OASIS Alert

Published on Tue Apr 02, 2013 PDF

Relying on pre-set interventions could lead to denied claims.

Some OASIS fairy tales are repeated so often they become legend. Make certain you aren’t operating under the false impression that these OASIS myths are true stories.

Myth: When your OASIS form is integrated with all the other assessment questions, it provides all the documentation you need at the start of care. You have no need to put in clinical notes. Simply check off items like how many pressure ulcers the patient has and whether he is visually impaired.

Fact: Checkboxes aren’t necessarily enough to document your patient’s condition, said Ann Rambusch, MSN, RN, HCS-D, HCS-O, COS-C, with Rambusch3 Consulting in Georgetown, Texas. A clinical note can provide essential supporting detail that a checkbox cannot.

Myth: The pre-set interventions or library text in a computer program are sufficient for documenting your patients’ plans of care. The text may be general, but that’s because it has to work for a lot of patients.

Fact: Items that you’re cutting and pasting aren’t patient-specific, Rambusch said during the recent Eli-sponsored audioconference Coding and Documentation Vital to Your Home Health Claims. That’s a problem because you begin to rely on the pre-written text. Instead, you should write specific goals and assessments for each individual patient.

Myth: The physician’s signature on the POC signifies he agrees to all the codes and the interventions. There is no need to discuss these items with him before you send the POC.

Fact: “Nothing could be further from the truth,” Rambusch said. “You must call the physician if the POC changes between the referral order to provide care and the SOC visit.” If calling for wound orders, or anything else, you must discuss the particulars on the phone. Plus, this call is when you can validate diagnoses and verify or resolve medication issues.

Myth: When the order reads: “May start week of …” you can start care any day during that week.

Fact: You must see patient within 48 hours of the order, Rambusch said. You can write “week of” but you’re expected to start care within 48 hours.

Myth: You must have the right diagnosis code to justify care.

Fact: Accurate diagnosis codes are important, as are OASIS responses, but documentation is king. If you don’t support the codes in the documentation, you’re at risk of denial, Rambusch said.