OASIS Alert

When your agency begins to use ICD-10, you’ll need much more specific information from your intake staff to assess, code, bill, and keep your money. “ICD-10 is going to throw a whole new wrench in the spokes of our already wobbly wheel,” says Delaine Henry, COS-C, HCS-D, with Health Care Management and Billing Services in Lafayette, La.

When it comes to gathering good information at intake, a form that prompts clinicians to ask for what you need is invaluable. Try this example from Pat Jump with Rice Lake, Wis.-based Acorn’s End Training & Consulting.

CLIENT PHONE REFERRAL/INTAKE FORM

Inquiry Date__________Referral Date (M0104)_________TIME_______CALLER___________________#________

Inpatient Discharge Date (M1005)_________Agency Staff Taking Referral:__________________________________

Referral Source

Pt. Name_______________________________________BD___/___/____ TEL.#____________________________

Address_________________________________________________________________________________________

Pt. Allergies______________________________Service Request:  SN  PT  SLP OT  HHA  Homemaker

PAYER(s):  Medicare PPS  HMO/Medicare Advantage  Medicaid  Waiver  Private Insurance  Private Pay 

Other ________________________________ Payer Verification Done (by HHA Staff):  Yes  No _____________

PHYSICIAN-ORDERED SOC (M0102) __________________ Start Of Care (M0030) _______________________

PHYSICIAN FOR POC______________________________TEL.#______________ LIC/NPI ___________________

ADDRESS______________________________________________________________________________________

Specific Orders & Misc. Notes_______________________________________________________________________

_______________________________________________________________________________________________

Was Face-to-Face Encounter Completed:  Yes  No 

Was Depression Screening done?  Yes  No If yes, results: ________________________________________

Physician-ordered protocols (specify)?________________________________________________________________

Recent History of Falls:  Yes  No ________________________________________________________________

Immunization status: Influenza vaccination_____________________ Pneumonia vaccination___________________

Pressure Ulcer history (include stages)?_______________________________________________________________

Current Pressure Ulcer Treatment_____________________________________________________________

Equipment Needs: ________________________________________________________________________________

Family Contact Information: ________________________________________________________________________

Client Accepted for Service:  Yes  No (list reason not accepted) ________________________________________

OASIS WORKSHEET FOR REFERRAL/ADMISSION

M0110 Episode  1 early  2 later  UK unknown  NA not applicable, no Medicare case mix group to be defined

(M1011) List each Inpatient Diagnosis and ICD-10-C M code at the level of highest specificity for only those conditions actively treated during an inpatient stay having a discharge date within the last 14 days (no V, W, X, Y, or Z codes or surgical codes): 

M1018 Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay within past 14 days

1 — Urinary incontinence
2 — Indwelling/suprapubic catheter
3 — Intractable pain
4 — Impaired decision-making
5 — Disruptive or socially inappropriate behavior
6 — Memory loss to the extent that supervision required
7 — None of the above
NA — No inpatient facility discharge and no change in medical or treatment regimen in past 14 days
UK — Unknown