OASIS presents its own set of challenges for clinicians and coding specialists. The OASIS accuracy is created when clinicians and coding specialists become OASIS experts. We need to know the questions that are Process Measures, that are used in Home Health Compare, that are impacting payment, and that are reviewed as Potentially Avoidable Events.
With the OASIS data set, M0010 – M0069 and M0140 –M0150 are a part of the Patient Tracking form. In most agencies, this information is gathered by the Intake team and verified by the clinician in the home. The information includes the Patient Name, address, social security number, Medicare and Medicaid number, birth date, gender, race/ethnicity, and current payment source.
The OASIS Clinical Records section includes M0080 Discipline of Person Completing Assessment, M0090 Date the Assessment Completed (see Part 1 of this series for details regarding the differences between the Initial and the Comprehensive Assessment), M0100 Reason for Assessment, M0102 Date of Physician-ordered SOC, M0104 Date of Referral, and M0110 Episode Timing (Early/Later).
The OASIS Patient History and Diagnoses section includes M1000-M1055, M1000 Inpatient Facility Discharges and M1005 Inpatient Discharge Date.
M1010 must be completed if the patient had an inpatient stay within the last 14 days. However, only the ACTIVE diagnoses should be listed. CMS states that “actively” means something more than regularly scheduled medications and treatments needed to maintain an existing condition. OASIS accuracy is a must.
CMS will expect to see that M1012 has been answered even with an “UK” or “NA.” You need not code those procedures but you must have answered the M1012. CMS will not allow this M question or any M question to be blank.
M1016 Diagnoses Requiring Medical or Treatment Regime Change Within Past 14 Days is important as it prompts documentation as to why home health care is needed. Points to keep in mind; a physician referral or appointment to home health care does not, by itself, identify a change in treatment regime (CMS 4b- Q40). In M1016, do NOT include conditions that have improved within the past 14 days. Resolved conditions are NOT to be placed in M1016.
In Chapter 3 of the OASIS manual, CMS states, “The purpose of this question, M1016, is to help identify the patient’s recent history by identifying new diagnoses that have exacerbated over the past 2 weeks. This information helps the clinician develop an appropriate plan of care, since patients who have recent changes in treatment plans have a higher risk of becoming unstable.” This OASIS question requires completion by the clinician.
The Coding Specialist will attempt to assign V codes that further define care, such as aftercare or attention to or admission for therapy. They will recommend sequencing to the seriousness related to the assessment seen, the plan of care proposed, and the frequencies of each discipline ordered. They will work to ensure that coding guidelines, conventions for both coding and OASIS are maintained as well as keeping alert to new CMS instructions such as the 2013 PPS instructions for M1024.
Effective January 1, 2013, CMS limited the use of M1024 to fractures. Only acute fractures qualify to earn case mix points when paired with the appropriate V code (V54.1 or V54.2 ). We must ignore the current instructions in the OASIS Manual, as they were not updated. CMS has stated that we may place resolved conditions in M1024 , but there will be no case mix points given.
Onset and Exacerbation dates are NOT mandated by CMS.
Please note that coding comorbidities can paint the picture of the patient’s complex situation and needs. Comorbidities can affect the care plan and impact overall outcomes. If they will be actively addressed, they should be listed in M1022. Let’s create a scenario and sandwich it between our OASIS review.
Mr. P., age 68, was referred to Wonderful Home Health Care for PT and OT services following an acute CVA with hemiplegia to his right (dominant) side. The physician states on the Face to Face that Mr. P. also has CHF, diabetes type II, HTN, and suffers from depression. Because his B/P had been elevated in the acute care setting the physician ordered a small dosage of Lopressor
The home health intake nurse asked about nursing involvement, but the physician believed the B/P was under control and nursing was not needed. He believed that PT and OT were the only disciplines needed.
The therapist did not dispute this, believing that when he got to the home, if he saw a need he would notify the physician of that skilled nursing need. Mr. P’s B/P was 160/90 on the initial home visit. Mr. P had dyspnea with moderate exertion and he had 1-2+ pitting edema in the LE. Though Mr. P has been diagnosed as a diabetic for 9 years, it has been controlled by diet and exercise. M1730, his PHQ-2 score was positive for depression and Mr. P. has been taking the antidepressant Paxil for 2 years.
The functional OASIS items yield
-M1800 grooming at a score of 2, requires assistance
-M1810/M1820 dressing at a score of 2, requires assistance
-M1830 bathing at a score of 5, unable to get in or out of the shower or tub
-M1840 toilette transfer score of 2, unable to transfer self
-M1860 ambulation score of 3, requires supervision or assistance at all times
Since this is the first Medicare episode, thus considered an early episode
and has 10 PT and 7 OT visits scheduled, it will fall under equation 2 of Table 4A.
The therapist will speak with the clinical supervisor as he believes that on every visit he must verify B/P and will do so upon his arrival as well as after the patient performs ambulation and prescribed exercises.
If the B/P rises or dyspnea increases, he is asking for SN. PT also has noted that he will ask about the blood sugars upon every visit and will have obtained the physician prescribed acceptable blood sugar parameters. Upon evaluation of the PHQ-2 and the patient’s overall demeaner, the therapist believes he will work initially with the patient to increase motivation. If, over the next 10 days, he sees no improvement, he will suggest follow up protocols be introduced since the PHQ 2 score indicated depression. The physician will be asked for SN psych nurse order to evaluate the patient, as this level of depression may significantly impact motivation, thus adversely affecting participation in the rehabilitation plan of care.
However, at this time, this case remains therapy only.
Let’s look at the coding:
M1020 V57.89 Admission for Multiple Therapy 0 CM points
M1022 438.21 LE CVA hemiplegia, dominant side 2 CM points With M1810/1820 dressing score of 2 3 CM points
M1022 250.00 Diabetes w/o complications 13 CM points
M1022 401.9 HTN 0 CM points
M1022 311 Depression 8 CM points
M1022 428.0 CHF 8 CM points
The clinical severity points of the OASIS and the coding reflect 31 points or C3
The Functional Status points of the OASIS reflect 12 points or an F 3
The Service Utilization points including M2200 equal 17 therapy or an S2
The combined Clinical, Functional, Service Score is a C3F3S2
The case mix weight for this episode is 2.46
The reimbursement for C3F3S2n is $5, 261.40
The coding specialist will validate that there is congruency in the documentation of the OASIS as well as the narrative note and the integrated OASIS assessment. She/he will note medications, review the F2F, as well as the H&P.
Not all cases will have this high of a case mix weight and it is important that the therapist sees the potential involvement for psych nursing. It is also important that if a therapist is not comfortable monitoring the diabetes or the hypertension, that they share their assessment and concerns with the Director of Clinical Services so skilled nursing is involved.
This example also shows the importance of adding the comorbidities, if actively being monitored, as they added $935.00 to this case. CMS wants to pay agencies appropriately for the resources being utilized and is willing to pay for cases that are more complex. A solid assessment, detailed documentation, and a strong well thought out plan with active intervention is required.
If the documentation is poor, the coding specialist cannot code to the highest level of specificity. THE PATIENT CAN BE SHORTCHANGED THE CARE THEY DESERVE. Be certain your agency has a process in place that tracks and encourages detailed documentation follow up. Coding is a collaborative effort between the coding specialist and the clinician. THE CODING SPECIALIST CAN ONLY CODE WHAT WAS DOCUMENTED. Is your coding team assisting your clinicians to better understand the specifics required to code various diagnoses? Documentation is key now and with ICD-10 coming, it is imperative. It is no wonder that agencies are seeking assistance from Coding specialty firms. Look for a firm that believes so strongly in their coding accuracy that they pay for an external independent audit to substantiate that level of accuracy. You need to know that the Coding firm completing your coding that will be placed on your claims meets the tough scrutiny of an external audit. If we can assist, please contact Select Data at 714.524.2500.
The next two ezines will focus on completing and answering the OASIS properly for accurate Clinical, Functional, and Service Scores as well as having complementary narrative notes that support the diagnostic codes assigned.