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Coding Specialists and their supervisors require an expert understanding of the OASIS, Coding Guidelines, and Conventions for both OASIS and coding completion accuracy. The goal is an accurate and complete assessment, a well constructed patient-centered care plan, and achieved clinical outcomes. Coding must be properly sequenced, reflective of the plan, and completed to the highest level of specificity. To consistently achieve this goal, the coding specialist must be knowledgeable in more than just coding.
Home Health Coding relies on an understanding of complex processes. CMS, through the Balanced Budget Act of 1997, created the 60 day predetermined episodic payment process known as the Prospective Payment System. Major revisions were made to the system in 2008 and again in 2010.
In order to derive the episodic payment amount for each patient, characteristics were predetermined using answers from the OASIS data set.
General points re OASIS: Outcome and Assessment Information Set
It is used for payment calculation.
It is used for systematic comparative measurements and to identify
potentially avoidable outcomes of care/events.
And lastly, it is used to identify best practices to manage patients.
The data elements in the CMS Table 2a Federal Register vol72 identify three dimensions.
I.Clinical Domain which encompasses the following items:
Primary and Secondary Diagnoses
Diagnosis to diagnosis interactions or combinations
Diagnosis to case mix item interactions or combinations
Individual case-mix items
II. Functional items including the following data elements:
III. Service Domain which encompasses therapy
The answers to the OASIS data elements are grouped into home health resource groups consisting of the case mix weights assigned. CMS has audited and analyzed claims data arriving at diagnoses that require additional resources for care. Because these particular diagnoses tend to cost more to deliver care, they carry greater impact to the episodic payment. They are termed case mix diagnoses.
As stated in the Conditions of Participation (484.55), each patient is to receive a comprehensive assessment that will reflect their current health status and additionally assist to demonstrate that patient’s progress toward achievable outcomes. The comprehensive assessment must also identify the patient’s ongoing need for home care, meet their medical, nursing, and therapy needs and it must identify home health benefit eligibility as well as determine the patient’s home bound status.
The initial assessment (not to be confused with the comprehensive assessment) is meant to determine immediate care, support, and safety needs. It must be completed within 48 hours of the patient’s return from an inpatient stay or on the date specified by the physician. The Initial assessment determines eligibility for the patient’s Medicare home health benefit, including medical necessity and home bound status. It must be completed by a Registered Nurse if skilled nursing and therapy have been ordered. If skilled nursing is not ordered then it must be completed by a licensed physical therapist or speech/language pathologist (speech therapist). If no skilled care is provided at this initial assessment visit, then it will not be determined as the Start of Care (SOC). If skilled care is provided, this is termed the SOC and the agency has 5 days to complete the Comprehensive
Assessment that includes the OASIS data set. Most agencies combine these assessment visits, completing one assessment visit.
The OASIS data set alone is not intended to be a comprehensive assessment tool by itself which is why that instrument must be incorporated within the head to toe, total patient oriented comprehensive assessment. This Comprehensive Assessment assists the clinician in planning care with the patient for the 60 day episode. The OASIS answers determine the scores in the three domains; clinical, function, and service. Collectively, the information gathered must be congruent supporting the plan of care and providing the basis for the ICD prospective coding.
Payment will be determined by individual answers as well as interaction with other answers and/or diagnoses.
The Clinical domain will be impacted by answers to Diagnoses M questions M1020, M1022, and M1024, and additionally, M1030 Therapies, M1200 Vision, M1242 Pain, M1308 and M1324 Pressure Ulcers, M1334 Stasis Ulcers, M1342 Surgical Wounds, M1400 Dyspnea, M1630 Bowel Incontinence, M1630 Ostomy, and M2030 Injectable Drugs. These M answers determine C1, C2, and C3.
The Functional domain per the Federal Register vol 72 lines 46-51 includes: M1810 Dressing Upper Body, M1820 Dressing Lower Body, M1830 Bathing, M1840 Toileting, M1850 Transferring, and M1860 Ambulation. These answers account for F1, F2, and F3.
The Service Utilization domain is determined by visits. It is not a part of the Treatment Authorization Code but is necessary to determine the equation of the claim. There are three therapy thresholds: 6, 7-9, and 11-13 visits and they interact with early and late episodes. Those interactions equal S1, S2, S3, S4, and S5.
In Part 1, we discussed, in general, the case mix adjustment model, the garnering of case mix points, the Initial and the Comprehensive assessment. In Part 2, we will discuss OASIS Conventions, Non Routine Supply (NRS) codes, and items that may cause many clinician questions.
When coding, the coding specialists presume coding conventions are followed by clinicians. If incongruences are observed, they should question any discrepancies noted. Select Data coding specialists will electronically notify clients of the congruency and cite the source regulation requiring the supportive documentation. They will also cite the clinical documentation specific incongruencies.
General OASIS item conventions
1. When conducting the assessment, report what is true on the day of the assessment unless the question states otherwise. That means, document should include the full time of the assessment and the 24 hours prior to the assessment.
2. For OASIS purposes, a care episode, also termed a quality episode must have a SOC or ROC and a conclusion; transfer or discharge.
3. If the patient’s ability varies on that day of assessment, report what is greater 50% of the assessment time frame unless the item states differently. The latter could be seen in M questions such as M 2020 Management of Oral Medications or M 2030 Management of Injectable Medications.
4, Minimize the use of NA or Unknown.
5. When documenting current status, observation should be used independent of prior assessment info. There will be process items that will identify answers should be answered re what has occurred ” since the previous assessment”
6. Combine observation, interview, and other relevant strategies to complete OASIS data items.
7. When an OASIS item refers to assistance, this means assistance from another person that may include physical contact as well as verbal cues and supervision.
8. Items are to be completed comprehensively and accurately adhering to all identified skip patterns.
9. Be aware of what is and is not included in each item and answer the item as to what is to be included.
10. Consider medical restrictions when determining ability.
11. Be certain to understand word definitions used in the OASIS data set.
12. Follow the rule outlined in the Item Specific Guidance.
13. Stay current with OASIS updates.
14. Only one clinician is to take responsibility for accurately completing the OASIS assessment. Collaboration may be sought in items such Medication items and Coding.
15. If the OASIS item specifies one calendar day, that means until the end of the NEXT calendar day.
16. Use of I.e. means “only in these circumstances.” Scoring of that item should be limited to the examples given. Use of e.g. Means “for
example” and the clinician may use other relevant examples when scoring that item.
For ADLs, the clinician should report ability not actual performance or willingness to perform the task. Look at how safely the patient can perform the tasks. If their ability varies among tasks, be certain to report to report what is true I. The majority of multi-task items, giving additional weight to those performed most frequently.
Source: Chapter 3 OASIS-C Medicare Guidance Manual 12/12
Be aware of NRS codes and variables. Diagnoses: skin conditions such as cellulitis, gangrene, chronic ulcers, trauma wounds, burns, post op complications, and care of a tracheostomy, cystostomy, and urostomy garner NRS points.
In addition, other OASIS data items such as pressure ulcers, stasis ulcers, surgical wounds, Ostomy for bowel elimination, therapy at home such as IV, parenteral, enteral, bowel incontinence, and urinary catheter also derive NRS points.
How the clinician places diagnoses as to primary and secondary positions also affects the NRS points. The diagnoses should support
OASIS items related to non routine supply points I.e. if a pressure ulcer is listed in M1308 then it should be reflected in M 1020 or M 1022.
Non Routine Supply points are cumulative and that payment is added to the HHRG payment. Improper or incorrect sequencing of codes could cost an agency $200-500 per episode. Make certain NRS codes are understood.
Clinicians must be careful in understanding correct staging, etiology, and healing processes of ulcers. Discuss with the coding specialist so correct diagnoses are listed. They should be seeking substantive documentation for all diagnoses to correctly code and to mitigate audit risk.
Coding and OASIS
Review the OASIS items as they relate to coding to ensure proper coding. Proper coding for the home health clinical record means OASIS data integrity, congruence of the OASIS and narrative documentation, accuracy of the med profile, and clear concise overall documentation supportive of the diagnoses and their sequencing.
As stated above, it all begins with a properly completed Comprehensive assessment that includes the OASIS data set. This assessment drives both the discipline specific careplan as well as the Medical POC. As per the Conditions of Participation (484.55) the comprehensive assessment is required for All home health patients.
It must include an evaluation of the patient’s Medical, Nursing, Rehabilitative, Social, and Discharge Planning needs.
The OASIS must be completed by one clinician. Though the assessing clinician may collaborate, the assessing one clinician must perform the assessment follow up on any observations of patient status reported by any other agency personnel. Source: CMS Q&As Cat 2 Q 52.
Home bound status and medical necessity must be clearly established as well as the patient and clinician collaborative plan of care that will be used to drive patient outcomes.
The OASIS items are not required on patients receiving maternity care, patients under the age of 18, patients only receiving personal care or chore services, patients for whom Medicare or Medicaid insurance is not billed, and patients having a single visit in a quality episode.
Questions clinicians ask
Q1. What if I am uncertain if this is a patient early or late episode.
A 1. Follow agency policy and remember, an UK defaults to early for the RAP, but will be corrected by CMS for final claim.
Q 1. What if I am uncertain as to the inpatient diagnosis? Can’t the office fill these in?
A 1. The clinician should verify these diagnoses from the H&P, speaking w the physician, and speaking with the patient.
Q 3. Are they needed for coding?
A 3. Yes
Q.4. How do I complete M1016? I have heard conflicting statements.
A 4. There should be no surgical codes. List the underlying diagnosis.
There should be no E or V codes. The response may well include some of the same diagnoses as M 1010, if the condition was treated during an inpatient stay AND caused changes in the treatment regimen. If all changes were made because diagnoses improved, then mark NA. Example, If the patient was insulin dependent, but during the last 14 days the sub Q insulin was replaced with an oral, then he has improved. Q&A Cat 4b Q41.11
Q 5. Should I list secondary diagnoses by symptom control rating?
A 5. No, secondary diagnoses should be listed in the order that best reflects the seriousness of the condition and to justify the disciplines and services provided.
Accurate Coding is dependent on accurate Assessment
In Part 3 we will examine how to determine relevant diagnoses, given the unique challenges presented by the home health industry.
Part 3 – Coding Expectations and Challenges in Home Health:
In the home health setting, assigning ICD-9-CM codes presents unique challenges. Since home health agencies usually do not receive all of the information needed regarding the patient’s medical condition, clinicians must develop and /or hone strong communication skills, as they will be calling physician and other resource offices frequently. Coding Guidelines and Conventions require specific information for ICD-9-CM Coding. ICD-10 is even more demanding and the specificity is even more stringent.
Unlike the inpatient setting where the present and prior medical record, labs, diagnostic reports, summaries, and history and physicals are readily accessible, home health is dependent upon the referral source, as well as the physician and his/her office. It is also dependent upon the sophistication of the technology systems for efficiencies.
The home health clinician must seek the H&P, pertinent lab reports, discharge summary, and necessary home health admission orders. She/he must complete the Comprehensive assessment, identify high risk areas, such as falls, nutrition, skin breakdown, and mental health risks, and establish a prospective plan of care that complements the assessment, collaborates with the patient and other team members and achieves the identified goals. The clinician must review all medications, including over the counter preparations the patient and/or his caregiver may be purchasing. The clinician must also review the diet as it relates, not only to nutritional needs, but as it impacts medication synergistic effects, antagonistic effect, or any other contraindications.
Clearly, the home health clinical documentation must be meticulous, show support of diagnoses chosen as the focus of care as well as co-morbidities and other related diagnoses. In addition, the documentation must confirm collaboration with the physician as well as reflect his/her defining specifics of many diagnoses, such as COPD or COPD exacerbated, and must show POC review and agreement.
A segment of the POC (485) includes patient diagnoses that will necessitate a well defined plan of care. Diagnoses coding is a key component of that plan of care and should reflect sequencing based upon the symptom control of the diagnoses. The codes should provide the table of contents of the patient record that includes the Comprehensive Assessment, other discipline assessments, careplan, and visit notes. A clinician, an auditor, or a surveyor should be able to review the listing of the assigned codes in the sequence noted and have a solid understanding of what must have been in the assessments and what should be in the careplan and documented in subsequent visits.
Homebound status and Medical necessity
The initial areas that must be reviewed by the coding specialist are the clinical documentation supporting homebound status and medical necessity. The number one citation for surveyors last year was inadequate supportive documentation to support medical necessity for home health care. One may ask, just how is that possible? Essentially, the clinical documentation did not substantiate need and the assessment did not meet skilled need requirements.
¡ “Skilled services are those services that are medically reasonable and necessary to the treatment of a patient’s illness or injury” CMS
It must be clearly documented that the services provided required the skills of the professional clinician AND that the patient condition/illness/injury warranted those services. Cite specific examples of patient care and condition needs.
The Coding Specialist relies on specific sources that include the Coding Clinic, enacted by Congress as the Official Coding Source. Other approved sources include CMS Coding Guidelines and the ICD-9-CM Coding Conventions, as well as the OASIS C Guidance Manual, both Chapter 3 data items and Appendix D diagnoses, as well as the Medicare Benefit and Claims processing Manual.
Per CMS, only the assessing clinician can determine the primary and secondary diagnoses, and assign symptom control settings based upon the assessment of the patient. Clinicians can collaborate with Coding Specialists because of the complexities of ICD-9CM coding conventions and guidelines.
The Coding Specialists can assist the clinician in determining sequence based upon documentation after the chief or primary focus of care has been determined. The primary diagnosis is to be the most serious condition that is “skilling” the care under the CMS Conditions of Participation.
Other diagnoses or comorbidities listed should delineate how they may impact the healing process or the length of recovery. The clinician should list how they will actively treat these diagnoses.
¡ Remember that the records:
¡ MUST have a specific order for EVERYTHING the clinician does
¡ The clinician:
-MUST do EVERYTHING that has a physician order and
-MUST document EVERYTHING done…thoroughly.
The clinical deficiency items frequently cited:
¡ Repetitive clinical notes are frequently seen stating the same things over and over with no patient progress identified. How is it that the clinician is unable to teach a new med successfully within a visit or two ask the MACs.
¡ Notes from different disciplines reflect lack of plan coordination
¡ Visit notes do not substantiate orders and goals on Plan of Care/485
Clinical interventions are without orders. These are areas that continue to generate survey deficiencies.
Three Types of Teaching
Clinicians should keep in mind the Three Types of Teaching:
¡ Initial Teaching of a patient requires instruction on a new order, new medication, or a new diagnosis.
¡ Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching.
¡ Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment that the patient and/or caregiver has had prior instruction.
¡ Teaching on new medications must include instruction or intervention on the related diagnosis.
The clinician providing injections such as insulin, require specific documentation to support the need; specifically why the patient cannot self inject the med such as tremors, impaired cognitive function, and no willing and capable caregiver.
¡ Be certain the skilled nursing visit supports the diagnosis and the reasons for the SN visit.
If the primary diagnosis is DM but the majority of the visits are directed toward CAD, the SN should be alerted as it appears there is an incorrect primary diagnosis.
The Coding Specialist should look at the OASIS questions and clinician answers as they relate to coding.
In the next three parts of this series, we will focus on the OASIS questions more specifically. In home health, you cannot code without an OASIS review. Next time, let’s code, and create the HIPPS/HHRG and the episodic reimbursement. Here is where you see the impact of an experienced Coding Specialist.
Part 4 – Let’s Start Talking OASIS and Let’s Start Coding:
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.
Coding specialists require an expert understanding of OASIS and clinical documentation in order to properly assign codes. Coding must be properly sequenced, reflective of the patient’s plan of care, and completed to the highest level of specificity. To achieve this goal of accuracy, the coding specialist must be knowledgeable in more than just coding.
Let’s start Part 5 with M1030- . Remember, these therapies must be those received at home, excluding all received in outpatient settings. If this assessment will result in the therapy, mark the applicable therapy such as insulin pump, intrathecal, and eclipse bulb infusion devices. Remember, flushes count also. Response 2-parenteral nutrition includes TPN or lipids.
If a triple lumen is used with the TPN/lipid infused in one port and the other lumen flushed to maintain patency, mark both responses 1 and 2. If a single lumen is used for TPN with pre and post flush as part of the parenteral nutrition protocol, then mark response 2. Specificity is a must.
Response 3 includes nutrition by nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal.
Do NOT mark response 3 if the feeding tube is used only to hydrate with water or used for meds or only flushed to keep it patent.
Responses 1, 2, and 3 can impact reimbursement.
M1040- CMS Q and A 1/13 #6 states flu season begins when the vaccine is available for administration and typically ends 3/31. If October- March is not a part of the episode, then the answer is NA. This answer is used to exclude beneficiaries who won’t be a part of the process measure computation.
M1045- This question identifies the reason the flu vaccine was not received. Read and respond carefully.
M1100- Patient Living Situation looks at both the living situation and the availability of caregivers who provide assistance in person. Select the row that identifies the patient’s living situation. Next, select the column that shows availability of assistance without regard to the types of assistance. The caregiver does not need to live with the patient. However, when answering this question, do not include assistance received by phone or a device such as Lifeline. A call bell, however, that can reach on-site assistance in a congregate setting is considered in-person assistance.
CMS states clinical judgment determines which hours constitute “regular” daytime or nighttime for the patient based on their specific activities and needs.
Vision and Pain Items
M1200- Vision (with corrective lenses if the patient usually wears them). To answer this question, remember it is the ability to see and function within an environment. If the patient has a neck injury and cannot move his head side to side, that could obstruct functional vision. Consider situations such as that example.
Responses 1and 2 to M1200 can impact reimbursement.
M1220- Understanding of Verbal Content. Assess the patient’s ability to comprehend spoken words and instructions in the patient’s primary language. Consider both hearing and cognitive ability. Consider the need for an interpreter.
Use “UK” if the patient is not able to respond or if it is impossible to assess.
M1240- Has the patient had a formal Pain Assessment using a standardized pain assessment that can be understood by the patient and conducted by a clinician within the required time frames.
M1242- Frequency of Pain interfering with patient’s activity or movement. The patient should be assessed when moving and be certain to consider pain when sleeping and eating. Pain need not totally prevent an activity, but may cause a longer time to complete an activity or cause a desire to restrict an activity. The assessment demands more than just if a patient has pain.
Responses 3 and 4 may impact reimbursement for M1242.
Integumentary Items- M1300-M1350
This section seems to present the greatest challenge to clinicians and coding specialists.
M1300-Pressure Ulcer Assessment- Select Response 1 if the patient’s risk for pressure ulcer development was clinically assessed. Choose “yes” only if the patient was screened with a standardized tool. Use the answers on the tool to determine M1302 answer. New guidance states to give credit for the standardized tool use in M1300. But if the clinician believes there is risk and the tool sites otherwise, the clinician is to rely on his/her clinical expertise.
M1306- Identify if the pressure ulcer is a Stage II, III, IV, or Unstageable.
M1307- Identify the oldest Stage II
M1308- Identify how many pressure ulcers: Stage II, III, IV, or Unstageable.
M1308-a, b, c, and d all impact on PPS reimbursement and NRS Reimbursement
M1310-M1314- Identify the Measurements of the Stage III, IV or Unstageable
M1320- Status of the Ulcers
M1322- List the Number of Stage I Ulcers.
Responses 1, 2, 3, and 4 impact Reimbursement.
M1324- Stage the Most Problematic Stage I, II, II, or IV Pressure Ulcer
Responses 2, 3, 4, and NA impact Reimbursement
Be certain the clinician and the Coding specialist have a solid understanding of pressure ulcers. Have the WOCN and National Pressure Ulcer Advisory Panel (NPUAP) Guidance nearby.
STAGES as defined by NPUAP:
Stage I- Intact skin with non blanchable redness of a localized area frequently over a bony prominence. It may be painful and softer and/or warmer that adjacent skin.
Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. It may present as a shiny or shallow ulcer without slough or bruising.
Stage III- This ulcer presents full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. Tunneling may be present.
Stage IV- Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. May include tunneling.
Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, tan, gray, green, or brown) or eschar (brown or black) wound bed.
Healed Stage I ulcers are not considered at risk for future ulcer development.
Healed Stage II ulcers are at minimal risk for future ulcer development.
Stage I and II pressure ulcers may heal via regeneration of the epidermis across the wound surface. This is termed epithelialization.
The old adage “once an ulcer, always a pressure ulcer” is no longer considered true.
Stage III and IV ulcers never fully heal and always remain a risk. If a pressure ulcer was a Stage III at SOC and is granulating throughout the episode, the ulcer remains a Stage III ulcer. A previously Staged III or IV Ulcer that breaks down again should be staged at its worst stage.
Reverse staging is never appropriate and debridement does not change the classification of the wound for OASIS purposes.
Stage III and IV pressure ulcers, per CMS, can change into a surgical wound if a muscle flap, skin advancement flap, or rotational flap procedure is performed.
The WOCN OASIS Item Guidance states:
Newly epithelialized- all descriptors must be true:
-Wound bed completely covered with epithelium, no exudates, no avascular tissue, no slough or eschar, and no signs or symptoms of infection
Early/Partial granulation- all descriptors must be true:
-Equal to or greater than 25% of wound bed is covered with granulation tissue, less than 25% wound bed covered with avascular tissue (eschar and/or slough), no signs and symptoms of infection, and the wound edges are open and not curled under.
Fully granulating- all descriptors must be true
-Wound bed filled with granulation tissue to the level of surrounding skin or new epithelium with no dead space (depth), no avascular tissue (eschar and/or slough), no signs or symptoms
-Equal to or greater than 25% avascular tissue (eschar/slough), clean non granulating wound bed, closed or hyperkeratotic wound edges, signs and symptoms of infection, persistent failure to improve despite appropriate comprehensive wound management.
M1330- Does the patient have a stasis ulcer?
Responses 1 and 3 for M1330 impact Reimbursement.
M1332- Current Number of Observable Stasis Ulcers.
Responses 2, 3, and 4 for M1332 impact Reimbursement.
M1334- Status of Most Problematic Observable Stasis Ulcer.
Responses 1, 2, and 3 for M1334 impact Reimbursement.
M1342- Status of Most Problematic Observable Surgical Wound
Responses 2 and 3 for M1342 impact Reimbursement
The most problematic wound may be the largest, the infected, or the most resistant to treatment. For this assessment purpose, a closed site, whether by healing, sutures, staples, or chemically bonding is documented as a surgical wound until re-epithelialization. See CMS Q&A 13 Surgical incisions healing by primary intention do not granulate. Because of this, the only response that could be appropriate for surgical wound healing by primary intention would be 0-Newly epithelialized or 3- Not healing. Newly epithelialized should be chosen if the surgical incision has epidermal resurfacing across the entire wound surface, and no signs and symptoms of infection exist.
Cardiac and Respiratory Items
M1400 When is the patient dyspneic or noticeably Short of Breath. The clinician should answer as to what is true the day of assessment; either during the assessment or the prior 24 hours. If the patient becomes SOB when dressing, talking, or brushing their teeth, that would require a Response 2-minimal exertion. If the patient is ordered O2 24 hours a day, then assess with the oxygen. If O2 is used intermittently, then do not use O2 when assessing. Remember, the assessment is to assess function based on use of O2, not the physician’s order of O2.
Note the difference in scoring Pain and Dyspnea. M1042 states frequency of pain interfering with an activity or movement. In assessing dyspnea, interference is not mentioned.
Responses 2, 3, and 4 for M1400impact Reimbursement
M1500 and M1510 Heart Failure and Follow up. Consider any new or ongoing heart failure symptoms that occurred at or since the previous OASIS assessment. Read the responses carefully noting Response 1 means on the same day the symptoms were identified and the doctor acknowledged receipt of the information.
M1610- Urinary Incontinence or Urinary Catheter Presence is assessing for urinary diversion such as ileal conduit, urostomy, ureterostomy, nephrostomy, with or without a stoma. Choose Response 1 if there is any incontinence including “when I cough” or if time-voiding is used. If a catheter is inserted during the comprehensive assessment, select Response 2. However, do not use Response 2 if the only reason for inserting the catheter is to irrigate with an antibiotic.
Response 2 for M1610 impacts Reimbursement.
M1615- When does Urinary incontinence occur?
Be careful as to what constitutes Day and Night for the patient.
M1620-Bowel Incontinence Frequency.
Responses 2, 3, 4, and 5 impact Reimbursement
M1630- Ostomy for Bowel Elimination
Responses 1 and 2 for M1630 impact Reimbursement.
Cognitive, Anxiety, Behavior Items
M1700- Cognitive Functioning should be assessed only the day of assessment.
M1710-Confusion-The extent the patient is confused should take into account behavior of the past 14 days.
M 1720- Anxiety symptoms should be assessed for the 14 days prior to and the day of the assessment.
M1730- Depression symptoms should be assessed the day of the assessment and as the tool used dictates. (If using a standardized tool such as the PHQ2, the prior 14 days are utilized). Tools such as the PHQ2 are used for screening only not as diagnostic tools. Be certain when using these tools that language is not changed. The patient is the source of the information, not the caregiver. A total score of 3+ should require additional screening.
M1740-Cognitive, Behavioral, and Psychiatric Symptoms must be noted from the recent past, especially as has occurred several times, or at least one time per week.
Consider neurological deficits related to stroke, mood disorders, anxiety disorders, or those who receive opioid therapy. Consider specific behaviors severe enough to make the patient unsafe to self or others or cause considerable stress to caregivers or require additional intervention. There is a need to determine if any non compliance is due to a disorder or a choice made by the patient.
M1745-Frequency of Disruptive Behavior Symptoms should be noted from “less than once a month” to recent past including at least one day more than the past month. Consider sleeplessness, agitation, wandering, or combativeness.
M1750- Psychiatric Nursing Services should be placed on the POC.
The above information is intended to assist the clinician and coding specialist hone in on areas that present frequent questions and/or routinely require addition clinical documentation and clarification in order to assign codes at the highest level of specificity. In the last article of the series, we will look at the functional questions and focus in on why auditors are so easily able to spot incongruence between the clinical assessment and the related frequencies and duration as well as specific outcomes planned and those actually achieved.
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?