Home Health Coding and OASIS Expert

What kind of story does your OASIS assessment tell auditors?

When your OASIS documentation paints an incomplete picture of the patient’s need for skilled services, you’re putting your reimbursement at risk. Shore up your claims by making certain your responses don’t land you on the rejection pile.

Know What the Auditors want to See

When auditors review your charts they look for documentation of the plan of care, the patient’s eligibility, homebound status, orders, and skilled need, says Sharon Litwin, RN, BS, MHA with 5 Star Consultants in Camdenton, Mo.

Agencies are seeing homebound denials in claims where the functional domain section of the OASIS shows a patient is independent, Litwin said during the recent Eli-sponsored audioconference Building a Strong Foundation in Homecare. If you’re reporting a lot of “1s” and “0s” in ADL and IADL items M1800 through M1910 indicating a fairly independent patient, “you’d better be able to document that this patient is homebound. Because by OASIS scoring, they may not be, and they may not have skilled need either,” Litwin tells Eli.

Auditors look for objective terms such as “a taxing effort” and hope to match them with functional questions on OASIS, such as shortness of breath, pain, balance, ADLs, and IADLs, Litwin said. When there’s not a good match, you can expect downcodes and denials.

And if the auditor sees documentation indicating that your patient does occasionally go on outings, it’s important that you also document that it was a taxing effort — and why, Litwin said. Otherwise, you are bringing the patient’s homebound status into question.

Terms such as “considerable and taxing effort” and “dyspnea upon exertion” are not enough to indicate the patient is homebound, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas. And checkboxes for indicating homebound status haven’t worked in a long time, she says. “Homebound must be linked to the patient’s injury or illness.”

Just checking the right boxes on the OASIS functional items isn’t enough to withstand audit scrutiny, either, Selman-Holman says. Your clinical documentation must support those answers.

Mistake #1: No indication why you’re seeing the patient.

When reviewing charts, “about 20 percent of the time, I have no idea why a patient is being admitted to home care,” said Litwin. “You want to tell a story in your chart, but you don’t want it to be a mystery novel,” she said.

You must be thorough, specific, and acurate with your OASIS responses and your documentation to secure appropriate epsiode payment and avoid denials.

A strong narrative paragraph at the end of the OASIS can pull the story together, Litwin says. “The clinician can say what the skilled need is, what disciplines they need, why they are homebound and then write a short ‘report.’” You can also send this narrative to the physician who needs a report and it can help with completion of the face-to-face.

Try this: Complete the OASIS in a manner where you see the patient answering the questions rather than just asking him to answer questions, Litwin said. Have the patient walk around, take off his shoes and socks to check for wounds, pulses, and color. Then have him put them back on.

“If you ask a patient about her lower body dressing, she may say she’s fine, but ask her to demonstrate and it may be another story,” Litwin said. “You don’t even have to ask the question if you see it during assessment.”

Mistake #2: Documentation and OASIS don’t match up.

When reviewing an OASIS, auditors look at all the M items. If they don’t match up or are inconsistent and if the narrative documentation doesn’t match up, “that could really nail you,” Litwin said. Inconsistency could indicate a lack of coordination of care, incorrect OASIS responses, or that someone in the office is changing scores, she said.

Exception: You can expect inconsistency sometimes because different items have different timeframes and instructions. For example a patient could be a “3” on ambulation and still be a “0” on toileting transfer because the “0” response indicates with or without a device. He may need someone to be with him at all times to ambulate, but use a wheelchair to get to the toilet. “In the case of that inconsistency, I would expect documentation to explain the situation and the patient’s functional limitations,” Selman-Holman says.

An example of an error: OASIS item M1860 — Ambulation/Locomotion is scored 4 — Chairfast, unable to ambulate but is able to wheel self independently, but the home health aide documents that the patient walked to the bathroom with assistance that same day. You’ll only select response “4” for Ambulation/Locomotion if the patient isn’t ambulatory at all.

Remember: The comprehensive assessment documentation and your OASIS scores must paint a true and consistent picture of your patient, Litwin cautioned. The Centers for Medicare & Medicaid Services “sees the patient through these scores and all other documentation.”

Mistake #2: Physical therapy and nursing tell two different stories.

The consistency of your OASIS responses and documentation should flow to visit notes from all disciplines, Litwin said. If each discipline has a different take on the patient’s condition, you’re setting your claim up for failure.

“Nurses often score patients as more independent than they are,” Litwin said. “Therapists usually don’t.” This could be because therapists are trained to walk around the house while nurses are trained to sit and assess and talk with the patient, she said. Whatever the reason, it’s important for all disciplines to make certain the information they report is consistent.

“Frequent OASIS training to your clinicians is critical so that all clinicians doing the comprehensive OASIS assessments know the standard approach and the intent of each M item,” Litwin says.

For example: OASIS item M1400 — When is the patient dyspneic or noticeably Short of Breath is answered 2 — With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet). But the physical therapist documents that the patient is able to ambulate 200 feet without any difficulty.

In this case, it’s the clinician’s OASIS response that describes a patient who is less independent than the he seems in the therapist’s documentation. It’s very important to remember that documentation remains in harmony throughout all disciplines, Litwin said. This plays into coordination of care — do the OASIS scores match up with what nursing and physical therapy are reporting?

Bottom line: If you hope to avoid downcodes and denials, your documenation and OASIS responses must support the need for clinicians to be in the home, Litwin said. “Denials and downcodes are often due to incomplete documentation to support the services that are provided to the patient.”

Note: Order a recording of transcript of the audioconference Building a Strong Foundation in Homecare here: www.audioeducator.com/home-health/building-strong-homecare-foundation-12-02-2014.html.