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M1840 and M1845: Don't Overlook Toileting Tasks

Published on Tue Apr 03, 2012

Patients with ostomies needn't managing the equipment to score as independent in hygiene.

Accurately assessing and reporting your patient's toileting ability can be more complicated than it first appears. Get comfortable with the quirks of these items to make sure you're answering correctly and earning the points your agency deserves.

Establish the Basics

OASIS item M1840 -- Toilet Transferring asks you to report your patient's current ability to get to and from the toilet or bedside commode safely and to transfer on and off the toilet or commode.

Your response options for M1840 are:

  • 0 -- Able to get to and from the toilet and transfer independently with or without a device.
  • 1 -- When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.
  • 2 -- Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).
  • 3 -- Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.
  • 4 -- Is totally dependent in toileting.

Scores of "2" or higher in item M1840 can earn you up to 3 points in the functional dimension. Plus, if your patient has a Neuro 1 -- Brain disorders diagnosis and a score of "2" or higher for this item, you could earn up to 10 points in the clinical domain. A score of "2" or higher and a Multiple sclerosis diagnosis could earn your agency as many as 18 clinical points, depending on the episode. Because these two items can generate both clinical and functional points, it's difficult to isolate the items and pinpoint payment impact, but coding them correctly can affect your agency's bottom line.

OASIS item M1845 -- Toileting Hygiene asks you to assess your patient's current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, this item includes cleaning the area around the stoma, but not managing the equipment.

Your response options for M1845 are:

  • 0 -- Able to manage toileting hygiene and clothing management without assistance.
  • 1 -- Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.
  • 2 -- Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
    •
  • 3 -- Patient depends entirely upon another person to maintain toileting hygiene.

Assess Your Patient's Ability

You'll need to consider four steps when assessing your patient for M1840, says Dee McCarraher, RN, HCS-D, COS-C, with Family Care Home Health in Richmond, Va. That includes your patient's ability to get to the bathroom, get on the toilet, get off the toilet, and then get back out of the bathroom. Plus, you'll need to consider all the things the patient has to walk around to get to the bathroom, steps he may have to climb, and whether a walker even fits in those spaces, if applicable, McCarraher notes.

Assessing your patient's toileting hygiene in M1845 also takes multiple steps, says Rhonda Will, RN, BS, COS-C, HCS-D with Fazzi Associates. You must consider both your patient's perineal hygiene ability and her clothing management, Will says.

With M1845, you need to consider not only cleanliness, but can the patient safely stand up and get her clothes fixed or "do she and the walker almost end up in the tub?" McCarraher says.

Try this: Ask the patient to demonstrate his ability for these items. You will gather a more accurate assessment than if you simply ask about his ability.

When choosing your response for these items, make sure that all the tasks involved meet the score you select or you're choosing the wrong response, Will says.

Master these Tricky Situations

Suppose your patient lives alone. On the day of assessment, she shows you that she is able to get to and from the toilet and perform the transfer safely with assistance of another person (you). In your clinical judgment, this is true all the day of assessment. But, because she has no caregiver she uses a bedside commode. How would you answer M1840?

For this patient, it's appropriate to select response "1" (When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer), the Centers for Medicare and Medicaid Services says in an OASIS Q&A. Your "response should reflect the patient's ability to safely perform a task, regardless of the presence or absence of a caregiver." If she is able to safely get to and from the toilet and transfer with assistance, then response "1" reflects her ability, regardless of the availability of a consistent caregiver in the home, CMS says.

But what if the same patient has no bedside commode at the time of assessment? You may order a bedside commode from the equipment company, but the patient should still score "1" for this item rather than "2," Will says. You must report what is true on the day of assessment. You assessed that the patient is safe with assistance in her current bathroom environment.

For M1840 and other functional tasks, you can't base your assessment of the patient's ability to use equipment and assistive devices safely on a clinical assumption of how the patient would do if she had the equipment, Will cautions. You can determine her ability only when the equipment is present in the home.

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