In Part 1, we discussed, in general, the case mix adjustment model, case mix diagnoses, garnering case mix points, and the Initial and the Comprehensive assessment.
Part 2, 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
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.
In Parts 5 and 6 we will review OASIS more in-depthly.
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.