OASIS Alert

Could your ADL item response send a patient to the nursing home?

The OASIS ADL/IADL items allow you to earn clinical and functional points as well as provide support for a patient’s need for skilled care. But if you have fallen prey to one of these common mistakes, your reimbursement could be taking a hit.

Mistake # 1: Asking patients about their ability.

"One of the biggest mistakes a clinician can make is to determine the correct OASIS answer by simply asking the client or family about his or her ability to get dressed," says Pat Jump, MA, BSN, RN, COS-C, with Rice Lake, Wis.-based Acorn’s End Training & Consulting. This mistake can impact your answers to M1810 -- Current ability to dress upper body safely and M1820 -- Current ability to dress lower body safely, resulting in a loss of points.

Why? Patients often exaggerate their ability for a variety of reasons, including the fear that they may not be able to stay in the home if they struggle with getting dressed, Jump says.

But failure to get an accurate picture of the client’s ability to get dressed has costly repercussions, Jump says. For example, depending on the diagnostic codes you report for this patient, you risk losing case mix points and revenue if you incorrectly choose a response that shows the patient is independent in dressing.

Watch out: You could bring your patient’s homebound status into question if he or she scores as totally independent in all of the ADLs, Jump warns.

Mistake #2: Focusing only on putting on and taking off clothing.

Clinicians often answer OASIS dressing items M1810 and M1820 based solely on the patient’s ability to take his clothing on and off, says Lista L. Clark, RN, BSN with Healthcare Provider Solutions in Nashville, TN. "They forget that transfer and ambulation are required to get the clothing," she says.

For example: Getting dressed includes walking to the closet and reaching up to get clothing. It doesn’t make sense if a patient scores as needing assistance with ambulation but your M1810 and M1820 responses show him as able to dress himself, Clark says.

What’s at stake: If answered correctly, the dressing items support the need for physical and occupational therapies.

Mistake #3: Jumping the gun on interventions.

"Another fairly common mistake is for the clinician to complete an intervention for the client before assessment," Jump says.

For example: A client reports that he could get dressed by himself if his clothes were moved to a closet in the lower level of the home rather than having them in the upstairs closet. The clinician responds to this request by relocating the clothes for the client and then completing the assessment.

To paint a more accurate picture of the patient’s needs and the care your agency will provide, the clinician should assess the client with his current clothing situation, Jump says. After the assessment the clinician can move the clothes for the client and re-assess things at subsequent visits, capturing the improvement on the next OASIS.

Mistake # 4: Starting from the top.

Clinicians should learn to read the OASIS answers for each item from the bottom up, Jump advises. "If the items are read from top to bottom, the clinician tends to stop reading the choices when the answer seems correct," she explains.

But if the clinician instead reads all of the answers before choosing a response, he or she might find a more appropriate response that more accurately reflects the client’s status, Jump says. This sounds like a simple thing but it can have a big impact on accuracy.

Mistake #5: Forgetting to tie documentation and OASIS responses together.

"When I complete clinical record audits I frequently find that the client’s health status reflected in the OASIS answers does not match the status as described in the clinical notes," Jump says.

"The vast majority of the time, the OASIS answers reflect a much more independent client with far more capability than is described in the clinical notes," Jump explains.

For example: It’s common to find a client who, according to the OASIS, is independent in taking medications, yet the clinical notes report severely arthritic hands, forgetfulness, and extreme difficulty with ambulation, Jump says. Based on the clinical notes I would question the client’s ability to get medication containers open, remember to take medications and ambulate to the location of medications.

"Sometimes as I interview the clinician who completed the documentation, there is a reasonable explanation for the disparity, but it is not documented in the clinical record," Jump says. To avoid such discrepancies, take the time to make sure that your OASIS responses and the documentation support each other.

Mistake #6: Downplaying a patient’s need for assistance.

Some clinicians worry that accurately representing the abilities of patients who live alone will have a negative consequence, Clark says. "I often hear clinicians say ‘I can’t say they need assistance when they are living alone or they will be put into a nursing home,’" Clark says.

Reality: "If the patient needs assistance, that supports the need for your services," Clark advises. "The patient requires your assistance to become safe doing these tasks so they won’t need to go to the nursing home," she says.

With the ADL items, CMS is giving you the opportunity to show the need your patient has for the services you provide, Clark says.

Note: For more specific tips that will boost your ADL item accuracy, see the story on page 16.