Posts Tagged ‘Coding’

OASIS C Publicly Reported Outcomes

Saturday, September 14th, 2013

As an adjunct to the 6 part OASIS and Coding Go Hand in Hand Series, many individuals have asked for a list of OASIS Publicly Reported Outcomes. We have complied, dividing the OASIS M questions into the following CMS categories:

Home Health Outcomes (Risk Adjusted)

M1340- Does this Patient have a Surgical Wound?

M1400- When is the Patient dyspneic or noticeably Short of Breath?

M1610- Urinary Incontinence or Urinary Catheter Presence.

M2020- Management of Oral Medications


Utilization Outcomes  (Risk Adjusted)

M0100- RFA6 Emergent Care without Hospitalization

M0100- RFA9 ACH or Discharge to the Community (disposition of the patient)


Potentially Avoidable Events

M1306- At least Unhealed Pressure Ulcer at Stage II or Higher

M1306- Increased Pressure Ulcers

M2300- Emergent Care (looking for Wound Infection)


Process Measure Outcomes (no Risk Adjustment)

M0102- Physician ordered Start of Care

M0104- Referral Date

M0030- SOC Date

M0032- ROC Date

M0100- Reason for Assessment

M1040-M1045 Influenza Vaccine

M1050-M1055 Pneumococcal Vaccine

M1240- Pain assessment

M1300-Pressure Ulcer Assessment

M1510-Heart Failure


M1910-Multi Factor Falls Risk assessment

M2002- Medication Follow up

M2004- Medication Intervention

M2015- Patient/CG Drug Education Intervention

M2250- POC Synopsis

M2400a- Intervention Synopsis- Diabetic Foot Care

M2400b-Intervention Synopsis- Falls Prevention

M2400d- Intervention Synopsis- Monitor/Mitigate Pain

M2400e- Intervention Synopsis- Pressure Ulcer Treatment


Payment (PPS) Items

M0110- Episode Timing

M1020/M1022/M1024 Diagnoses

M1030- Therapies


M1242- Frequency of Pain Interfering with Activity

M1308- Current Number of Unhealed (non epithelialized) Pressure Ulcers at Each Stage

M1330- Does the Patient have a Stasis Ulcers

M1322-Current Number of Stage 1 Pressure Ulcers

M1324-Status of Most Problematic (observable) Pressure Ulcer

M1334- Status of Most Problematic Stasis Ulcer

M1342- Status of the Most Problematic (Observable) Surgical Wound

M1400-When is the Patient dyspneic or noticeably Short of Breath

M1610- Urinary Incontinence or Urinary Catheter Presence

M1620- Bowel Incontinence Frequency

M1630- Ostomy for Bowel Elimination

M1810- Ability to Dress Upper Body

M1820-Ability to Dress Lower Body


M1840-Toilet Transfer

M1850-Transfer Bed to Chair, or ability to turn and position self in bed if bedfast


M2030-Management of Injectable Meds

M2200-Therapy Visit Needs

OASIS and Coding Go Hand in Hand: Reinforcing Clinical Understanding Part 5

Saturday, September 14th, 2013

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.

Living Situation

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

d/t slough/eschar.

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

Not Healing

-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.

OASIS and Coding Go Hand in Hand: Reinforcing Our Understanding Part 2

Saturday, September 14th, 2013

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.

Part 2

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

Non-Routine Supplies

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.

OASIS and Coding Go Hand in Hand: Reinforcing Clinical Understanding Part 4 – Let’s Start Talking OASIS and Let’s Start Coding

Friday, August 23rd, 2013

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.

HOSPICE 2014 Proposed Rule and CODING

Thursday, June 13th, 2013

Medicare Program; 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform

In the May Select Data ezine, we commented re the overall proposed rule. In this article, let’s discuss specifically the CMS clarification of a number of coding requirements.

Clarifying Diagnosis Coding in Hospice Claims 

The proposed rule solicits comments with the intent of clarifying a number of coding requirements in Hospice; especially regarding non specific diagnoses such as Debility and Adult Failure to Thrive (AFTT)

Longstanding policy requires that hospices as well as home health agencies adhere to ICD-9-CM coding guidelines.  CMS clarifies that hospice providers should not use certain non-specific diagnoses such as Debility and Adult Failure to Thrive which are essentially symptom syndromes and that, under coding guidelines, are not principal diagnoses. Claims submitted with these diagnoses would be returned to the provider, under the proposed rule, for a more definitive appropriate diagnosis. Hospices should code the principal diagnosis using the underlying condition that is the main focus of the patient’s care. However, Debility and Adult Failure to Thrive can be listed on claims as secondary diagnoses that can support prognosis, if appropriate.

According to the Proposed Rule, these actions are being taken as root causes are not being listed in at least 13.9% of Hospice claims where Debility has been the principal diagnoses listed on claims. CMS stated concern that individualized patient-centered plans of care are difficult to develop for patients with ill defined principal diagnosis and that the patient may not receive the full hospice benefit allowed.  CMS is interested in gaining a better understanding of those who are served by the Medicare hospice program.

What is the Impact of this Segment of the Proposed Rule?

Agencies should cease the use of Debility and Adult Failure to Thrive as primary diagnoses as, at the very least, the diagnoses are symptom codes and when used as a primary diagnosis, are not in keeping with ICD-9-CM Coding Guidelines. Instead, choose a primary diagnosis that is more descriptive of the patient’s disease and/or describes the disease trajectory and end-of-life palliative interventions.

Use other comorbidities and health conditions that support the prognosis, as needed.

Agencies should use, if appropriate, these Debility and Adult Failure to Thrive diagnoses in a secondary diagnosis position on the claim.

When assessing to code, remember to review the full Plan of Care to determine body system, signs and symptoms, psychological, emotional, and spiritual issues that have been identified as requiring the greatest need for palliative interventions.  Review physician orders as well as the medication profile. Each of these segments contribute to the primary and overall focus of care.

Patients under the Hospice benefit with ill defined diagnosis will soon have claims rejected under this proposed rule. Ill defined diagnoses and a POC that has changed little for a long period of time will soon be chosen for audit or claim denial. Don’t let your agency have claims denied because of poor coding. Take steps NOW!