Home Health Coding and OASIS Expert

Your OASIS responses can help support your claims for insulin injections — but only if you’re thorough and accurate. Make sure to follow up so you don’t miss documenting vital details of these often overlooked areas.

Missing information: Agencies are seeing denials for diabetic care because an auditor didn’t find any documentation showing the reason why that patient needed a nurse to inject, 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. “One patient was severely intellectually disabled. She didn’t understand why she was supposed to stick her finger or what to do with the results.”

Unfortunately, the agency in this case didn’t document or code for the patient’s intellectual disability, Selman-Holman says. The OASIS items didn’t support why she was homebound either. Physically she was functionally able even though she did require supervision 24 hours per day. But documentation as to why this person needed this level of care was severely lacking, Selman-Holman says.

No manifestations: Another problem arises when the physician gives the agency a diagnosis of diabetes but doesn’t mention any manifestations. “We may suspect manifestations based on our assessments but we cannot code them as such without the physician’s verification,” Selman-Holman says.

To avoid doubling back after the fact, make the effort to ask questions about your diabetic patients, even at intake, Selman-Holman suggests. “The patient has diabetes? What manifestations does he have?”

Misunderstanding M2030: OASIS item M2030 — Management of Injectable Medications reports the patient’s ability to safely and reliably inject his medications. Many times, responses to M2030 don’t take into account CMS guidance on this item, Selman-Holman says.

Remember, M2030 requires an assessment of the patient’s cognitive and physical ability to draw up the correct dose accurately using aseptic technique, inject in an appropriate site using correct technique, and dispose of the syringe properly.

If your patient lacks knowledge of safe needle and syringe disposal on the day of the assessment, the patient is considered unable to take injectable medication unless administered by another person, and you should select response “3.” If she needs reminders regarding safe needle/syringe disposal, you would choose “2.”

Don’t miss these details: Keep the M1700-M1750 — Neuro/Emotional/Behavioral items in mind and use them to document the cognitive disabilities your patient may have. If manual dexterity is the issue, double check how you’ve answered questions that require manual dexterity, such as M1800 — Grooming, M1810/1820 — Dressing, and M1845 — Toileting hygiene. And a lack of a caregiver willing to inject can be indicated in items such as M1100 — Patient Living Situation and M2102 — Types and Sources of Assistance.