Home Health & Hospice Week

A new OASIS Q&A tries to tackle that issue, but questions remain.

The importance of obtaining accurate diagnosis coding information under the Patient-Driven Groupings Model may make answering M0104 more of a challenge. The Centers for Medicare & Medicaid Services has stepped in with some guidance on what constitutes a valid referral, but the information in the latest quarterly OASIS questions-and-answers may need more clarification, one expert says.

In Q&A No. 3 issued on Jan. 21, an agency asks CMS this question: “A complete referral is received from a physician at an inpatient facility on 01/01/2020 and has a diagnosis that does not fall into a PDGM clinical grouping; patient is discharged to home health on 01/01/2020. Intake staff calls physician requesting a more specific diagnosis. The more specific diagnosis is received on 01/04/2019 and care is started on 01/05/2020. Will M0104 be changed to 01/04/2020 based on the update to the specificity of the diagnosis?”

CMS’ Answer: “M0104 specifies the referral date, which is the most recent date that verbal, written, or electronic authorization to begin or resume home care was received by the home health agency. A valid referral is considered to have been received when the agency has received adequate information about a patient (name, address/contact info, and diagnosis and/or general home care needs) and the agency has ensured that the referring physician, or another physician, will provide the plan of care and ongoing orders. In the scenario described, if your agency received adequate information as outlined above (including a relevant diagnosis) a valid referral is present on 1/1/2020 to allow the home health admission to be initiated and the M0104 date would be based on the date the referral was received. The assessment process, along with collaboration with the physician, may lead to identi­fication of additional diagnoses for care planning and/or reimbursement purposes.”

Why it matters: “Very, very few providers have any idea that the description of what constitutes an official ‘referral’ is found in the OASIS Users Manual,” points out consultant Pam Warmack with Clinic Connections in Ruston, Louisiana. “It is so important that they study and understand this definition, as it will result in the ability to be compliant with the timeliness of admission requirements.” If home health agencies don’t comply with the five-day window to complete the Start of Care OASIS, they risk survey citations.

The definition in the Manual, which CMS refers to in the Q&A, is: “A valid referral is considered to have been received when the agency has received adequate information about a patient (name, address/contact info, and diagnosis and/or general home care needs) and the agency has ensured that the referring physician, or another physician, will provide the plan of care and ongoing orders. In cases where home care is requested by a hospitalist who will not be providing an ongoing plan of care for the patient, the agency must contact an alternate, or attending physician, and upon agreement from this following physician for referral and/or further orders, the agency will note this as the referral date in M0104 (unless referral details are later updated or revised).”

However, CMS’ response based on this definition may need even further clarification, says Sherri Parson with consulting firm Quality In Real Time in Floral Park, New York. In the submitted scenario, CMS “concluded that the agency had a valid referral initially, even though in their explanation an adequate referral included a relevant diagnosis,” Parson tells Eli. “If the diagnosis supplied to the home health agency isn’t valid for the agency to open up an encounter and treat the patient, then I’m not sure that it is a relevant diagnosis.”

If it were a secondary diagnosis, “then yes, the referral date I would agree would be the original referral date,” Parson explains. “However, to not have an appropriate focus of care would make it impossible to have a relevant referral.”

The M0104 response-specific instructions in the OASIS Guidance Manual even indicate that “the date the agency received updated/revised referral information for home care services to begin would be considered the date of referral.” However, that refers to a delay due to “the patient’s condition or physician’s request (for example, extended hospitalization).”

Stay tuned: “I would look for CMS to further clarify this response,” Parson says.

Note: A link to the latest OASIS Q&As is at https://qtso.cms.gov/reference-and-manuals/oasis-quarterly-q. The updated OASIS Guidance Manual is at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/OASIS-D-Guidance-Manual- final.pdf.