Home Health & Hospice Week

CMS issues clarifications on confusing OASIS questions.

Under the coming prospective payment system revisions, how accurately you answer OASIS will affect your reimbursement rate more than ever.

The Centers for Medicare & Medicaid Services Survey and Certification Group recently provided extensive answers to 36 questions from the OASIS Certificate and Competency Board.

Among the questions-and-answers were ones regarding these case mix items:

Question: Do you time continence for M0520?

This OASIS item will be new to case mix under revised PPS, accounting for a whopping 17 points in the Non-Routine Supplies (NRS) payment add-on. That could take the episode from a NRS severity level 0 at $12.96 as proposed, to level 2 at $109.48. It could also bump it from a level 3 ($215.17) to a level 4 ($367.34).

Answer: There is no specific time a patient must stay continent to no longer be incontinent. You must use clinical judgment and current clinical guidelines to decide if the cause of a patient's incontinence is resolved, CMS says in Question 23.

Question: Does an adapted home setting affect M0650/M0660?

CMS will use this OASIS item on dressing to calculate PPS' functional domain score (see Eli's HCW, Vol. XVI, No. 22). It can garner up to six functional domain points for an episode.

Answer: If a patient can safely access clothes and put them on and remove them, you can consider him independent in dressing, CMS says in Question 25. This is true even if he is in a wheelchair and has specially adapted closets and drawers to simplify the process.

Take All OASIS Items Seriously

Even if an OASIS item doesn't directly impact PPS payment, it's still important to answer it as accurately as possible for outcomes, medical review, billing and data integrity reasons, experts emphasize.

A year after the last major OASIS Q&A clarifications, clinicians continue to find many OASIS M0 items unclear. Sequence of visits, hospitalizations around crucial recertification dates and emergent care issues continue to draw queries. More highlights of the new Q&As include:

• Who visits first? Agencies still are confused about sequence of visits when both nursing and therapy are ordered at start of care (SOC). "A registered nurse must conduct the initial assessment unless it is a therapy only case." CMS instructs. So when the physician orders nursing at SOC, the RN must be the first person to see the patient and complete the initial assessment, Question 2 clarifies.

The initial assessment determines the patient's immediate care and support needs and whether the patient is eligible for the Medicare home health benefit. It is not the same as the comprehensive assessment that includes the OASIS, CMS says.

Beginning therapy need not wait for the comprehensive assessment, only the initial one, the answer states. "If the PT visits the patient before the RN when both nursing and PT are ordered at SOC, your agency will be out of compliance with the Medicare Conditions of Participation," CMS warns.

Tip: This requirement holds true only for the SOC assessment, CMS notes in Question 12.

• Does "skilled" replace "reimbursable" in M0030? CMS inadvertently changed the language in M0030 in the June 2006 revision to Chapter 8 of the OASIS Implementation Manual, Question 7 reveals. "Continue to define Start of Care as the date the first covered or reimbursable service is provided," CMS says.

Example: The nurse makes a one-time non-billable visit to do the initial assessment, and the home health aide makes a "reimbursable" visit before the physical therapist makes a "skilled" visit. The SOC date is the date of the aide visit.

• How do you know when a procedure is diagnostic in M0100? "Diagnostic testing refers to tests, scans and procedures utilized to yield a diagnosis," CMS says in Question 9. Don't apply a single criterion, such as whether the procedure requires anesthesia, CMS cautions in the Q&As. The same procedure can be used for diagnosis or treatment, the agency acknowledges, and the clinician must consider each case individually.

Example: Many people receive routine screening colonoscopies, but some have the procedure to cauterize internal hemorrhoids or excise polyps, explains senior clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen.

You may need medical records to determine whether the patient had a diagnostic or surgical procedure while in the hospital. "However, this information may be very difficult for HHAs to obtain, given the general difficulty obtaining timely (or any) medical records from hospitals," Adams adds.

• What qualifies as a surgical wound for M0482? This issue continues to challenge agencies. An incision and drainage of an abscess is not a surgical wound, CMS says in Question 17. But if a drain is inserted and left in at the end of the procedure or if the abscess is surgically excised, this would result in a surgical wound, CMS clarifies.

In a paracentesis procedure, leaving a drain in place results in a surgical wound. But inserting a needle, draining the fluid and then removing the needle does not, CMS says in Question 18.

The needle puncture into the femoral artery during a cardiac catheterization procedure is not a surgical wound, CMS says in Question 19.

Surgical repair of a traumatic laceration does not create a surgical wound, but if there is underlying damage (such as a torn tendon) that is surgically repaired, a surgical wound results, CMS says in Question 20.

Stick to the rules: A PICC line is not a surgical wound for OASIS data collection purposes, even if it is inserted using the same techniques used for a central line that is considered a surgical wound, CMS says in Question 21.

Note: To download your own copy of the May 2007 OASIS Q&As, go to www.oasiscertificate.org and select "resources." The May 11 letter containing these Q&As is posted on the OCCB Web site, www.occb.org.

For more information on OASIS, subscribe to Eli's OASIS Alert at www.elihealthcare.com/spec_oasis.htm or by calling 1-800-874-9180.