OASIS Alert

For each diagnosis you list in M1020 or M1022, you'll also need to report the numeric code and degree of symptom control in Column 2.

Take note: Don't use the rating for symptom control of each diagnosis as a guide for determining the sequencing of the diagnoses listed in Column 1, says Trish Twombly, BSN, RN, HCS-D, CHCE, COSC, director of coding with Foundation Management Services in Denton, Texas. Symptom control and sequencing may not coincide.

Your symptom control options include:

0 -- Asymptomatic, no treatment needed at this time;

1 -- Symptoms well controlled with current therapy;

2 -- Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring;

3 -- Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring; and

4 -- Symptoms poorly controlled; history of rehospitalizations.

To assess the degree of symptom control you'll need to review the presenting signs and symptoms, type and number of medications, frequency of treatment readjustment, and frequency of contact with the health care provider, Twombly says.

Approach: To help establish degree of symptom control, inquire about the degree to which each condition limits daily activities, Twombly suggests. Assess the patient to determine whether symptoms are controlled by current treatments. Then clarify which diagnoses/symptoms have been poorly controlled in the recent past.