool) and the TUG (single factor tool) are used, base decision on the results of the MAHC 10. 4bQ159.5.2.

If a single factor, validated assessment tool is used with another factor or non-validated tool, base decision on validated assessment tool.

433


Must use a tool appropriate for the patient. If the patient is not able to participate in tasks required to

allow the completion and scoring of the assessment(s) that the agency chooses to utilize, “0 – No multi-factor fall risk assessment conducted” should be reported.

A single tool may not meet the fall risk assessment needs of all patients in the agency.

The risk factor finding is based on the scoring protocols of the assessment utilized, and depending on the assessment tool used, this may or may not require them to complete all the tasks. It is up to the individual provider/agency to determine which tool(s) will be used, and what the valid administration and scoring protocols are for each tool considered.

434

MedicationsM2000s435

Contactwithphysician‐ TermsDefined:

Contact with physician is defined as communication by:TelephoneVoicemailElectronic meansFax Or any other means that conveys the

message of patient status

436

M2000DrugRegimenReview437

M2000DrugRegimenReview

Timepoints SOC ROC Include all medications / all routesPrescribed OTC

Process MeasuresCaptures agency’s use of best practicesThis one is required in CoPs

438


Portions of the drug regimen review may be completed by agency staff other than the assessing clinician e.g., identification of potential drug-drug interactions or potential dosage errors Review findings must be communicated to the

assessing clinician so that the appropriate response for M2000 may be selected

439

ExamplesofCollaboration

The "collaborating clinician" might contact the patient by phone, to discuss issues with the patient regarding side effects they may be experiencing, or effectiveness of the medication. In any case, it is the assessing clinician who is ultimately responsible for ensuring a complete DRR was performed and for reporting the appropriate responses for medication related OASIS items.

Note that collaboration options do NOT allow a second clinician to contribute to the drug regimen review by utilizing information gathered from a second clinician's in-home assessment. 4bQ160.3.3.

440


Each Agency will need to create a workable process to ensure compliance

The M0090 date (date assessment is completed) would be the date the two clinicians collaborated and the assessment was completed.

A complete drug regimen review must be completed to answer ‘1’ or ‘2’ If not complete, must answer “Not assessed/reviewed.”

It should be noted that in situations where nursing is admitting for a therapy only patient, the nurse could not complete or even start the comprehensive assessment (including drug review tasks) prior to the SOC date. 4bQ160.3.3.

441

M2000

In therapy only cases, can an LPN in the office work cooperatively with the therapist to complete the Drug Regimen Review by performing elements of the drug regimen review that the therapist will not be completing?

4b-Q160.3.1

442

M2000

No. Only registered nurses, physical therapists, speech language pathologists and occupational therapists are qualified to perform comprehensive assessments. LPNs are not qualified to perform comprehensive assessments, so they may not work cooperatively with therapists in order to complete the drug regimen review.

443

Whataboutapharmacist?

Current guidance states that only clinicians qualified to perform comprehensive assessments may collaborate on the Drug Regimen Review. On therapy only cases, can the therapist collaborate with a pharmacist when completing the Drug Regimen Review? 4b-Q160.3.2

Yes!! Define agency policy and documentation requirements!

444


Response 1 No problems foundMedication list from inpatient facility matches the

medications patient shows the clinician at the SOC/ROC assessment

Assessment shows that diagnoses/symptoms are adequately controlled by meds as prescribed

Patient possesses all medications prescribedPatient has a plan for taking meds safely at the

right timePatient is not showing signs/symptoms that could

be adverse reactions caused by medications.

445


Response 2 Problems found Med list from the inpt facility does not match the

medications the patient shows the clinicianDiagnoses/ symptoms for which patient is taking

meds are NOT adequately controlledPt seems confused about when/how to take meds

indicating a high risk for med errors.Pt has not obtained meds or indicates that he/she

will probably not take prescribed meds due to financial, cultural, or other issues with medications.

446


Response 2 Problems found (con’t) Patient has signs/symptoms that could be adverse

reactions from medications. Patient takes multiple non-prescribed medications

(OTCs, herbals) that could interact with prescribed meds Use the timeframe to try to resolve the problems

found. If a med related problem is identified and resolved

by the agency staff by the time the assessment is completed, the problem does not need to be reported as an existing clinically significant problem. 4b-Q160.4

447


"If a medication related problem is identified and resolved by the agency staff without physician involvement by the time the assessment is completed, the problem does not need to be reported as an existing clinically significant problem.”

You are not required to report a clinically significant medication issue that was resolved (with or without physician involvement) before the assessment was completed. An example would be family delivering medications that were not in the home at the time of the initial visit. Note that by not reporting it, your agency would miss the positive impact to your process measure adherence rate. 3rdQ 2014

448

Consider the potential for an increased risk due to impairment or decline in an individual’s mental or physical

condition or functional or psychosocial status Complex medication plan Multiple physicians Multiple pharmacies

In M2000 - Drug Regimen Review, are ALL drug interactions considered "potential clinically significant medication issues"? 4b-Q160.2

No, the OASIS-C Guidance Manual states that potential clinically significant medication issues include serious drug-drug, drug-food and drug-disease interactions.

449

Notallpotentialmedsideeffectsareconsideredclinicallysignificantmedissues

Problems found during review, should be selected if the “Patient has signs/symptoms that could be adverse reactions from medications.” It further defines a side effect as "an expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence."

A side effect would be considered "a potential clinically significant medication issue" if it "poses an actual or potential threat to patient health and safety".

4b-Q160.3

450

Notallpotentialmedsideeffectsareconsideredclinicallysignificantmedissues

The determination of whether a medication issue meets this threshold to be considered "a potential clinically significant medication issue" should be based on the clinician's judgment in conjunction with agency guidelines and established standards for evaluating drug reactions, side effects, interactions, etc. Online resources or these standards can be found in Chapter 5 of the OASIS-C Guidance Manual.

4b-Q160.2, 160.3

451

M2002MedicationFollow‐up452

M2002MedicationFollow‐up

Timepoints SOC ROC Medication ‘issues’ communicated with

physician (or designee) within one calendar day

Someone else may communicate with the physician but who has to answer the data item?

What about the on-call physician who says to call back Monday? 4b-Q160.5

Agency policy must define this process Process Measure

453

M2002MedicationFollow‐up

Response “1” Physician responds to the agency communication

with acknowledgment of receipt of information and/or further advice or instructions

If the physician or physician designee responds within one calendar day and there is a resolution to the clinically significant medication issue or a plan to resolve the issue

Two way communication AND reconciliation or plan by the end of the next calendar day. 4b-Q160.6

Response “0” Interventions are not completed as outlined in this

item and Clinician should document rationale in the clinical record

454

Example

• A clinically significant medication issue is identified on day 5 after the SOC and the physician is notified. The physician doesn’t respond until the 6th day after SOC, what is the answer? 4b-Q160.5.1

X

455

M2002;M2004

Multiple clinically significant medications issues were identified as I completed the SOC assessment. Only one was resolved within one calendar day. How do I answer M2002 and then 2004?

4b-Q160.6.2

In order to select ‘yes’ on M2002/M2004, ALL clinically significant issues must have been resolved (or plan to resolve) within one calendar day.

456

M2004MedicationIntervention457

M2004MedicationIntervention

Timepoints Transfer Discharge Identifies if potential clinically significant problems

such as adverse effects or drug reactions identified at the time of the most recent OASIS assessment orafter that time were addressed with the physician

Process measure

458


Response 1 – YesPhysician responds to the agency

communication with acknowledgment of receipt of information and/or further advice or instructions within the specified timeframe.

Response 0 – No Interventions are not completed as outlined in

this item and the clinician should document rationale in the clinical record.

Collaboration between clinicians does not violate the ‘1 clinician’ rule

459


If the last OASIS assessment completed was the SOC or ROC, and a clinically significant problem was identified at that SOC or ROC visit, the problem (and/or related physician communication) would be reported at both the SOC/ROC (on M2002), and again at Transfer or Discharge (on M2004), since the time frame under consideration for M2004 is AT or SINCE the previous OASIS assessment

460

M2010Patient/CaregiverHigh‐RiskDrugEducation

461

HighRiskDrugsDefined

High-risk medications are those identified by quality organizations as having considerable potential for causing significant patient harm when they are used erroneously. Institute for Safe Medication Practices (High Alert

Med List) JCAHO, etc.

Examples of high risk meds that could have a severe negative impact on patient safety and health Hypoglycemics Anticoagulants

462

M2010Patient/CaregiverHighRiskDrugEducation

Timepoints SOC ROC Educate on high risk meds first

Unrealistic to expect that pt education on all meds can occur on admission

Remember the timeframe Others can provide the education, but who has to

mark the data item? 4b-Q161.4

Does not require a list of high risk meds educated on; there would be documentation in the record 3rdQ 2014

463

M2010HighRiskDrugEducation

Response “0” Interventions were not completed as outlined in this

item. Clinician should document rationale in the clinical

record, unless the patient takes no high risk drugs (see Response NA)

Response “1” High risk meds are prescribed and education was

provided ALF—staff are considered caregivers; may or may

not be appropriate to educate those administering medications 4b-Q161.3

Education can be over the phone 4b-Q161.4

464

PatientTakingHighRiskDruginError

…And that is the only high risk drug taken If the patient was taking a high risk medication

in error, and was educated by your staff to discontinue the medication as well as the special precautions they need to take and how and when to report a problem that occurs as a result of taking that medication, M2010 may be answered "Yes".

465

M2015Patient/CaregiverDrugEducationIntervention

466

M2015DrugEducationIntervention

Timepoints Transfer Discharge Identifies if clinicians instructed the pt/cg (ALF—

staff are considered caregivers) 4b-Q162.3, 162.4

Education can occur over the phone 4b-Q161.4

How to manage meds effectively and safely through knowledge of:Medication effectivenessPotential side effects Drug reactions When to contact the appropriate care provider

467


No-- Interventions are not completed as outlined in this

item Care provider should document rationale in the

clinical record Yes--Includes education by any agency staff

Has to be all 4 components If assessment of the patient/caregiver's baseline knowledge reveals

the patient received the education from the pharmacist, you can include this education in M2015. This would require that the pharmacist educated the patient/caregiver to monitor the effectiveness of all drug therapy (prescribed, as well as all OTC), drug reactions, and side effects, and how and when to report problems that may occur to the appropriate care provider. Note that just including written materials in the bag with the medications at the time the medication is dispensed may not provide the specified education. The education of the patient may also be a collaborative effort, in which the pharmacist may provide part of the education, with other healthcare providers. 4b-Q162.

468


Mr. Walt’s ROC was completed November 8th. The SN documented education on all (high risk and non high risk meds) of the patient’s meds was completed at that time. The SN’s documentation included how and when to report problems that may occur.

Mr. Walt is transferred to the hospital on November 10th. How will you complete M2015? 4b-Q162.2

469

M2015 - Patient/Caregiver Drug Education Intervention, reports if, at the time of or since the previous OASIS assessment, the patient and/or caregivers were educated regarding ALL their medications (not just the high risk medications), including how and when to report problems that may occur. If this specified education was accomplished for all medications at the time of the previous OASIS assessment, the appropriate response for M2015 would be “Yes”.

470

M2015

When answering M2015 - Patient/Caregiver Drug Education Intervention, if you provide education intervention on all medications during the first episode, but no education in the second episode because the patient had no new medications and there was no need to re-teach on all medications, do you have to answer “No” for M2015 at Transfer/Discharge?

471

The Condition of Participation 484.55 requires a Drug Regimen Review (DRR) at every comprehensive assessment time point. When performing the DRR, at the Recertification, if the assessing clinician evaluated the patient's retention of prior teaching and determined and documented that the patient possessed all the required knowledge related to all medications, then M2015 would be answered "Yes" at Transfer/Discharge. If the assessing clinician had not re-assessed the patient's medication knowledge and found the patient to be fully knowledgeable or not provided drug education related to all medications at the time of or since the previous OASIS assessment, the M2015 response would be "No" at Transfer/Discharge

472

M2020ManagementofOralMedications

473


If patient’s ability to manage oral meds varies from medication to medication, consider the medication for which the most assistance is needed when selecting a response.

If the medication is ordered prn, and on the day of assessment the patient needed a reminder for this prn, then the patient would be a "2". If on the day of assessment, the patient did not need any prnmedications, therefore no reminders, then assess the patient's ability on all of the medications taken on the day of assessment. Ch 3

474


Assess patient’s ability to take medications reliably and safely at all times

Identifies patient’s ability, not willingness or compliance or actual performance

Patient must be viewed from holistic perspectiveMental Emotional Cognitive status Activities permitted Environment

475


Ability can be temporarily or permanently limited by:Physical impairments (e.g. limited manual

dexterity)Emotional/cognitive/behavioral impairments

(e.g., memory deficits, impaired judgment, fear)

Sensory impairments, (e.g., impaired vision, pain)

Environmental barriers (e.g. access to kitchen or medication storage area, stairs, narrow doorways)

476


Timepoints SOC/ROC/DC Includes all prescribed and OTC oral meds

included on the POC Excludes topical, injectable and IV meds Excludes inhalation meds and sublingual meds

(Oct 2012)

Excludes swish and expectorate meds (Jan 2013)

Meds given per gastrostomy or other tube are not po 4b-Q167.8

Does not include filling/reordering 4b-Q166

Swallow and absorbed through GI system!!

477


Response 0 Patient sets up her/his own ‘planner device’ and is able to take the correct med in the correct dosage at the correct time

Response 1 Patient is independent in oral med

administration, but requiresanother person to prepare individual doses

(e.g., sets up a planner device) And/or if another person develops a drug

diary or chart which the patient relies on to take meds appropriately

478


Response 2Patient requires another person to provide

reminders What about a device that provides reminders?

Who sets up the device? 4b-Q167.5

479

ExamplesofResponse34b‐Q167.5.1

A patient who decided not to take her new medications, because the varying doses worried her, and she was unsure of the instructions. There had not been a medi-planner set up, nor reminders tried. The clinician would select Response 3 because it is unclear until reassessment if the interventions will be successful.

A patient who, upon assessment, was not able to take prescribed medications at the correct time and doses even though reminded.

A patient who, on the day of assessment, was prescribed oral medications, but was unable to safely swallow.

480

The patient is on multiple medications which span 3 times a day. Yesterday, the doctor started her on a varying dose of Prednisone. The patient admits to being confused about the directions and right dosage. The clinician observes that the med box the patient set up is filled correctly with all usual medications, but not correctly with the prescribed Prednisone administration. The clinician also notes that the medication for last evening remained in the pill planner. Upon questioning, the patient admits to being tired and forgetting to take her evening medication. The nurse discusses the use of an alarm clock to remind her to take her evening medication and fixes the Prednisone dosage for the rest of the week. Considering this patient needed help with setting up one medication (Response 1) and a reminder for another (Response 2) in the last 24 hrs, what is the correct scoring with rationale for this situation?

4b-Q167.9

481

"3-Unable to take medication unless administered by another person because on the day of the assessment, the patient did not possess the ability to take the Prednisone at the correct time and dose and demonstrated that through her report and actions (required knowledge of the drug's dose and administration schedule ) Rationale: •Day of assessment•Do not report ability after skilled intervention, as this is not a reflection of what was true in the most dependent medication during the day of assessment.

•The patient has to demonstrate success at taking meds as ordered, at all times to move from a ‘3’.

482

M2020

If the patient does not have her prescribed medications in the home because she cannot afford them and she does not plan on getting them, what is the most appropriate response for M2020?

4b-Q167.5.2

483

M2020

You are reporting the patient's ability to take all oral medications reliably and safely at all times on the day of the assessment. If the patient did not take her medications on the day of the assessment because they were not present in the home, you cannot make assumptions about a patient's ability to take medications she doesn’t have. If the medications were not in the home, you would not be able to determine if she could take each medication at the correct time and dose. The patient's status would be reported as “3-Unable to take medications unless administered by another person”.

484

Quiz

Mrs. Wobble is unsteady while ambulating and requires supervision for ambulation. She possesses the knowledge to take her medications reliably and safely if the bottles are placed near, or if she has supervision while ambulating to the medication storage area. Please advise how this patient would be scored for M2020, Management of Oral Medications. The item intent instructions include guidance related to the patient’s ability to access the medication, how does this play into the question when the physical impairment causes the patient to require human supervision or assistance and not the cognitive aspect (such as for reminders)?

4b-Q167.5.3

485

Answer

M2020 reports a patient's ability on the day of the assessment to take the correct oral medications at all the correct times. This would include the tasks of accessing the medications from the location where they are routinely stored in the home, preparing the medications (including opening containers or mixing oral suspensions), selecting the correct dose and safely swallowing the medications, typically involving having access to a beverage. If someone other than the patient must do some part of the task(s) that are required for the patient to access and/or take the medication at the prescribed times, then the patient would NOT be considered independent (Response 0).

486

MoreScenarios

Scenario: Medications are routinely stored in the refrigerator located downstairs. The patient requires someone to assist them at medication administration time to walk to the location where the medications are routinely stored, or someone must retrieve the medications and bring them to the patient; Response "3" would apply. In this situation, just someone preparing the doses in advance did not enable the patient to self-administer their medications.

Scenario: The patient requires someone to prepare the medication doses in advance (e.g. visually they can't discern the appropriate dose) and to walk with them at all times to be safe. Someone prepares the medi-planner and sets it within the patient's reach with the water they need to take the meds, the appropriate score is a "1", as the patient can access the medications from where they are routinely stored and has the water available to swallow the medication safely. 4b-Q167.5.3

487

MoreScenarios

If the medications were routinely stored in the kitchen and/or the water was not available for the patient to self-administer and the patient required someone to assist them to the location where the meds were stored and or to water, the appropriate score would be a "3".

Scenario: Patient does not need doses prepared in advance, but the medications are routinely stored in a location that the patient cannot access due to a physical, sensory, or environmental barrier. The patient is scored a "3". During the episode, an environmental modification was made, e.g. changing the medication storage and water supply to a location that the patient can access, the patient could be scored a "0" at the next OASIS data collection time point. 4b-Q167.5.3

488

M2030ManagementofInjectableMedications

489


Timepoints SOC/ROC/FU/Discharge Assess patient’s ability to take all injectable

meds reliably and safely at all times Excludes

IV medications Infusions (i.e. meds given via pump)Meds given in the physician’s office or other

settings outside the home 4b-Q168.3

490

M2030ManagementofInjectableMeds

Response -0 Patient sets up own meds with correct med, dose and

time Response -1

Patient independent in injectable med administration except that another person must prepare doses and/or if another person must develop a drug diary or chart

Response -2 Reminders to take meds are necessary, regardless of

whether the pt is independent or needs assistance in preparing individual doses and/or developing a drug diary or chart.

Note: Reminders provided by a device that the patient can independently manage are not considered ‘assistance’ or ‘reminders’

491

M2030ManagementofInjectableMeds

Response 3—Unable to take medication unless administered by another personThe physician orders the nurse to administer the

medication (represents a medical restriction against self-administration) if not for convenience 4b-Q168.2, 168.3

If injectables are not in the home (whether currently due, due at a future point during the episode or prn) Response 3 - Unable to take injectable medication unless administered by another person is appropriate.

If an injection is ordered but not administered the day of assessment, the clinician will use the assessment of the patient’s cognitive and physical ability and make an inference regarding what the patient would be able to do. 4b-Q168.1.01.

492


If patient’s ability to manage injectable meds varies from medication to medication, consider the medication for which the most assistance is needed when selecting a response.

The patient administers his own insulin safely and reliably but his doctor has ordered B12 IM. What response? 4b-Q168.4

What if the doctor wants the patient to come into his office for the IM injection?

The doctor orders that the patient receive a flu vaccine?? 4b-Q168.5.1

493

WhatdoesM2030include?

M2030 requires an assessment of the patient's cognitive and physical ability to draw up the correct dose accurately using aseptic technique, inject in an appropriate site using correct technique, and dispose of the syringe properly." My patient, at the SOC, was throwing his used needles and syringes into the trash. He stated he was never told how to properly dispose of them. 4b-Q168.3.1

If the patient lacked the knowledge regarding safe needle and syringe disposal on the day of the assessment, the patient was unable to take injectable medication unless administered by another person, Response 3. If the patient needed reminders regarding safe needle/syringe disposal, they would be scored a "2".

494

M2030atDischarge

Scenario 1: The first two weeks of the episode, the patient had Lovenox SQ ordered. The patient is being discharged 4 weeks later with no injectable medications currently ordered. At discharge, is the answer NA - no injectable medications prescribed or do we assess their ability from earlier in the episode?

Scenario 2: Is the order to administer the flu vaccine at the beginning of the episode included when selecting a response for M2030 at the Discharge assessment?

Answer to both: If there are no current, ongoing orders for an injectable to be administered IM or SQ via needle and syringe in the home at the time of the assessment, the appropriate response is NA. 4b-Q168.1.1

495

M2040PriorMedicationManagement

•Timepoints SOC ROC•If patient’s ability varies from one med to another, consider •the med that takes the most assistance when selecting •your answer. Includes only those administered at home 4b-Q168.5.2

496

OASIS C-1

M2040 PriorMedicationManagement

Answer is based on the medication which required the most assistance

Independent Patient completed activity by him/herself (with

or without assistive device) Without physical or verbal assistance from a

helper or reminders from another personReminders provided by a device that the pt

can independently manage are not considered assistance or reminders

497

M2040 PriorMedicationManagement

‘Needed some help’ means that the patient required some help from another person to accomplish the task/activity.

‘Dependent’ means that the patient was incapable of performing any of the task/activity. For oral meds this means that the pt was capable only of swallowing meds that were given to him/her. For injectable meds, this means that someone else must have prepared and administered the meds.

NA There were no oral or injectable meds

498

M2102TypesandSourcesofAssistance

499


500

Prosthetics, ace bandages,TED hose, etc are not included here


501

M2102MedicationsandProcedures/Treatments

Row c – Medication administration refers to any type of medication (prescribed or OTC) and any route of administration including oral, inhalant, injectable, topical, or administration via g-tube/j-tube, etc.

Row d – Medical procedures/treatments include procedures/treatments that the physician or physician-designee has ordered for the purpose of improving health status. Some examples of these procedures/treatments include wound care and dressing changes, range of motion exercises, intermittent urinary catheterization, postural drainage, electromodalities, etc. Devices such as TED hose, prosthetic devices, orthotic

devices, or other supports that have a medical and/or therapeutic impact should be considered medical procedures/treatments, not as ADL/dressing items in Row a.

502


503

Equipment,Safety,Advocacy

Row e – Management of equipment refers to the ability to safely use medical equipment as ordered. Examples of medical equipment include oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies, continuous passive motion machine, wheelchair, hoyer lift, etc.

Row f – Supervision and safety includes needs related to the ability of the patient to safely remain in the home. This category of assistance needs includes a wide range of activities that may be necessary due to cognitive, functional, or other health deficits. Such assistance may range from calls to remind the patient to take medications, to in-person visits to ensure that the home environment is safely maintained, to the need for the physical presence of another person in the home to ensure that the patient doesn’t wander, fall, or for other safety reasons (for example, leaving the stove burner on).

Row g – Advocacy or facilitation of patient's participation in appropriate medical care includes taking patient to medical appointments, following up with filling prescriptions, or making subsequent appointments, etc.

504

DialysisandInfusions

Dialysis through a central line is included in M2102 e. as long as the dialysis occurs in the home. M2102 e. reports the caregiver’s ability and willingness to manage the equipment as ordered and includes oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment of supplies, continuous passive motion machine, wheelchair, hoyer lift, etc. Dialysis is an infusion therapy.

If the patient were receiving such therapy outside the home, (e.g. at a dialysis center), then M2102 e. would be marked “0-No assistance needed – patient is independent or does not have needs in this area”, assuming the patient care did not include use of any other included services at home (oxygen, enteral nutrition, etc.).

Flush only—syringe is equipment to be managed

505

M2102Generally

If patient needs assistance with any aspect of a category of assistance (such as needs assistance with some IADLs but not others), consider the aspect that represents the most need and the availability and ability of the caregiver(s) to meet that need.

If more than one response in a row applies, (for example, the caregiver(s) provides the assistance but also needs training or assistance), select the response that represents the greatest need (“caregiver(s) needs training/supporting services to provide assistance”).

Response 3 if: “Caregiver(s) not likely to provide” indicates that the caregiver(s)

has indicated an unwillingness to provide assistance, or that the caregiver(s) is/are physically and/or cognitively unable to provide needed care.

“Unclear if caregiver(s) will provide” indicates that the caregiver(s) may express willingness to provide care, but their ability to do so is in question or there is reluctance on the part of the caregiver(s) that raises questions as to whether the caregiver will provide the needed assistance.

506

Quiz

I have a patient who has just started chemotherapy with IV access present. She is unable to take oral medications or food and has a gastrostomy tube that is being flushed with water to maintain patency. The patient is scheduled to return to the physician in two weeks for further assessment and to obtain enteral nutrition orders. How do I score M1030, M2020, M2102 at SOC?

M1030, Therapies at Home - If the patient's IV access for the chemotherapy was ordered to be flushed in the home, Response 1 would be appropriate, otherwise it would be 4-NA, as the patient is not receiving one of the listed therapies at home.

M2020, Management of Oral Medications, would be NA-No oral medications prescribed.

M2102, Types and Sources of Assistance, e. Management of Equipment - Even though the patient's g-tube is only being flushed with water to maintain patency until the feeding is ordered, the patient/cg must maintain the enteral nutrition equipment, so it would be appropriate to assess and report the level of caregiver ability and willingness to provide assistance with managing the equipment.

507

M2102‘4’NotUsedGenerally M2102. How is "Assistance needed, but no Caregiver(s)

available" defined? Would it apply to a son who is managing equipment and assists with ADLs safely and independently, but is unwilling to assist with medication administration and is unable to take the patient to doctor's appointments?

"4 - Assistance needed, but no non-agency caregiver(s) available" means the patient has no one involved in providing any level of care to them at all. In your example, the patient has a son who is providing some level of caregiver assistance; therefore, Response 4 would not be an appropriate response.

If the son was willing and able to manage equipment and assist with ADLS, the appropriate responses for Row a and Row e would be "1- Non-agency caregiver(s) currently provide assistance". If the son was unwilling to assist with medication administration and unable to take the patient to doctor's appointments, the appropriate responses for Row c, Medication administration and Row g, Advocacy or facilitation would be " Response “3 – Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance” because this response is defined as including situations where the caregiver is unwilling or unable to provide the needed care. 4b Q170.12.

508

M2110HowOftendoesthepatientreceiveADLorIADL assistance?

509

No longer answered at discharge

MealsonWheels

A community based service, like Meals-on-Wheels, that is providing needed assistance with meals would be considered when answering M2102 and M2110. Note that if the patient needs assistance with any aspect of a category of assistance, such as IADLs, you are to consider the aspect that represents the most need and the availability and ability of the caregiver to meet that need. If the patient, who is receiving delivered meals, is also receiving other IADL assistance, the clinician must determine the IADL that requires the most need and then the availability and ability of the caregiver to meet that need.

510

M2250PlanofCareSynopsisOASISC‐1

511

ExactWords?

When completing M2250, Plan of Care Synopsis, it is not required that you include the exact words used in the M2250 item, just that interventions representing the specified best practice be included in the physician-ordered Plan of Care. In some cases, if all you included were the exact words, it would not meet the requirements. For example, if the order read “Monitor and mitigate pain”, the phrase “mitigate pain” would not be a specific intervention that could be followed in an effort to relieve pain. It would be expected that an order for a specific intervention be included, e.g. Tylenol 500 mg q6h, teach guided imagery techniques to relieve pain, etc. However, in other cases, using the exact words from the M item would suffice, e.g. “Monitor lower extremities for lesions and teach patient/caregiver proper diabetic foot care.”

512

Isanorderrequired?

If your agency wants to “get credit”, you must have an order for the interventions included in M2250.

Row A: The specific parameters must be included on the Plan of Care. The physician has to be aware of what he/she is agreeing to and cannot possibly be aware of every home health agency’s standardized parameters.

In order to answer "Yes" to the responses, the Plan of Care must include patient-specific parameters provided/approved by the physician, or inclusion of your agency specific parameters, which the physician has agreed meet the individual needs of this specific patient. As with any physician orders, these must be approved either through verbal or written approval by the physician prior to providing care.

If the agency utilizes agency standardized guidelines without specific physician approval and orders, then "NA" should be reported for M2250a.

513

M2250atROC

If the ROC comprehensive assessment with OASIS was completed after the CMS-allowed 48 hour time frame, do all the best practice questions need to be answered “NA”?

The ROC comprehensive assessment must be completed within 48 hours of discharge following a qualifying inpatient stay or within 48 hours of knowledge of a qualifying stay in an inpatient facility. If the ROC assessment is late, "Yes" may still be selected for the best practices in M2250, Plan of Care Synopsis, if the relevant orders were present within the 48 hour ROC time frame.

If not present by the end of the 48 hour time frame, answer No, unless NA. 4bQ172.4.1.

514

Depressionordepressionsymptoms

A patient has depressive symptoms as identified by a PHQ-2 score of “4”, but the patient has no diagnosis or current treatment for depression. If the clinician notifies the physician of the depressive symptoms and is instructed to continue to monitor the patient, with no orders for specific treatment, what response would be selected for M2250d?

After reporting the patient's positive depression screening to the physician, “Yes” may be selected. A physician order to continue to assess for signs of depression could be considered an intervention for depression and would also meet the criteria for the “Yes” response for M2250d but would not be required as long as the physician was notified that the patient had screened positive for depression. 4bQ172.8.1.

515

AntidepressantMedication

If the patient has a diagnosis of depression, the presence of an existing antidepressant medication in the medication profile/Plan of Care is considered a depression intervention. If there is an anti-depressant ordered and no diagnosis of depression, the assessing clinician would need to confirm why the medication was prescribed as anti-depressants are often indicated for diagnoses other than depression. If the medication was not prescribed specifically for depression, it would not be considered a depression intervention. 4bQ172.9.

516

AssessAnyway

During a SOC visit, the assessing clinician determines the patient is not depressed, has no symptoms of depression and no diagnosis of depression. Because she has assessed for signs & symptoms of depression as part of her initial comprehensive assessment and will continue to assess the patient for signs & symptoms of depression as part of her psychosocial assessment during her revisits, she selects the intervention "Skilled observation and assessment of signs and symptoms of depression " on her Plan of Care. May we answer “Yes” on M2250, Row d since the Plan of Care has a depression intervention?

If the clinician determines it would be appropriate for a specific patient and obtains an order for "Skilled observation and assessment for signs and symptoms of depression" from the physician during the SOC or ROC allowed timeframe, M2250d may be answered "Yes" even if the formal assessment was negative and/or the patient has not been formally diagnosed with depression.

Note, just checking off an intervention on a Plan of Care does not equate to "obtaining a physician order." 4bQ172.9.02.

517

ReferralforTreatment

If the patient’s depression screen was positive and the assessing clinician suggests the patient join a depression support group or schedule an appointment with a psychiatrist, would this be considered a “referral for other treatment”?

No. It has to be a physician’s order. 4bQ172.9.03.

518

PhysicianNotifiedofPositiveDepressionScreen

Row d: If the physician-ordered Plan of Care contains orders for further evaluation or treatment of depression, AND/OR if the physician has been notified about a positive depression screen, select “Yes.” Examples of interventions for depression may include new or existing medications, adjustments to already-prescribed medications, psychotherapy, or referrals to agency resources (for example, social worker). If the patient is already under physician care for a diagnosis of depression, interventions may include monitoring medication effectiveness, teaching regarding the need to take prescribed medications, etc. If the patient has no diagnosis of depression AND does not meet criteria for further evaluation based on a formal or informal depression assessment, select “NA” (unless the physician has been notified about a positive depression screen, or orders for further evaluation or treatment of depression are present). If more than one depression screen was completed by the assessing clinician, all must be negative in order to select “NA.”

519

MonitorandMitigate

An ordered pain medication is considered an intervention to mitigate pain. Assessing for the effectiveness of the pain medication is considered an intervention to monitor pain. If both the pain medication and an order related to pain assessment are included in the physician-ordered Plan of Care, M2250e would be “Yes”. 4bQ172.9.09.

520

MoistWoundTreatment

Row g. may be answered "Yes" if, by the end of the allowed assessment time period (5 days after SOC date/2 days after inpatient facility d/c for ROC) the physician-ordered Plan of Care includes orders for pressure ulcer treatment based on the principles of moist wound healing. The assessing clinician may also answer "Yes" in cases where the moist wound healing treatment was requested of the physician, by the end of the allowed assessment time period. It would not be required that the response from the physician be obtained in order to qualify as a "Yes". If the physician response is "No, moist wound healing is not appropriate for this patient, “NA” would be the correct response.

The parallel item in M2400 does not offer any option that an order for treatment using principles of moist wound healing was requested from the MD. So at M2400 if the MD does not order treatment based on principles of moist wound healing, “No" must be reported on Row f unless the patient meets the criteria listed to mark NA. 4bQ172.9.1.

521

MoistWoundTreatment

Moist wound healing treatment is any primary dressing that hydrates or delivers moisture to a wound thus promoting an optimal wound environment and includes films, alginates, hydrocolloids, hydrogels, collagen, negative pressure wound therapy, unna boots, medicated creams/ointments.

NOT a wet to dry saline dressing

522

NoFormalAssessmentRequired

M2250 reports if the physician-ordered Plan of Care includes specific interventions and should be marked “No” or “Yes”, depending on the presence of the orders, whether or not a formal assessment for the related issue was conducted. M2400 reports if specific interventions were BOTH included in the physician-ordered Plan of Care AND implemented. M2400 should also be marked “No” or “Yes” based on the presence of the orders and documentation of their implementation, whether or not a formal assessment for the related issue was conducted. If no orders were present, “NA” may be appropriate to mark, if the situation meets the conditions stated in the specific NA statements (e.g., “NA, Patient has no diagnosis or symptoms of depression).

523

524

M2400InterventionSynopsisOASISC1

525

526

2400InterventionSynopsis

In a situation of a Friday referral for a therapy only case, the RN makes a non-billable visit on a Saturday to meet the federal requirement that the initial assessment visit must occur within 48 hours of the referral. No nursing need existed and no billable service was provided, therefore Saturday was not the SOC date. The patient was a diabetic, but had no skilled nursing needs related to their diabetes, the nurse however, assessed the lower extremities for lesions, found no lesions, and verified the patient understood how to care for her feet. The PT did not assess the lower extremities for lesions and did not address the foot care education in any way before discharge.

None of the interventions that the nurse provided on the initial assessment visit would be considered when responding to M2400, Intervention Synopsis, even if orders existed, because the interventions were completed before the quality episode began on the SOC date. 4b Q182.2.2.

527

DepressionONLY

Referral for other treatment” is specifically listed as a qualifying intervention in item M2400.

“Yes” should be reported for the situation in which the referral is made for other treatment for depression, even if the treatment is never actually provided before the Transfer or Discharge time point. 4b Q182.3.

528

2400InterventionSynopsis

Documented lack of need for the education—May still answer yes

Attempt was made to educate and the patient refused or otherwise declined to receive the needed instruction with no further attempt– Answer No.

Multiple orders for interventions. Can we respond "Yes" to M2400 d if pain mitigation orders were implemented but not completed prior to discharge?

May answer "Yes" if there is evidence that the required assessment component was implemented AND evidence that at least one of the pain mitigation orders were implemented. 4bQ182.7.

529

M2400andLongTermPatients

For example, foley catheter patient—all teaching has been done so further visits to do teaching are non-covered.

How is M2400 completed? Since or at the last time OASIS completed If no orders on POC and/or no evidence of

implementation, then must mark ‘no’ (unless NA) During that time period, if specific orders were present,

and the clinician confirmed the patient/caregiver possessed the knowledge regarding the best practice that was taught in a prior episode at the Recertification visit or on a subsequent visit, then upon confirmation that the patient/caregiver possessed the knowledge, the intervention may be considered implemented.

530

M2400andLongTermPatients

“Reviewed pressure ulcer prevention, pain mitigation, and falls prevention with patient/caregiver. Patient/caregiver state understanding. No further intervention required.” (example note on recert assessment)

Adherence rate of 100% for the process measures???

Note that none of the process measures for long-term episodes (those that include a Recertification or Other Follow-up) are publicly reported

531

EmergentCareM2300s532

M2300EmergentCare533

M2300EmergentCare

Timepoints Transfer Discharge Identifies whether the patient was seen in a

hospital emergency department at the time of or at any time since the previous OASIS assessment. Responses to this item include the entire period at or since the last time OASIS data were collected, including use of hospital emergency department that results in a qualifying hospital admission, necessitating Transfer OASIS data collection. This item includes current events.

534

M2300EmergentCare

ExcludesUrgent care services not provided in a hospital

emergency department Doctor's office visits scheduled less than 24 hours

in advanceCare provided by an ambulance crew without

transportCare received in urgent care facilities

This item only includes holding and observation in the emergency department setting

535

M2300EmergentCare Response 0—No

No emergent care in hospital emergency dept ORPatient is direct admitted to the hospitalPatient was not treated or evaluated in the

emergency roomPatient had no other emergency department

visits since the last OASIS assessment.

536

M2300EmergentCare

Response 1 or 2--YesPatient went to a hospital emergency department,

regardless of whether the patient/caregiver independently made the decision to seek emergency department services or was advised to go the emergency department by the physician, home health agency, or other health care provider 4b-Q179

537

M2300EmergentCare

Response 2—Yes with admissionPatient went to a hospital emergency department

and was subsequently admitted to the hospitalAn OASIS transfer assessment is required

(assuming the patient stay was for 24 hours or more for reasons other than diagnostic testing).

538

M2300EmergentCare

What if a patient went to a hospital emergency department, was “held” at the hospital for observation, then released?The patient did receive emergent care.

The time period that a patient can be "held" without admission can vary

An OASIS transfer assessment is not required if the patient was never actually admitted to an inpatient facility.

539

DiesintheER

A patient who dies in a hospital emergency department is considered to have been under the care of the emergency department, not the home health agency. In this situation, a Transfer assessment, not an assessment for "Death at Home," should be completed. For M2300, select Response 1 - Yes, used hospital emergency department WITHOUT hospital admission.

540

M2310ReasonforEmergentCare541

M2310ReasonforEmergentCare

Timepoints Transfer/Discharge Emergency Room only If more than one reason contributed to the hospital

emergency department visit, mark all appropriate responses (include why even though not diagnosed) If a patient received care for a fall at home and was found

to have medication side effects, mark both responses. Improper medication administration, regardless of

who (patient, caregiver, or medical staff) administered the med improperly. 4b-Q181.5

542

M2310ReasonforEmergentCare

If the reason is not included in the choices, mark Response 19 - Other than above reasons.

If Pt received emergent care in a hospital ED multiple times since the last time OASIS data were collected, include the reasons for all visits.

Include both the reasons care was sought and care received. 4b-Q181.5.1

543

Injury?

When answering M2310 (Reason for emergent care) how is the term “injury” defined in Response 2-Injury caused by fall? I understand a fractured bone is an injury, but what about ecchymosis, increased edema, neurological changes (no confirmed neurological diagnosis as far as a bleed, etc.), lacerations, abrasions, etc.? 4b-Q181.5.2

Injury means that hurt, damage or loss is sustained by the patient. The assessing clinician may use this definition and clinical judgment to determine whether or not the patient was "injured" when they fell.

544

545

M2430

The clinician is to use his/her clinical judgment to determine if the patient's condition (for instance; "hypertension", or "change in mental status") resulting in hospitalization, fits into the categories/conditions reflected in the various M2430 responses (for instance; "Other heart disease", or "Acute mental/behavorial health problem"). If the clinician finds that none of the categories represent the reason(s) why the patient was hospitalized, then "Other" is the correct response. The clinician could provide more information for agency use in a narrative within the comprehensive assessment.

546

M2410TowhichInpatientFacility…

547


If the patient was admitted to more than one facility, indicate the facility type to which the patient was admitted first (for example, the facility type that they were transferred to from their home).

When a patient dies in a hospital emergency department, the RFA 7 - Transfer to an Inpatient Facility OASIS is completed. In this unique situation, clinicians are directed to select Response 1 – Hospital for M2410, even though the patient was not admitted to the inpatient facility.

Admission to a freestanding rehabilitation hospital, a certified distinct rehabilitation unit of a nursing home, or a distinct rehabilitation unit that is part of a short-stay acute hospital is considered a rehabilitation facility admission.

548


Admission to inpatient drug rehabilitation is considered an inpatient admission. Select Response 1 – Hospital, whether it was a freestanding drug rehabilitation unit or a distinct drug rehabilitation unit that is part of a short-stay acute hospital.

Admission to a skilled nursing facility (SNF), an intermediate care facility for individuals with intellectual disabilities (ICF/IID), or a nursing facility (NF) is a nursing home admission

When completing a Transfer, select Response 1, 2, 3, or 4. “NA” should be omitted from this item for transfer.

When completing a Discharge from agency – Not to an Inpatient Facility, select Response “NA.”

549

M2420DischargeDisposition550

M2420DischargeDisposition

Patients who are in assisted living or board and care housing are considered to be living in the community with formal assistive services.

Formal assistive services refers to community-based services provided through organizations or by paid helpers. Examples: homemaking services under Medicaid waiver programs, personal care services provided by a home health agency, paid assistance provided by an individual, home-delivered meals provided by organizations like Meals-on-Wheels. Therapy services provided in an outpatient setting would not be

considered formal assistance. Informal services are provided by friends, family, neighbors, or other

individuals in the community for which no financial compensation is provided. Examples: assistance with ADLs provided by a family member, transportation provided by a friend, meals provided by church members (specifically, meals not provided by the church organization itself, but by individual volunteers).

Noninstitutional hospice is defined as the patient receiving hospice care at home or a caregiver’s home, not in an inpatient hospice facility.

551

FacetoFaceandOASIS552

FaceToFaceEncounter

Mrs. Cline was admitted to ABC Home Health on January 1, 2012. She had not seen her physician since August, 2011.

Upon admission the RN explained the F2F regulation and was assured by the patient and her family that a visit would be scheduled prior to the 30 day point of January 31st .

Mrs. Cline’s appointment was scheduled for February 4th , 35 days after the SOC OASIS assessment………

553

In this scenario, the date when all Medicare eligibility was met would be 30 days prior to the F2F encounter (with the F2F encounter date counted as day 1).

The (M0090) Date Assessment Completed should be reported as the actual date the new OASIS assessment is being generated, even if no visit is provided on that date.

Timing warnings from the OASIS state system may be generated based on the difference between the start of care date and the date the assessment was completed (> 5 days), but these warnings may be unavoidable in these situations and can be disregarded.

554

Someparticularstobeawareof:

M0110 may need to be changed to reflect the correct episode timing

M2200 may need to be changed to exclude therapy visits provided before the date of eligibility. Medicare will not pay for services provided before the

date on which all Medicare HH eligibility have been met, which in the scenario described would refer to any services provided in the first five days of care.

If the original OASIS assessment had already been submitted to the State, it should be deleted, and the newly generated SOC OASIS assessment (with modified M0030/M0090 dates, M0110, M2200, etc.) submitted.

All assessments should be maintained in the agency clinical record, with documentation explaining the situation.

555

The‘WrapUp’forMrs.Cline…..

Agency provides first skilled visit January 1st Face-to-Face encounter occurs February 4th (Day 35) Date when all Medicare eligibility was established

January 6th (30 days prior to the F2F encounter, with F2F encounter date counted as "day 1")

Non-covered visit period (January 1st-5th) (M0030) SOC Date on generated OASIS (The date of

the first visit on or after January 6th) (M0090) Date Assessment Completed on generated

OASIS (The actual date new assessment is generated – on or after the February 4th F2F encounter.)

2-Q61

556

Whatdoes‘generate’mean?

“Generate" means that the OASIS can be copied from the previous one in its entirety except for updating specific questions mentioned, (like M0030, M0090, M0110, and M2200) with indifference to the actual condition of the patient at (or close to) the time of the new SOC date. 2-Q61.2

Generated means no one is actually doing an assessment so it does not have to be generated by the same qualified clinician who did the most recent OASIS. 2-Q61.5

557

SOCDate/NewPOC

SOC date is date patient became eligible for care (30 days prior to F2F encounter) OR the first billable visit after the date of eligibility.

First billable visit means any discipline making a billable visit (first covered visit). 2-Q61.9

A new Plan of Care (POC) must be developed based on the new SOC date with specific orders for services.

Begin date/SOC date that equals the date of the first billable service provided on or after the patient became eligible for the Medicare home health benefit (30 days prior to the F2F encounter). This POC should match the SOC date on the newly generated SOC OASIS.

The new Plan of Care must include all existing orders beginning with the new SOC date as well as any additional orders obtained to cover the 9-week cert period. The orders may have changed over time, and the new POC should reflect all orders relevant to the certification period of the new Medicare-covered episode.

The original POC should be kept in the clinical record for reference and documentation should be in the record explaining the late face-to-face and related actions.

2-Q61.10

558

Anotherexample:

Mrs. Dee’s SOC was January 1. She was supposed to be seen by her doctor after her SOC but then the doctor went skiing and the visit didn’t happen. Now, you’ve just done your end of episode audit and figured out that there is no F2F documentation on the chart. You call the physician’s office and you are politely told that the visit had to be rescheduled and Mrs. Dee will be seeing the doctor next week. That is day 70!!

559

WhatiftheF2Fdoesnotoccuruntilthenextrecert period?

Medicare will not pay for services provided before the date on which all Medicare HH eligibility have been met, which in the scenario described would refer to any services provided in the first 40 days of care. (F2F day minus 30 days)

Any original OASIS assessments which may already have been submitted to the State, (likely SOC and Recert Assessments in this scenario) should be deleted, and the newly generated SOC OASIS assessment (with modified M0030/M0090 dates, M0110, M2200, etc.) submitted.

All assessments should be maintained in the agency clinical record, with documentation explaining the situation.

560

WrapUpforMrs.Dee:

Agency provides first skilled visit January 1st Face-to-Face encounter occurs March 11th (Day 70) Date when all Medicare eligibility was established

February 10th (30 days prior to the F2F encounter, with F2F encounter date counted as "day 1")

Non-covered visit period (January 1st – February 9th) (M0030) SOC Date on generated OASIS (The date of

the first visit on or after February 10th) (M0090) Date Assessment Completed on generated

OASIS (The actual date new assessment is generated – on or after the March 11th F2F encounter.)

2-Q61.1

561

ClosestOASISAssessment

Closest assessment is the Recertification The Recertification OASIS only includes payment items. An incomplete OASIS cannot be submitted to the state

system and you may not "create" answers. You will generate your new SOC OASIS based on the

existing data from the assessment conducted closest to the date of eligibility.

If the closest assessment is a Follow-Up Assessment (i.e., a Recert or Other Follow-up), generate the new SOC using all the available Recert items first, then finish generating the assessment by using items from the SOC or ROC that was conducted closest to the date of eligibility.

Remember to update specific items, (like M0030, M0090, M0110, M2200, etc.) 2-Q61.6

562

ClosestOASISAssessment

Closest assessment is a Discharge Generate the new SOC using all available

Discharge items first, continue with generating the new assessment by adding additional items available from the Follow-up assessment (if any) that was conducted closest to the date of eligibility, and then finish generating the assessment by using items from the SOC or ROC that was conducted closest to the date of eligibility.

Remember to update specific items, (like M0030, M0090, M0110, M2200, etc.) 2-Q61.6

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M0110,M0102/M0104

M0110 Since the non-covered visits did not constitute a

Medicare PPS episode, that episode would not be considered for M0110. 2-Q61.3

M0102/M0104 A late F2F is treated as a payer change. In the

specific situation where a new SOC comprehensive assessment is generated for the sole purpose of changing the payer to Medicare, M0102 – Date of Physician-ordered SOC would be “NA”. For M0104 –Date of Referral, enter the day prior to the new Start of Care date.

2-Q61.3

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TherapyCounts

Because the therapy visits provided before the new start of care date (post-face-to-face completion) are not covered by Medicare, those visits do not count towards the Medicare-covered visit count for assessment timing. As was discussed in the CY 2012 final rule, only Medicare-covered visits are to be considered and counted. HHAs should track both Medicare-covered and non-covered therapy visits to keep count of the appropriate number of Medicare-covered therapy visits in these situations.

Reassessments? Adjust time period based on new SOC date

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DeletingPreviousAssessments

Original SOC assessment must be deleted before the newly "generated" SOC assessment is transmitted to the state.

All of the linked assessments must also be deleted. 2-Q61.7

The example in the Claims Processing Manual says to inactivate, but the example is a change from Medicare to Medicare HMO or vice versa. Those OASIS are required to be submitted. The OASIS for a non-covered patient is not required and is not wanted. 2-Q61.8

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All new assessments (e.g., Transfer, ROC, Follow-up, Discharge) that occurred after the new SOC date will need to be generated and transmitted. When generating these new assessments (i.e.

Transfer or ROC), copy the OASIS data from the original assessments (i.e. original Transfer or ROC data) except for updating, when appropriate, OASIS items like M0030, M0090, M0110, M2200, etc,.

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When the HHA resubmits these new assessments, they will then be linked to the new SOC assessment.

Must be deleted, not just inactivated. Previous episode was not covered by Medicare. The HHA must contact their State OASIS

Automation Coordinator (http://www.cms.gov/OASIS/07_AutomationCoord.asp#TopOfPage) and get a specific form signed.

Do NOT complete a DC OASIS for the invalid episodes!

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OASISC‐1/ICD10Manual

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html

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Presented by Selman-Holman & Associates, LLC · 2019. 12. 17. · OASIS C‐1/ICD‐10 Presented by...

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