In Part 6, we will conclude the review of OASIS and its impact on the required accuracy needs of coding. Agencies must improve their assessment and coding skills now in preparation for the indepth requirements of ICD-10-CM and the many changes required for the OASIS C1 data set.
In Part 1, we had discussed, in general, the case mix adjustment model, case mix diagnoses, garnering case mix points, and the Initial and the Comprehensive assessment.
Part 2, we reviewed each OASIS Convention that must be followed. When coding, the coding specialists presume coding conventions are followed. If incongruent documentation or inadequately supported documentation is observed, coding specialists should question any discrepancies and seek clarification.
Part 3, the Coding Expectations and Challenges in Home Health were openly presented including documentation required, the Coding Clinic, and OASIS C Guidance Manual as well as the Medicare Benefit and Claims processing manual. We also explored the three types of teaching.
Part 4, we presented a scenario, identified functional OASIS scores, assigned ICD-9-CM codes, listed Clinical, functional, and severity points, and noted the reimbursement. This section of the series received many favorable comments and was the most openly stated as being of real assistance to agency supervisors.
In Parts 5 we reviewed OASIS more indepthly up to Cognitive function items to assist the clinician with the specific OASIS requirements as well as application of specific OASIS Conventions.
Let’s look now at the OASIS Conventions that focus on ADLs. When the clinician performs the OASIS Comprehensive Assessment the time period under review is essentially the day of assessment. Convention states there should be no reference to prior assessment.
When the clinician is scoring each of the data elements, (s)he must consider the patient’s ability not how well they want to perform a function and how that ability relates to patient safety. In scoring consideration, looking at how well the majority of tasks are completed is a must. The patient’s compliance or motivation should not be confused with ability. The clinician must also assess the reasons for non compliance, such as whether or not noncompliance is due to impairment or choice.
Safety is primary and should be assessed through direct observation. Look at the assistive devices in the home as well as potential barriers to outcomes. Devices may include sliding boards, wheelchairs, canes, walkers, and crutches. Be certain to ask about devices used and/or ordered by prior physicians .
Clinicians should understand the specific M questions as to what is specifically to be assessed. Do not consider the caregiver when determining patient ABILITY. In looking at the grooming tasks, remember that washing one’s hair, taking a bath, or performing toilet hygiene is not included in M1800.
When assessing how well patients can dress themselves, consider prosthetics, orthotics and even TED hose as part of the patient’s apparel. Observe how the patient completes dressing. Look at the type of devices and apparel worn. If the device is to be permanent, then that must be considered when assessed.
Bathing can be dangerous. The clinician must focus on the ability to access the tub or the shower, ability to transfer in and out of the tub or shower, and the ability to reach needed items. Remember that drawing the bath water and washing ones hair is not a part of the M1830 question. It certainly should be a part of the integrated assessment separate from OASIS. For those patients who cannot safely bathe in a tub and instead use the sink, the clinician must look at the level of independence.
M1840 Toilet Transferring does not include Toilet hygiene, which is addressed in M1845. The latter question requires focusing on the ability of the patient to access all supplies needed to manage their hygiene where the toileting takes place. Completing the majority of tasks is not applicable as a convention in answering this M question.
The ability to transfer can be influenced by medications. Look at medication impact on ambulation, climbing stairs, as well as the location and surface for sleep. Ambulation includes safety on a variety of surfaces. For an assessment time frame, the clinician must use the “usual status greater than 50% of the time” convention, unless the patient is chair or bedfast.
The Medication Review
The Conditions of Participation state the Comprehensive Assessment must include a review of all medications currently being taken by the patient. That assessment must include review of all meds as to drug expectations, med reactions, potential adverse effects, drug interactions, duplication of meds and patient noncompliance with medications. The clinician has from the time of the assessment to the end of the next calendar day to contact the physician and communicate any issues. The issue reconciliation must be proposed by the physician within 5 days of the Start of Care. Remember, when answering M2020 Oral Medication, use response ‘0” if the pharmacy provides special packaging, such as easy-open containers or pre-filled medi-planners, that enables the patient to administer their own meds. In assessing Management of Injectable Medications, if the physician orders the RN to inject a med, score “unable” to administer injectable medications. Be certain to include all meds even if not administered that day of assessment.
M2100 Types and Sources of Assistance requires the clinician to consider the fact that if more than one response in a row applies, they must choose the one needed the most. Consider ability over willingness. Include reminder calls under supervision and safety.
Emergent Care and the Plan of Care Synopsis
M2200 Therapy Need is meant to identify the total number of therapy visits planned for the episode. Remember, the Assessment must be congruent with the proposed number of therapy visits.
Emergent Care M2300, means assessing the entire period included since the last OASIS Assessment, and M2310 requires inclusion of all reasons the patient sought and/or received care at the ER.
Pay special attention to M2250 Plan of Care Synopsis. CMS has stated that a physician ordered POC means the patient condition has been discussed with the physician and there is agreement between the agency and the physician as to the patient’s POC. Notice that for the diabetic foot care section there requires at least two orders: “monitoring for the presence of skin lesions on the lower extremities” as well as” educate patient/caregiver regarding proper foot care.”
Notice the falls risk section of M2250 requires falls prevention, pressure ulcer, and depression interventions. Document those interventions carefully.
Specificity has become the buzz word. The industry is seeing specificity required with the face 2 face. It will be demanded with ICD-10-CM coding and it is and will continue to be challenged with OASIS. Accuracy is a must.
Your agency needs assertive expert coding specialists now more than ever. Your coding specialists must verify Homebound status and Medical necessity before coding and OASIS review even begins. Then, an OASIS review and a review of other assessment data must be conducted so coding to the highest level of specificity is achieved.
In a future ezine article, let’s look at what is in a full OASIS Review as well as a modified review. Do you have matrixes for each PPS M question? In that article we will share some of those with your team. Select Data has specific review processes not only for the M questions but for integrated data elements also. Auditors are now looking at specific diagnoses groups. They are looking at comorbidities and sequencing. Auditors are also gearing up for ICD-10. Are you ready?