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OASIS Alert

Training:

HOLES IN YOUR DOCUMENTATION CAN LEAK MONEY

Published on Sat Mar 01, 2003

Plugging gaps in the OASIS assessment with adequate documentation can prevent downcoding and medical reviews and even lawsuits.

Documentation is a perennial issue,so while the focus of your training efforts may change, the need for training is ongoing.

The more familiar you become with the OASIS assessment process, the easier it will be to recognize the gaps that are built into the instrument, notes consultant Linda Krulish with Home Therapy Services in Redmond, WA. And once you find those gaps, provide your clinician with documentation tools that remind her where the gaps are, help her fill them and make the process as efficient as possible, she adds.

While a good clinical assessment probably will support the OASIS items that affect reimbursement, prudent agencies won't leave that to chance. To ensure you cover all bases, teach clinicians strategies they can use to support the appropriate reimbursement for each patient, experts recommend. Checklists or additional questions related to specific OASIS items can dramatically improve consistent documentation, Krulish says.

If the clinical record often doesn't support OASIS items affecting reimbursement, not only will you be downcoded, but you may be singled out for focused medical review or even fraud investigations, warns consultant  Pat Sevast with American Express Tax and Business Service in Timonium, MD.

Nursing documentation that doesn't support your assessment also "sets you up for legal problems and fraud and abusep roblems," warns North Andover, MA-based consultant  Maureen Yadgood.  All documentation is part of the legal record in liability cases, she adds.

Although fiscal intermediaries may downcode claims if they don't see supporting documentation somewhere other than on the OASIS assessment, it's probably not necessary to document supporting information for every item every week, Krulishsays. "Do what is clinically meaningful and clinically appropriate,"she advises, but be sure the chart clearly shows why you decided to answer the question the way you did.

Agencies should pay special attention to these frequently under-documented areas:

  • Vision impairment (M0390). Your clinical documentation should be consistent with the identified problem, Krulish says. If you say a patient has partially or severely impaired vision, you would expect to see evidence of it somewhere else. Have you documented that you provided large print reading materials, made suggestions about improving the lighting for safety or considered the vision problems in medication management?

  • Cognitive functioning (M0610). When caring for a patient who is confused, you should document the patient's mental state on each visit, Yadgood recommends. "Documentation should reflect what we're in there for," she emphasizes. Part of every visit should be evaluating and monitoring for safety, medication management and other basic care issues, she adds.

  • Bowel and bladder incontinence (M0530/ 540). Staff expectations that the elderly often are incontinent may be the reason this problem is inadequately documented, experts say. Generally, you should include incontinence in the treatment plan and document it in the record, Krulish counsels.

    You might need to address chronic incontinence only once, perhaps documenting the length of time it has existed, information about its cause, supplies being used and preventive education to avoid skin breakdown, she suggests. But document new problems such as recent incontinence of unknown origin or incontinence related to mobility issues more frequently as part of the treatment plan. "Show what you're doing to address the issue," she adds.

  • Pressure ulcers (M0445/450). Inconsistent wound documentation is as chronic as many pressure ulcers,experts agree. Don't limit your documentation to the answers OASIS requires, Krulish warns. The stage of the pressure ulcer is important, but you also need to know "if it is a 10-year-old healed ulcer," she says (see article 6).

     

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