OASIS Alert

Published on Mon Nov 17, 2003 PDF

And deficiencies may follow.

What's worse than problems caused by an error in the medical record? Problems caused by an improper correction to that record.

If more than one person completes your OASIS assessments, you may be setting yourself up for regulatory and reimbursement headaches. "Surveyors have been paying closer attention to the forms and citing condition-level deficiencies more frequently these days," warns attorney Virginia Caudill with Indianapolis-based Gilliland & Caudill.

Although the comprehensive OASIS assessment was always supposed to be the product of a single clinician, many home health agencies seem not to understand this point, experts agree. "It's really bad," says consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD. "Not only do you see two different handwritings, two different colored inks, but they don't identify who, what, where or when this all happened."

One registered nurse or therapist must complete the OASIS assessment. "If one nurse starts the assessment and drops dead, the nurse who is going to finish it must start all over again," Sevast quips. If referral information is entered on the patient tracking sheet, the assessing clinician still is responsible for confirming that the information is accurate.

But the clinician completing the assessment is allowed to consider and integrate information from other clinicians into the assessment, advises Chapel Hill, NC-based clinical consultant Judy Adams with the LarsonAllen Health Care Group. This process of confirming and validating observations on OASIS items - especially those affecting the case mix - is important to ensure the correct score, she says.

The nurse doing the assessment is making the decision about what diagnoses are on the OASIS and the 485 and about the order of the primary and secondary diagnoses, Sevast explains. Someone else can take that information and enter the numerical codes.

"We do not expect the clinician to carry an ICD-9 code book into the home," says fiscal intermediary Cahaba GBA in its Home Health Advisory Group Meeting Outcomes on the Cahaba Web site. A coder or other staff member may add the codes on the OASIS form, Cahaba agrees. But "it is not acceptable for a coder or clinician to change the order of diagnoses on the form, or add diagnoses that the assessing clinician did not list," the FI warns.

The OASIS assessment is part of the medical record - a legal document. And the clinician signing that document verifies the accuracy of the information it contains, the Centers for Medicare & Medicaid Services reminds agencies in the questions and answers at the end of Chapter 4 in the OASIS Implementation Manual. "Therefore, standards for clinical documentation indicate the OASIS data are collected by one person," CMS says.

Use An OASIS Correction Form 

Corrections to the OASIS form are done like corrections to any other part of the medical record, Cahaba instructs. "Corrections to the medical record can only be made by the author of the document," the FI warns.

One acceptable way to correct an error in the medical record is for the author to draw a line through the error, mark it as an error, make the necessary changes and date and initial any changes, Caudill counsels.

HHAs should have policies and procedures in place for correcting OASIS errors "in accordance with accepted professional standards," instructs regional home health intermediary Palmetto GBA in its Health Care Coalition questions and answers from March 3.

The trouble really begins after the clinician completes the OASIS assessment and someone else reviews it, Sevast says. Because the OASIS assessment is a legal document, you need to be very careful with changes or corrections, she warns.

"CMS starts with the concept that no one writes on the assessment except the clinician completing it," Sevast says. If the correction is made by the review person and not by the assessing clinician, you need to do that on a separate document, she advises.

CMS has indicated that once the reviewer has called the clinician and they agree on the correction, the agency can complete the data entry process after the call is documented, Sevast says. Even if the clinician will be correcting the documentation later, the agency need not wait for the clinician to come back in and complete the correction before submitting the data.

TIP: Follow these steps to complete a separate OASIS Correction Form, Sevast suggests:

1. The reviewer who has identified the problem calls the assessing clinician.

2. The two discuss the problem.

3. Both agree on the correct answer.

4. The reviewer documents the conversation.

5. The reviewer then signs the correction document. In some states the clinician also must sign off on the correction document, and in others she must eventually come back in and correct the original, Sevast says.

6. The reviewer attaches the correction document to the clinician's original documentation. "This forms a complete package, clearly identifying what was completed by the assessing clinician and what was completed by the second person," Sevast advises.