OASIS Alert

Expect payment diagnoses to become much more complex.

"Early" and "later" will have new meanings in 2008 and deciding which applies may require some digging.

These changes result from the proposals in the Home Health Prospective Payment System Refinement and Rate Update for Calendar Year 2008 (PPS update), the Centers for Medicare & Medicaid Services says in its May 4 submission asking the Office of Management and Budget to approve extending use of the OASIS data set beyond the Aug. 31 expiration date. CMS also outlines plans to delete, modify and add items to the OASIS assessment.

Many parts of the OASIS assessment will stay the same, including the time points for assessment, the absence of a requirement for locking data and the suspension of OASIS data collection for non-Medicare/non-Medicaid pa-tients, CMS says.

Expect OASIS form overhaul: No matter what changes CMS makes to the proposed PPS update in response to industry comments, the OASIS assessment form will require changes for both initial and follow-up assessments.

CMS needs to hear how OASIS changes will affect agencies, says clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen.

Consider the following five major changes and don't forget to make your voice heard:

1. M0175 errors will no longer cost you money. Data show M0175 (From which of the following inpatient facilities was the patient discharged during the past 14 days) lacked predictive value for the case mix model, CMS explains. And the administrative headaches associated with M0175 affected agencies and intermediaries alike. So CMS proposes removing this M0 item from recertification and other follow-up assessments because it will no longer be part of the case mix calculation under the PPS update. CMS also plans to delete the reference to the follow-up assessment in the "NA" response in M0175.

"Although the pressure will be off case mix accuracy in answering M0175, this item  will continue to be important for its impact on risk adjustment," Adams notes. Prior location of the patient has little, if any, impact on care planning, Adams believes, and removing M0175 from OASIS would have been a good thing. But "CMS has indicated they will address the many issues related to multiple OASIS questions and revise the overall document in 2009," so the home care community will have to wait until then for OASIS improvements, she adds.
 
2. M0110 will become part of the OASIS assessment. M0110 (Episode timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes) is a new factor in the case mix calculation under the proposed PPS update.

The agency will choose from the options "early" for single episodes or the first two episodes in a sequence of adjacent episodes, or "later" for the third or later episodes, CMS explains.

Fine print: For these definitions, epi-sodes don't have to directly follow one another, but can be "adjacent"--spaced apart up to 60 days, CMS says. And the definitions apply whether the subsequent or adjacent episodes take place at one home health agency or across multiple HHAs.

"Agencies are really going to have to train their staff to get this answered accurately and develop a process to efficiently gather this information," consultant Mark Sharp with Springfield, MO-based BKD tells Eli. Also, agencies will have to be very careful in capturing the accurate episode count for those patients who have transferred from another agency, adding some administrative burden much like M0175, he adds.

3. M0230 and M0240 will experience format and instruction changes. Updates regarding diagnosis coding in M0230 and M0240 (Diagnoses and severity index) are among the most visually different in the proposed OASIS assessment changes.

A four-column table--shared with the new M0246 item--organizes your answers:

• The first column contains the description of the primary and secondary diagnoses.
• The second column has space for the related ICD-9-CM code and the severity rating for each condition.
• The third column, which is optional, has a space for a numeric ICD-9-CM code if the code in the second column is a V code reported in the place of a case mix diagnosis.
• The fourth column, also optional, includes a space for a numeric code if a V code in column two replaced a case mix code and is part of a multiple code, such as a manifestation code.

"The proposed changes clarify how to appropriately fill out OASIS items M0230 and M0240, using ICD-9-CM sequencing requirements if multiple coding is indicated for any diagnosis," CMS explains.

4. M0246 will address case mix diagnoses in place of M0245. The addition of secondary diagnosis codes to the case mix system means the OASIS form must allow for reporting situations in which a V code replaces a case mix code in secondary diagnoses as well as in primary diagnoses, CMS explains. The current OASIS item M0245 allows that option only for the primary diagnosis, CMS adds.

"This item certainly adds to the complexity of home care diagnosis coding," says coding expert Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. It's been hard enough to convince coders to sequence V codes toward the bottom of M0240 so the risk adjustment factors from the numeric codes can accurately reflect their pa-tient load, she adds.

5. M0826 will challenge your therapy prediction abilities in place of M0825. If you thought answering "yes" or "no" to M0825 (Therapy need) was complicated, wait until you see the new item.

M0826 (Therapy need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits [total of reasonable and necessary physical, occupational, and speech-language pathology visits combined]?) leaves you a three-digit space to enter the number of visits expected and asks you to enter "000" if no therapy visits are indicated.

Upside: The proposed rule allows intermediaries to correct therapy projections and payment up or down at the episode's end. 

Note: The proposed changes to the OASIS data set are at www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/list.asp.

For a copy of the PPS refinements proposed rule, email editor Marian Cannell at marianc@eliresearch.com with "PPS Rule" in the subject line. For more detailed analysis of payment and other administrative changes, order Eli's Home Care Week at 1-800-874-9180.