Home Health & Hospice Week

Anticipated vs. unanticipated is the key to qualifying for one exception.

As home health agencies come to grips with the new “SPADE” items in OASIS-D, they are communicating their displeasure with one element of J1800 (Number of Falls Since SOC/ROC, whichever is more recent).

Response-specific instructions for J1800 stayed the same from the draft to final version of the OASIS-D Guidance Manual, saying agencies have to count an “intercepted fall” in J1800, and noting “an intercepted fall occurs when the patient would have fallen if he or she had not caught him/herself or had not been intercepted by another person — this is still considered a fall.”

Multiple questions in recently released OASIS-D Q&As address this issue.

Question: “Why are intercepted falls being considered a fall?” one agency asked. “This is opposite of what our agency considers a fall. It seems as though this is going to penalize agencies for falls that did not occur.”

Answer: “An intercepted fall is considered a fall because the patient would have fallen if he or she had not caught him/herself or had not been intercepted by another person,” the Centers for Medicare & Medicaid Services responds. However, right now quality measures aren’t tallying that item. Instead, “the cross-setting quality measure adopted for the CY 2020, ‘Application of Percent of Residents Experiencing One or More Falls with Major Injury,’ reports only falls that resulted in major injury during the episode of care (J1900 = Coding 1, 2),” CMS points out.

HHAs must count falls that aren’t witnessed, that are due to reasons like syncope, that occur outside the home, and that the patient did on purpose, CMS clarifies in multiple Q&As.

“This seems to harshly penalize agencies,” one agency said.

Clinicians can take advantage of two exceptions to counting falls. Falls don’t count when:

1. A fall occurs when “challenging a patient’s balance and training him/her to recover from a loss of balance.” That’s because it “is an intentional therapeutic intervention” and CMS “does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls,” the manual says.

The key: Determining whether the fall is anticipated is the clincher in this scenario, CMS indicates in the OASIS. If the patient unexpectedly falls during therapy, it still counts. It doesn’t matter what kind of licensed staff are performing the therapy at the time, CMS says in another Q&A.

2. The fall is due to “an overwhelming external force (such as, a person pushes a patient),” according to the manual.

However: Medicare’s definition of an external force is pretty specific. When an agency questioned whether slipping on a wet floor is an external force, CMS clarifies that the resulting fall “is caused by an environmental condition (water on the floor), not by an external force (a person pushing the patient).” Therefore, the fall still counts.

The intercepted fall and fall-counting issue is one that OASIS experts predicted would cause staff trouble when implementing OASIS-D (see Eli’s HCW, Vol. XXVII, No. 28). Use resources such as the OASIS-D Guidance Manual’s instructions and case scenario examples, new Q&As, and Medicare presentations to help educate your clinicians on how to respond to J1800 accurately.

Note: See the Q&As at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/November-2018-HH-QRP-Provider-Training-Q-and-A.pdf.