Home Health & Hospice Week

Falls, hospitalizations get a little more clarity.

Background: The Centers for Medicare & Medicaid Services added M1033 (Risk for Hospitalization) to the case mix system when the Patient-Driven Grouping Model took effect in January 2020. The item asks “Which of the following signs or symptoms characterize this patient as at risk for hospitalization? Check all that apply” and lists “History of falls (2 or more falls – or any fall with an injury – in the past 12 months)” as item 1 of 10.

This item helps determine the episode’s functional adjustment level and impacts reimbursement, notes consulting and services firm Qavalo. “M1033 is a vital part of the patient assessment” but “it has not been paid as much attention to due to its complexity,” the Philippines-based firm says in an online article.

Under PDGM, if four or more items are checked on M1033 (excluding items 8, 9, and 10), the grouper assigns 10 points in addition to points from the other functional domain items for low/medium/high scoring, CMS says in its 2023 final home health rule. CMS has proposed it go back up to 11 points next year, according to the 2024 proposed rule due to be finalized around Nov. 1.

That scoring under PDGM “gives the industry new reason to ensure the accuracy of this question,” highlights consulting firm Corridor in an article on its website.

Despite the item’s importance, it has relatively spare guidance in the OASIS-E Guidance Manual. “History of falls (Response 1) includes witnessed and reported (unwitnessed) falls” is the only subitem-specific instruction in the 396-page manual.

The following new question issued on Oct. 17 sheds just a bit more light.

Question 3: How are falls defined for M1033 - Risk of Hospitalization; response 1 - History of falls? For example, if a therapist is performing a therapeutic intervention that challenges a patient’s balance and the patient loses their balance would that be considered a fall?

Answer 3: M1033 - Risk for Hospitalization, response 1 - History of falls considers any fall in the last 12 months, with or without an injury, whether witnessed or unwitnessed.

For the purpose of coding response 1, falls are defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair, or bedside mat).

An intercepted fall is considered a fall. An intercepted fall occurs when the patient would have fallen if they had not caught themself or had not been intercepted by another person.

Falls are not a result of an overwhelming external force (e.g., another person pushes the patient) or an anticipated loss of balance resulting from a supervised therapeutic intervention where the patient’s balance is being intentionally challenged during balance training.

If in your scenario, the only fall that the patient experienced in the last 12 months was a result of a supervised therapeutic intervention where the patient’s balance was being intentionally challenged during balance training, then that would not be captured as a fall for M1033, response 1.

The new Q&A fails to address other difficulties with the item, such as combing through the plethora of information clinicians are supposed to consult to answer the question. “Interview the patient/caregiver, conduct physical assessment, consult with the physician, and/or review the clinical record, including but not limited to health history, and referral information,” the manual instructs for all of M1033.

The slim set of quarterly Q&As, containing only four items, has another one addressing M1033 too.

Question 4: We are seeking clarification for M1033 - Risk for Hospitalization; response 3 - Multiple hospitalizations (2 or more) in the past 6 months. In the Response Specific Instructions, it states “Multiple hospitalizations (Response 3) defines hospitalization as the patient being admitted for 24 hours or longer to an inpatient acute bed for reasons other than diagnostic testing.” Does “inpatient acute bed” include inpatient facilities other than an acute care hospital? Specifically, would admission to any or all of the following facilities be considered an “inpatient acute bed” for M1033 response 3: