OASIS Alert

And your confusion will soon affect your publicly reported outcomes.

Many home health agencies are answering M0520 incorrectly, and their mistakes not only dilute their bottom line, they also can come back to haunt agencies on Home Health Compare.

M0520 asks if the patient has urinary incontinence or if a urinary catheter is present. If you mark "1 - Patient is incontinent," the skip pattern directs you to M0530 to indicate when incontinence occurs. If incontinence occurs at any time, M0530 adds six points to the clinical severity domain of the home health resource group that determines reimbursement.

he wording of M0530 (When does urinary incontinence occur?) seems a bit confusing, because there is no response for a patient who is incontinent only during the day, says Linda Krulish, OASIS expert and president of Home Therapy Services in Redmond, WA. But looking at the response-specific instructions the Centers for Medicare & Medicaid Services provides in the OASIS manual clarifies the issue, she adds. If a patient is incontinent during the day only, use response "2" (during the day and night), CMS instructs.

Tip: If the patient has been incontinent but a catheter is inserted on the initial assessment visit, skip M0530, Cahaba GBA instructs in its Jan. 1 Medicare A Newsline.

Heads up: About 20 percent of the home care population is incontinent, experts estimate. But many patients are embarrassed to admit their incontinence and take great pains to hide the problem.

Challenge: Incontinence is easy to miss. You can't always rely on the patient to tell you about her incontinence, unless you ask correctly. The patient may not consider some leaking of urine as incontinence.

In addition to asking patients about incontinence issues, you should also be observing for evidence such as odor and incontinence or peripads in the bathroom or in the trash, says Linda Rutman, director of Munson Home Care and Home Services in Traverse City, MI.

You should also further question a patient if you find she has difficulty removing clothes, restricts fluids or takes a diuretic, has a bathroom that is difficult to access, is confused or has frequent urinary tract infections, experts say.

Clinicians often miss stress incontinence - where urine leaks during laughing, coughing or other activities that increase pressure on the abdomen, warns Chapel Hill, NC-based clinical consultant Judy Adams with the LarsonAllen Health Care Group. "For the most part stress incontinence, even when generally controlled with timed voiding will still show up as incontinence on M0520," because timed voiding will not work all the time, she says.

Educate staff that stress incontinence is part of M0520 and not a normal part of aging. Being very matter of fact when asking patients about incontinence and using words patients may be more comfortable with - such as, "do you have trouble reaching the bathroom before you begin dribbling urine," or "do you experience leaking when you laugh hard or cough" - may uncover the problem, Adams suggests.

And you should mark any incontinence during the day, even stress incontinence, with response "2," instructs Palmetto GBA in its Web site questions and answers.

Planning: One of the new quality outcome measures to be added to Home Health Compare next fall is improvement in urinary incontinence. And if agencies follow the OASIS manual instructions to the letter, "just about every patient you see will have urinary incontinence," notes Chicago-based consultant Rebecca Friedman Zuber.

Hidden trap: If the clinician completing the start of care OASIS does not pursue this issue, the incontinence may well show up as a decline at the end of the episode when the clinician completing the discharge OASIS has had time to develop a relationship of trust so the patient will address this concern, Rutman says.

And because the M0520 instructions are confusing, and many clinicians don't understand them, agencies that complete the OASIS item correctly may end up looking like they have patients with a higher incidence of incontinence. Further, a usual home health episode rarely gives patients time to improve their incontinence. Thus the measure doesn't really reflect what agencies are doing to improve patient outcomes, Zuber says. 

Editor's Note: Extensive information about incontinence and its evaluation and management is available as part of the nursing home quality initiative at http://www.medqic.org/content/nationalpriorities/nursinghome/nursinghome.jsp?topicID=413.