OASIS Alert

How your home health agency helps patients manage pain will be even more important after the national debut this month of Home Health Compare.

One of the 11 outcomes the Centers for Medicare & Medicaid Services will publicize nationwide on the Home Health Compare Web site is improvement in pain interfering with activity. This makes accuracy critical when answering M0420 (frequency of pain interfering with patient's activity or movement).

If you find your agency's numbers low in comparison to other agencies, look first to the OASIS assessment, experts suggest. Like the computer saying "garbage in, garbage out," some lower outcomes may indicate problems with assessment or documentation rather than care processes, says Mary St. Pierre with the National Association for Home Care & Hospice.

M0420 also is one of the questions that adds points to the home health resource group case mix classification, with a "2" or "3" adding five points to the clinical severity domain (see related story, p. 107). As with any question likely to increase the reimbursement paid to an agency for a home health episode, fiscal intermediaries may scrutinize this question closely, and agencies should focus extra attention on accuracy.

TIP: Constant pain does not always lead to answer "3" on M0420 ("All of the time").

M0420 is not a measurement of pain, but of how much pain interferes with activity, explains Linda Krulish, OASIS expert and president of Home Therapy Services in Redmond, WA. Even constant pain may interfere with activity only "daily, but not constantly" - perhaps during morning bathing or dressing, she explains. As with many other OASIS questions, you must combine what the patient reports with what you observe, she adds.

Not understanding the crucial difference between the presence of pain and its effect on activity can lead to downcoding, experts say. "Orders for pain medication may be consistent with the presence of pain, but does not validate that the patient's pain interferes with activity," Palmetto GBA warns on its Web questions and answers.

Your patient's cultural background also can make M0420 accuracy difficult. Cultural differences affect how patients perceive, discuss and treat pain, says Vienna, VA-based clinical specialist Mary Narayan. Some may be very stoic and others very dramatic in response to the same degree of pain, she tells Eli.

Some cultures view pain as essential to the healing process and patients may be reluctant to take medication to relieve pain, Narayan explains. Cultural differences also influence the effectiveness of numerical pain scales, she reminds clinicians. Include questions in the pain assessment to help discover the effect the cultural norms may have, she suggests.

Documentation Prevents Reimbursement and Legal Problems

Another common problem leading to downcoding is an OASIS assessment noting pain interfering with activity, but no documentation anywhere of clinical interventions, or further observations of the presence or absence of pain interfering with activity, experts say. Visit documentation needs to be consistent with both the start of care assessment and subsequent OASIS assessments, counsels Carol Conrad with Hamden, CT-based Simione Consultants.

If a patient's pain medication is ineffective in controlling or relieving pain throughout the 24-hour period, contact the physician, Conrad reminds agencies.

To avoid HIPPS downcoding, once pain is noted on admission in M0420, it must be addressed in visit notes, calls to the physician, medication changes or other medical record documentation, advises Ca-haba GBA in a recent home health update.

Clinicians need to be aware of the possibility of legal liability for substandard pain management, warns Burtonsville, MD-based health care attorney Elizabeth Hogue. Protect yourself by regularly monitoring the patient's pain, working with physicians to provide adequate pain medication and documenting your activities, she suggests.