CMS finalizes OASIS-D guidance manual ahead of January 2019 implementation date
Wounds and OASIS Documentation Presentation
Wounds and OASIS Documentation Key Facts
Upon completion of this session, attendees will be able to:
- Documenting surgical wounds
- Identifying and documneting skin ulcers
- Documenting other skin lesions and skin alteration
New Changes for OASIS C2 Data Sets Revisions
New OASIS C2 Revisions: Thinking about finalizing your OASIS-C2 forms? Read this before you do.
November 8, 2016, new revisions to OASIS-C2 item set. Select Data’s very own Compliance Officer, Susan Carmichael, MS, RN, CHCQM, and VP of Services Integration, Pam Hernandez, found an issue with multiple OASIS answers in the latest release from CMS for the OASIS-C2 Guidance Manual 6-29-16. Carmichael notified the Centers for Medicare & Medicaid Services of these inconsistencies last month. A corrected version of the OASIS C-2 Item Set, correcting 2 minor typos on page 3 of the all-time points version, has been posted on the OASIS Item Set page. The document can be found in the Downloads section (CMS, 2016).
For a full review of these OASIS-C2 corrections and more, attend our free 30-minute Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
SourcesCenters for Medicare & Medicaid (2016). OASIS Data Sets. CMS.gov. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/OASIS-Data-Sets.html
Select Connects With Clinicians
Free 30-minute trainings to help clinicians improve OASIS assessment accuracy.
You're Invited to attend
"Select Connects With Clinicians"
What is Select Connect with Clinicians?Every other month Select Data sponsors a 30 minute training free of charge for clinicians and support staff working in Home Health. This is an effort to support OASIS accuracy and compliance and to promote better outcomes for patients. For more information please send an email to email@example.com or call 866-538-CODE (2633). For assistance with PDGM, Coding, and OASIS & documentation review, contact SELECT DATA at 1.800.332.0555.
Pre-Claim Review Demonstration
Effective August 1, 2016, CMS institutes Pre-Claim review in Five States. The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017.
Pre-Claim Review Begins in Five States: August 1st is the First Date, Illinois is the First State
Effective August 1, 2016, Home Health Agencies in five states will begin the three year Medicare pre-claim review demonstration by which an agency will complete the patient assessment, initiate procedures, and establish services then submit a request via fax, mail, or electronic submission of medical documentation to the respective MAC for approval prior to the submission of the final claim. The MAC is expected to provisionally approve or disapprove the services within 10 business days. If the MAC denies the payment, the agency can resubmit a new request
What is the Difference between Pre-Claim and Prior Authorization?
Per CMS, with a Pre-Claim review, services have already begun and the request is submitted after assessments and services have been completed or begun. Prior Authorization requires a request prior to services being initiated. CMS states this new requirement is not creating new documentation requirements. The agencies are to submit the same information they currently submit for payment, but do it earlier in the process.
What States are Included in the Demonstration?
The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017. (Pre-Claim Demonstration for HH FAQ, 6/8/2016)
The demonstration is expected to have minimal effect on beneficiaries per CMS. The Pre-Claim request is submitted after a RAP but before the submission of the final claim. However, some agencies have expressed concern, stating that in an already fragile bottom line market, any further delay of payment could be harmful to the agency’s financial health.
CMS states the five states chosen “show extensive evidence of fraud and abuse in the Medicare home health benefit for treatment performed in these states” (CMS Pre-Claim Demonstration for HH, FAQ, 6/8/2016).
Decision, Documents Needed, and Options
For pre-claim review, the MAC will make the determination using regulation, National Coverage Determination, and Local Coverage Determination requirements. The MACs will be expected to respond within 10 business days for an initial request and 20 business days for a resubmitted request following a denial.
Resubmissions may be sent an unlimited number of times as necessary, but obviously, the agency will want to get the appropriate information submitted up front to minimize payment delays. There will be a tracking number on each decision notice and that number will be used on the claim.
CMS states that, generally those claims that had the provisional review will not have additional review. However, note that Z-PICs conduct targeted prepayment and post payment review which will continue and CERTS review a stratified random sample of claims annually to identify improper payments. That CERT sample may include the pre-claim reviewed items also.
If an agency would be denied payment and after resubmission still receives denial, they could follow the appeal process. If an agency submits a claim without a pre-claim review, per CMS, if that claim is deemed payable, it will be paid at a 25% reduction of the full claim benefit. Obviously, an agency would have serious financial if that became the agency process.
SourcesCenters for Medicare & Medicaid (2016). Pre-Claim Review Demonstration for Home Health Services. CMS.gov. Retrieved from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html
OASIS-C1 is the current version of the OASIS data set. It was developed from OASIS-C to accommodate the transition to the ICD-10 diagnosis coding system, as well as and other important stakeholder concerns such as updating clinical concepts, and revised item wording and response categories to improve item clarity.
OASIS-C1 Revisions for ICD-9 to ICD-10 Implimentation
The OASIS-C1 data item set was approved by the Office of Management and Budget (OMB) on February 6, 2014 and scheduled for implementation on October 1, 2014. However, on April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which announced October 1, 2015 as the new compliance date. Due to this delay, CMS had to ensure the collection and submission of OASIS data continued, until ICD-10 could be implemented. Therefore, we have made interim changes to the OASIS-C1 data item set to allow use with ICD-9 until ICD-10 is adopted. .
Frequently Asked Questions
OASIS-C1 / ICD-10 version:
- TheOASIS-C1 / ICD-10 version of the OASIS data set replaces the five ICD-9-CM-based items in the OASIS-C1 / ICD-9 data set (M1010, M1016, M1020, M1022, M1024) with the corresponding ICD-10 items (M1011, M1017, M1021, M1023, M1025). A table showing the differences between the OASIS-C1 / ICD-9 and OASIS-C1 / ICD-10 versions is available below in the Downloads section.
- TheOASIS-C1 / ICD-10 version of the OASIS data set received Paperwork Reduction Act approval from OMB on May 29, 2015.
- The OASIS-C1/ICD-10 data set is scheduled to be the version required for all assessments completed on or after October 1, 2015, when ICD-10 is scheduled to be implemented by CMS.
- The complete set of OASIS-C1/ICD-10 data items, as well as the subsets of OASIS-C1/ICD-10 items that are to be collected at each time point (Start of Care, Recertification, etc.) can be found in the Downloads section below.
- Detailed instructions for use of the OASIS-C1/ICD-10 data set can be found in OASIS-C1/ ICD-10 Guidance Manual, which is posted on the OASIS User Manuals page (see the link in the “Related Links” section below.)
- If you have additional questions about completion of the OASIS-C1/ ICD-10 items, you can consult the OASIS Q&As using the "OASIS Q&As" link in the Related Links section below.
- TheOASIS-C1 / ICD-10 version data must be encoded and submitted to CMS using the OASIS Data Specifications, version 2.12.n. These can be accessed via the “OASIS Data Specifications” link in the “Related Links” section below.
The delay of ICD-10 also impacted the implementation of OASIS C1 that had been scheduled for implementation October 1, 2014. OASIS C1 was delayed as five (5) of the data items require the use of ICD-10 codes. CMS published interim changes to the OASIS C1 data set. CMS modified OASIS C1 version to be implemented January 1, 2015, three months later than the original implementation date.
The new data set will be called “OASIS C1/ICD-9” hybrid version containing all the OASIS C1 changes that were approved in February, 2014, but the specific ICD-10 items will be replaced with their original ICD-9 coding item counterparts. That means that:
- M1010 (inpatient diagnosis) will be in the hybrid version instead of M1011.
- M1016 not M1017 will be present in the January, 2015 version.
- M1020/M1022/M1024 will be back instead of the proposed M1021/M1023/M1025.
Starting January 1, 2015, OASIS assessment data will be submitted to CMS via the Assessment Submissions and Processing (ASAP) System, stated CMS.
The new OASIS C1/ICD-9 version is to be used on all assessments with a M0090 date on or after January 1, 2015.
OASIS-C1 / ICD-9 version:
- A modified version of OASIS-C1 (referred to as “OASIS-C1/ ICD-9 version.”) was created. It replaced the five OASIS-C1 items that use ICD-10 diagnosis codes (i.e. - M1011, M1017, M1021, M1023, M1025) with the corresponding ICD-9-CM based items from OASIS-C (i.e. – M1010, M1016, M1020, M1022, M1024).
- TheOASIS-C1/ ICD-9 version underwent an “emergency” Paperwork Reduction Act review by OMB and was granted approval on October 10, 2014 for implementation on January 1, 2015.
- The OASIS-C1/ICD-9 data set is required for all assessments completed on or after January 1, 2015 and until ICD-10 is implemented or until another disposition is made by CMS.
- The complete set of OASIS-C1/ICD-9 data items, as well as the subsets of OASIS-C1/ICD-9 items that are to be collected at each time point (Start of Care, Recertification, etc.) can be found in the Downloads section below.
- Detailed instructions for use of the OASIS-C1/ICD-9 data set can be found in OASIS-C1/ ICD-9 Guidance Manual, which is posted on the OASIS User Manuals page (see the link in the “Related Links” section below.)
- If you have additional questions about completion of the OASIS-C1/ ICD-9 items, you can consult the OASIS Q&As using the "OASIS Q&As" link in the Related Links section below.
- TheOASIS-C1 / ICD-9 version data must be encoded and submitted to CMS using OASIS Data Specifications, version 2.11.n. These can be accessed via the “OASIS Data Specifications” link in the “Related Links” section below.
The Eight items Scheduled for Elimination
|M1012 List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care||To be deleted at all time points
|M1012 List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care.||To be deleted at all time points|
|M1310 Pressure Ulcer Length||To be deleted at all time points|
|M1312 Pressure Ulcer Width||To be deleted at all time points|
|M1314 Pressure Ulcer Length||To be deleted at all time points|
|M1350 Does the Patient have a Skin Lesion or Open Wound||To be deleted at Follow up FU and Discharge DC only|
|M1350 Does the Patient have a Skin Lesion or Open Wound||To be deleted at Follow up FU and Discharge DC only|
|M1410 Respiratory Treatments||To be deleted at Discharge DC|
|M2110 How often does the patient receive ADL or IADL assistance||To be deleted at Discharge DC only
|M2440 For what Reasons was the patient Admitted to a Nursing Home?:||To be deleted at all time points|
M1011 is a new M question that is expected to be collected for Case-Mix Adjustment purposes.
As of December, 2013, CMS states the number of questions per RFA type are as follows
|RFA 1||SOC decrease from 95 to 91 questions|
|RFA 3||ROC decrease from 80 to 76 items|
|RFA 4||Recertification/FU remains the same with M1350 deleted but M1011 added|
|RFA 6||Transfer decrease from 19 to 18 questions|
|RFA 9||RFA 9 Discharge decrease from 61 to 55 items|
Sequential order by item
|M1700||The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in response “2”|
|M1730||“Validated” was added for clarity since both “standardized” and “validated” are specified in the OASIS guidance manual. Also added was the phrase “patient was screened” to response “2” for clarity and consistency|
|M1010||Inpatient diagnosis will be changed to item number M1011 Inpatient Diagnosis|
|M1016||Diagnosis requiring medical or treatment regime change within 14 days will be changed to M1017 Diagnoses requiring medical or treatment regime change within 14 days|
|M1020||Primary Diagnosis changed to M1021|
|M1022||Other diagnoses changed to M1023 Other Diagnoses|
|M1024||Payment Diagnoses changed to M1023|
|M1032||Risk for hospitalization changed to M1033 Risk for hospitalization|
|M1334||“Response 0 – Newly Epithelialized” will be eliminated since this is an inappropriate option for this item (epithelialized stasis ulcers are not reported in OASIS)|
|M1040||Influenza vaccine changed to M1041 Influenza vaccine data collection period|
|M1045||Reason influenza vaccine not received changed to M1046 Influenza vaccine received|
|M1050||Pneumoncoccal vaccine changed to M1051 Pneumococcal vaccine|
|M1055||Reason PPV not received is changed to M1056 Reason PPV not received|
|M1308||Current number of unhealed non-epithelialized pressure ulcers at each stage is replaced by new item M1309 Worsening in pressure ulcer status since SOC/ROC. Column 2 is deleted|
|M1310, M1312, M1314||Pressure ulcer length, width, depth DELETED
|M1310, M1312, M1314: M1340||New skip directions were needed due to deletion of M1350 at follow-up and discharge
|M1310, M1312, M1314: M1340: M1350||Skin lesion or open wound DELETED at Recert and D/C
|M1400||The “e.g.” abbreviation was eliminated and replaced with “for example” to increase clarity in responses “2” and “3”|
|M1410||Respiratory treatments DELETED at discharge|
|M1500||The wording in the item was revised to clarify that the reporting period includes the time of the assessment|
|M1510||Wording in item was revised to clarify that reporting period includes the time of the assessment; “e.g.” abbreviation eliminated and replaced with “for example” in responses “2” and “5”|
|M1610||The “i.e.” abbreviation was eliminated and replaced with “specifically” to improve clarity in response “2”|
|M1730||“Validated” was added for clarity since both “standardized” and “validated” are specified in the OASIS guidance manual. Also added was the phrase “patient was screened” to response “2” for clarity and consistency|
|M1740||: The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in response “4”|
|M1800||The “i.e.” abbreviation was eliminated and replaced with “specifically” to improve clarity in item stem|
|M1830||The phrase “throughout the bath” was deleted from the response “5” to include patients who need intermittent assistance bathing self in bed, at the sink, in a bedside chair, or on the commode|
|M1860||The “i.e.” abbreviation was eliminated and replaced with “specifically” to improve clarity in response “0”. The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in response “1” and “2”|
|M1880|| The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in the item stem. The “i.e.” abbreviation eliminated and replaced with “specifically” to improve clarity in response “0”
|M1890||The “e.g.” abbreviation eliminated and replaced with “for example” to improve clarity in response “1”|
|M1900||To improve clarity, responses were modified so that all the relevant ADLs/IADLs are listed. The “i.e.” abbreviation was eliminated and replaced with “specifically,” and the “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity|
|M1910||Unnecessary wording was deleted. The words “standardized, validated” have been added for consistency with the instructions in the OASIS-C guidance manual. The terms “no, low or minimal” have been added to reflect the fact that many falls risk assessment tools use these three terms to indicate low risk and congruency with terminology is more apparent.|
|M2000||The “i.e.” was replaced with “specifically,” and “e.g.” was replaced with “for example. Wording was revised to reflect the OASIS guidance manual. The term “adverse” was added to describe drug reactions while the term “significant” was added to describe side effects, and “non-adherence” was added to non-compliance.|
|M2004||Wording in item and the NA response was revised to clarify that the reporting period includes the time of the assessment. The “e.g.” abbreviation was eliminated and replaced with “for example” in responses “2” and “5”|
|M2015||Wording in the item as well as the NA response was revised to clarify that the reporting period includes the time of the assessment. The word “significant” was added to the item to describe side effects|
|M2040||The data collection period was clarified in the item. The term “ability ”was removed from the item title to be consistent with similar items|
|M2100||Types and sources of assistance changed to M2102 Types and sources of assistance. The Item title was simplified to “Types and Sources of Assistance”. Column headings were revised to clarify that “caregiver” refers to non-agency caregivers (such as family members, friends, or privately paid caregivers) and excludes care by agency staff; added text to column heading to clarify that “No assistance needed from Caregiver in this area” means that the patient is independent or does not have needs in this area. Response options were simplified by combining “Caregiver(s) not likely to provide assistance” and “Caregiver(s) unwilling/unable to provide assistance”|
|M2110||Frequency of ADL or IADL assistance DELETED at discharge|
|M2250||Plan of Care synopsis: The “Not Applicable” responses were revised for rows “b,” “c,” “d,” “e,” “f,” and “g” to add detail, improve clarity, and be consistent with guidance in the OASIS-C manual. The line between “NA” and the text boxes were removed to improve clarity|
|M2250: M2300||Wording in item was revised to clarify that the reporting period includes the time of the assessment. The word “status” was added to “holding/observation” to bring the term into alignment with current instructions in the OASIS-C manual|
|M2250: M2300: M2310||The wording in the item was changed to “seek and/or receive” to bring it into alignment with current instructions in OASIS-C manual. The response “1” was revised to include “adverse drug reactions” to being it into alignment with current instructions in the OASIS-C manual.|
|M2400||The wording in the item was revised to clarify that the reporting period includes the time of the assessment. “Not Applicable” responses have been modified to add detail, improve clarity, and be consistent with responses in M2250 as well as the guidance in the OASIS-C manual. The line between “NA” and the text boxes was removed to improve clarity|
|M2430||The “e.g.” abbreviation was eliminated and replaced with “for example” to improve clarity in responses “3” and “5”
|M2440||Reasons for nursing home admission DELETED|
In total, unless additional changes are made, OASIS will move from 114 items to OASIS C1 with 110 items
HIS Data Elements
CMS believes the standardized data collection instrument will allow a more uniform patient-level data collection for quality reporting purposes. There are 51 data elements to be utilized on two HIS forms: Admission and Discharge. There are both administrative data elements as well as clinical process data elements. The latter includes:
- Pain Screening and full Assessment
- Dyspnea (SOB) Screening and Treatment
- Medications (Opioids and Bowel Regimen)
- Patient Preferences
- Beliefs and Values
7 NQF endorsed quality measures
- 1634 Pain Screening
- 1637 Pain Assessment
- 1639 Dyspnea Screening
- 1638 Dyspnea Treatment
- 1637 Patients treated with opioids and given a bowel regimen
- 1641 Treatment Preferences
- 1647 Beliefs/Values Addressed
OASIS-C refinements were focused on clinical assessment using standardized tools with subsequent processes chosen for intervention and care for the patient.
Risk assessment followed by specific process algorithms is a focus. With OASIS-C, CMS to included a way to measure an agency's use of evidenced based best practices. Since research supports the fact that best practices assist to prevent the exacerbation of serious conditions, then it is easy to see the CMS expectation that processes of care implemented according to evidenced based guidelines will ultimately lead to better clinical outcomes.
Diagnosis coding sections changes included M0230, M0240, and M0246 will be identified as M1020, M1022, and M1024. CMS is seeking an accurate portrait of the patient and their conditions. CMS eliminated the severity level identification and instead moved to listing other diagnoses "in the order to best reflect the seriousness of the patient's condition and justify the disciplines and services provided". The diagnoses should be sequenced by "the degree they impact the patient's health and need for home health care, rather than the degree of symptom control". Documentation is key. Expert clinician/coders reviewing the record for proper coding will be vital. A point to note: Be very aware of coding hypertension, GERD documentation, Low vision documentation omissions, diabetes documentation and the correct coding choice, there are over 10, and personal histories of falls.
OASIS B refinements were focused on finance.
Outcome and Assessment Information Set (OASIS)
The OASIS is a key component of Medicare's partnership with the home care industry to foster and monitor improved home health care outcomes and is an integral part of the revised Conditions of Participation for Medicare-certified home health agencies (HHAs).
Background of Outcome and Assessment Information Set (OASIS)
Most data items in the OASIS were derived in the context of a CMS-funded national research program (co-funded by the Robert Wood Johnson Foundation) to develop a system of outcome measures for home health care. This program and the OASIS, have evolved over 10-year developmental period. The core data items were refined through several iterations of clinical and empirical research. Other items were added later by a workgroup of home care experts to augment the outcome data set with selected items deemed essential for patient assessment. The goal was not to produce a comprehensive assessment instrument, but to provide a set of data items necessary for measuring patient outcomes and essential for assessment – which HHAs in turn could augment as they judge necessary. Overall, the OASIS items have utility for outcome monitoring, clinical assessment, care planning, and other internal agency-level applications.
The Outcome and Assessment Information Set (OASIS) is a group of data elements that:
- Represent core items of a comprehensive assessment for an adult home care patient; and
- Form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).
The OASIS items were designed for the purpose of enabling the rigorous and systematic measurement of patient home health care outcomes, with appropriate adjustment for patient risk factors affecting those outcomes. Outcomes have been defined in many ways, but those derived from OASIS items have a very specific definition: they measure changes in a patient’s health status between two or more time points.
The OASIS was designed to provide the necessary data items to measure both outcomes and patient risk factors. The OASIS is thus key to outcome measurement and performance improvement using outcomes. OASIS data items address sociodemographic, environmental, support system, health status, functional status, and health service utilization characteristics of the patient. The data are collected at start of care, 60-day follow-ups, and discharge (and surrounding an inpatient facility stay).
Policy regarding The Outcome and Assessment Information Set (OASIS)
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.
Frequently Asked Questions
OASIS data items encompass sociodemographic, environmental, support system, health status, and functional status attributes of adult (nonmaternity) patients. In addition, selected attributes of health service utilization are included. These several different types of attributes should be part of a comprehensive patient assessment, but we emphasize that the OASIS was not developed as a comprehensive assessment tool.
In addition to measuring patient outcomes, OASIS data have three important uses in the areas of:
- Patient assessment and care planning for individual adult patients;
- Agency-level case mix reports that contain aggregate statistics on various patient characteristics such as demographic, health, or functional status at start of care; and
- Internal HHA performance improvement.
All applications build on and are implemented most efficiently and effectively when OASIS data items are thoroughly integrated into HHA clinical documentation.
Because most OASIS items describe patient health and functional status, they are useful in assessing the care needs of adult patients. HHAs will find it necessary to supplement the OASIS items in order to comprehensively assess the health status and care needs of their patients (for example, the OASIS does not include vital signs which are typically included in patient assessments).
Clinicians have remarked that their first impression is that the OASIS data set appears lengthy. However, they later acknowledge that its length is not due to new items in addition to those HHAs currently use in their assessments. Rather, it is due to the greater precision that characterized many of the items and simply requires more detailed descriptions of each response. This precision is necessary to measure outcomes, which is the primary purpose of the data set, but it also contributes to more precise assessment of patient condition. Once clinicians become familiar with the items, they generally find that assessment time does not change significantly because a few new items are added, rather that existing items are replaced with their OASIS counterparts.
The enhanced assessment is also useful in care planning, since it facilitates identifying areas where patient status differs from optimal health or functional status. As more precise assessments lead to improved care planning, they in turn facilitate better care because clinicians can more effectively focus on improving or maintaining current (precisely measured) health status.
CMS has finalized two rules relating to HHAs. One rule revises the existing HHA Conditions of Participation by requiring that HHAs collect OASIS data. The other expands those new Conditions of Participation by requiring HHAs to report OASIS to their State survey agency.
HHAs are required to electronically transmit OASIS data to the standard State system, which has been installed by CMS. CMS has installed the additional software to accommodate this data transmission in each State. The State agencies have the overall responsibility for collecting OASIS data in accordance with CMS specifications. The State is also responsible for preparing OASIS data for retrieval by a central repository to be established by CMS.
One of the goals for OASIS automation is to fulfill the HHA provisions of the Balanced Budget Act (BBA) of 1997. The BBA includes a Medicare requirement for HHA prospective payment that depends on the data acquired by the OASIS system. This provision of the BBA will be effective for HHAs’ cost reporting periods beginning on or after October 1, 2000. Another CMS goal is to provide States with enhanced ability to direct on-site HHA inspection resources through the use of OASIS data. See OASIS Regulations for details.
|RFA Type||RFA Description||Assessment Completed||Locked Date||Submission Timing|
|01||SOC – further visits planned||Within 5 calendar days after the SOC date (SOC = Day 0)||Effective 6/21/2006 No required lock date||Effective 6/21/2006 Transmission required within 30 calendar days of completing the assessment (M0090)|
|03||ROC – after inpatient stay||Within 2 calendar days of the facility discharge date or knowledge of patient’s return home|
|04||Recertification - F/U||The last 5 days of every 60 days, i.e., days 56-60 of the current 60-day period|
|05||Other F/U||Complete assessment within 2 calendar days of significant change of patient’s condition|
|06||Transferred to Inpatient Facility – not discharged from agency||Within 2 calendar days of the disch/trans/death date or knowledge of a qualifying transfer to inpatient facility|
|07||Transferred to Inpatient Facility – discharged from agency||Within 2 calendar days of the disch/trans/death date or knowledge of a qualifying transfer to inpatient facility|
|08||Died at home||Within 2 calendar days of the disch/trans/death date|
|09||Discharged from agency: Not to Inpatient Facility||Within 2 calendar days of the disch/trans/death date|
Since its adoption, the OASIS Data set has been continually refined. You can read more about the specific changes in our posting, OASIS Updates.
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.
Payments of home health claims are calculated using case-mix groups derived from the OASIS assessments of the skilled patient /beneficiary. Home health agencies submit the case-mix groups on their claims as a HIPPS code. January 1, 2015 saw the elimination and/or change of nearly 200 diagnoses once eligible for case mix under the Pulmonary, Psych 1 and 2 as well as blindness/low vision categories. OASIS documents are now submitted to the ASAP national not state) repository and claims are submitted and processed by the Fiscal Intermediary Shared System (FISS). Until the change, the transmission of OASIS data and the claims processing systems were entirely separate. No comparison between the OASIS information and the claim data was performed. The OIG, in a 2012 report identified this issue as payment vulnerability and the OIG urged CMS to develop and implement systems that would allow a comparison between the OASIS and the claim information prior to finalizing claims for payment. This is a part of moving away from the “Pay and Chase” model identified by former Secretary Sibelius as an antiquated model. The aggressive algorithms that are now used to screen claims are one step in this model The new system is ready. Beginning April 1, 2015 the FISS system will validate the HIPPS code on submitted claims against OASIS data. If it is found that the HIPPS code on the claim is different than the HIPPS code on the OASIS file, the claims processing system will pay the claim based on the HIPPS code from the OASIS document. This additional point of data validation/review is expected to occur within the normal 14 day final claim processing time frame. CMS does not expect it to delay agency payments. At this time if no OASIS information is on file, the claim will process and pay based on the HIPPS code reported on the claim. But no OASIS data on file will be flagged. Clients face penalties if they are not submitting OASIS data as Federal regulations require the submission of OASIS data as a condition of payment. If, during medical review, no OASIS information is found on file the claim is expected to be denied. The OIG recommended that CMS use this claims- matching process to deny home health claims when the OASIS information is not on file during this data validation check. CMS plans to enforce this requirement so your agency must be ready. Coding, billing, and compliance are what come to mind when the industry thinks of Select Data. Call us today: 1.800.332.0555
What does this mean for your agency?The 2015 PPS Rule brings many changes including the elimination of case-mix points for nearly 200 codes from pulmonary, psych 1 and 2, as well as blindness/low vision diagnoses categories. OASIS items such as M1200 (Vision) and M2030 (Injectable drug use) will lose case-mix value. In general, there is a reduction of case mix diagnoses for clinical items but high therapy (14+ visits) episodes garner more points. Industry experts believe we will see more therapy in cases as the reward for higher therapy episodes is there. Other experts believe the trend of declining home health aide utilization will continue as agencies strive to better manage certain cases such as those with high ADL assistance. In certain of these cases, an OT consult, plan, and OT intervention could decrease dependence on an aide and focus more on patient and/or patient caregiver optimal level of functioning and caregiving.
Recalibration of case mix adjusterThe recalibration of the home health case-mix adjuster can have significant impact on individual agencies. From 2000-2014, the 124 variables remained relatively the same, but in 2015 there has been significant change as CMS overhauls the four equation model which has been used to determine clinical and functional points for episodes. The new 124 variable model saw 63 prior variables dropped with 21 new variables added. Collectively, this new model impacts all 153 case-mix categories. (Dombi, 11/19/2014 NAHC Seminar). CMS states the changes are to be budget neutral, however, some home health experts state home health agencies that focus on skilled nursing services with less therapy are likely to experience reimbursement decreases. Many experts have states their surprise at the reward for high therapy episodes. CMS contends the changes occurred because of utilization patterns in 2013 final claims data. This means that one thing is clear, therapists are documenting time spent with the patient better than nurses. They are accustomed to justifying billable time. Nurses are going to need to be more exact as to the tasks and education completed with the patients and families and have the documentation that supports the depth of time spent to achieve the skilled visit.
Coding Guidelines have not changedThe Coding Guidelines have not changed, so coding for COPD, depression or Alzheimers will still occur as appropriate. Those codes just will not garner the case mix points once attached. CMS continues to seek the appropriate portrait be painted of the patient’s conditions and needs.
Additional areas of focusFor instance CMS is honing in on insulin injections being given by home health agencies. CMS expects to see supportive diagnoses that justify why the patient requires agency personnel to administer prescribed insulin. They have identified 164 diagnoses, certain of which they expect to see on final claims when a patient is receiving agency administered insulin injections. Those diagnoses categories include:
- Cognitive/behavioral conditions
- Vision condition
- Effects of Stroke and other disorders of the Central Nervous System
Diagnoses with case mix attachedDiagnoses groups that have case mix still attached include:
- Selected benign neoplasms
- GI disorders with ostomy
- Heart disease or HTN, not both
- Ortho conditions
- Skin ulcers
- Certain Brain disorders