OASIS Alert

Question: Our patient’s depression screen was positive. The assessing clinician suggested that he join a depression support group or schedule an appointment with a psychiatrist. Can we select “Yes” in M2250 — Plan of Care Synopsis, row d? Does the clinician’s suggestion count as a “referral for other treatment?”

Answer: It’s not appropriate to answer “Yes” for M2250d in the scenario you describe. You can only take credit for a referral for services for further evaluation or treatment when you have an order in the physician-ordered plan of care (POC) for the referral. And that referral must be documented before the end of the start of care (SOC) or resumption of care (ROC) comprehensive assessment time period, the Centers for Medicare & Medicaid Services points out in the April 2014 Quarterly OASIS Q&As.

The order for a referral for evaluation or treatment in the physician-ordered POC can be for:

• Agency services, such as those provided by a psychiatric nurse or social worker; or 
• Services provided by an external provider or organization, such as a psychiatrist or a community mental health center, CMS says.

When your clinician suggests to the patient that he seek further evaluation or treatment, it isn’t the same as providing a referral. A referral requires your agency to provide the patient with detailed information that he can use to make an appointment or obtain the service, CMS says. For example: The name and phone number of a psychiatrist. Or, your agency can contact the provider to arrange an appointment for the patient.

Tip: The referral doesn’t have to be implemented for your agency to mark “Yes” in M2250d. As long as there is an order for a referral in the physician-ordered Plan of Care, you can take credit for this intervention.

As for falls prevention interventions which are recorded in M2400c, “a referral for services for further evaluation or treatment meets the criteria for a response of ‘Yes’ only if there is an order in the physician-ordered Plan of Care for the referral AND the referral was made by the agency,” CMS reminds. “Once a referral has been made, it is not required that the patient has followed through or received the services related to the referral by the time of discharge for a response of ‘Yes’ in M2400c.”