OASIS Alert

But not everyone agrees with the answers.

OASIS drives both reimbursement and outcomes, but years after starting to use OASIS, CMS is still explaining it. And you have more OASIS training to do.

If an OASIS assessment was easy, CMS wouldn't have to keep clarifying how to get it right. The Centers for Medicare & Medicaid Services on June 5 added 57 questions and edited five in the set of OASIS Questions and Answers available through its Web site. These changes affect three of the 12 sections of online questions.

These three sections now include a total of 271 Q&As to help clinicians answer OASIS accurately. The additional questions underscore the complexity of the assessment and "how [accuracy] depends on adhering to the 'official' interpretation," says senior clinical consultant Judy Adams with the Charlotte, NC-based Larson Allen Health Care Group.

Many of the added questions have been available earlier either through training provided to surveyors, responses to questions posed by the National Association for Home Care & Hospice or other Web resources. It's important to collect them in one place, though, so everyone can be "on the same page," says Linda Krulish president of Redmond, WA-based OASIS Answers Inc. Forty-four of the added questions were ones the OASIS Certification and Competency Board previously submitted to CMS and received answers for over the last year, Krulish tells Eli. OCCB then posts the responses on its Web site.
 
Focus First On These Problem Areas

Three areas continue to cause clinicians significant difficulty, Adams says:

1. Pain Assessment. M0420 is not a measurement of pain, but of how much pain interferes with activity, Krulish explains.
 
"Clinicians seem to have a particularly hard time with this question," Adams says. Many want to answer it on the basis of whether the patient has pain. And even when they do recognize the focus of the question, they are unclear about how to define pain interfering with activity, she adds. Clinicians also struggle with the M0430 question about intractable pain, she notes.

M0420 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. 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. This means agencies should focus extra attention on accuracy.

Training opportunity: The number of new questions makes it even more important for OASIS training to be an ongoing process, Adams says. Many clinicians take an "all or nothing" approach and interpret M0420 to mean the pain must totally interfere with the activity. Now you can use questions 70 to 72 in section four of the Q&As to illustrate how pain can interfere with an activity without preventing it, Adams suggests.

For clinicians confused about how to answer M0420 when pain medication works, but side effects interfere with activity, refer them to question 73, she says. And questions 75 and 76 will clarify the requirements for saying the patient has intractable pain in M0430, she adds.

Tip: Be sure the clinician documents very carefully if the answer to M0420 is that pain doesn't interfere with activity but M0430 says the patient has intractable pain, Adams warns. And to avoid 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 Cahaba GBA in a Web site home health update.
 
2. Wound Assessment. The number of added questions related to wounds reflects the difficulty clinicians face daily in correctly answering the OASIS wound items, Adams says. Agencies receive limited referral information and must identify and assess many kinds of wounds, she adds.

Question 98 clarifies the importance of looking at the intent of each M0 item and then answering based on the 24-hour period of the assessment, Adams explains.

The clinician knows that the patient had a stage 4 pressure ulcer and that ulcer is now covered by eschar. She also knows that the stage 4 ulcer cannot be reverse staged, so it will always remain a stage 4 ulcer. But if for the assessment period she can't observe that pressure ulcer because of the eschar, she can't say on M0450 that the patient has a stage 4 pressure ulcer.

M0450 "is just asking for a numeric count of the number of pressure ulcers at each stage on the day of assessment," Adams ex-plains. For the OASIS pressure ulcer questions, the previous stage 4 ulcer doesn't exist, because its base is not currently observable.

Don't overlook: If your agency policies allow, OASIS provides a five-day window to complete the assessment. Consider waiting to answer the wound assessment questions if you expect the ulcer to be observable - such as after debridement - within that time period, experts say. In this example, you could gain 53 clinical severity points, and $1500,  for a Stage 4 pressure ulcer.

3. ADL Assessment. Clinicians new to OASIS may have difficulty understanding how the assessment artificially breaks up activities of daily living, Adams says.

For example, the total process of bathing is assessed by different OASIS M0 items: bathing, dressing and transferring items. And some parts of the process - preparing the bath, shampooing hair or drying off with a towel - are not assessed at all, she explains. This same kind of artificial division occurs with toileting assessment.

Smart idea: Review questions 136 through 148 to focus on specific details clinicians confront in trying to accurately assess ADLs, Adams suggests.

Caution: NAHC disagrees with several of the answers CMS has provided (category 2, questions 47 and 190 and category 4B, questions 53 and 178) and plans to follow up on these concerns. 

Note: for the latest OASIS wound Q&As go to www.qtso.com/guides/hha/cat4.pdf.