Excellence in OASIS-C COS-C Prep & OASIS Training

Transcription

1 Excellence in OASIS-C COS-C Prep & OASIS Training Webinar Series - Session 3 March 19, :00 3:00PM EST PRESENTER: JOAN L. USHER, BS, RHIA, COS-C, ACE JLU HEALTH RECORD SYSTEMS TEL: (781) FAX: (781) Web Site: jluhealth@verizon.net 1 Session 3 Agenda 1. Understanding Case Mix Diagnoses 2. Review of Inpatient Diagnostic Questions M1010, M1012, M Review of Home Health Diagnostic Questions M1020, M1022, M Begin Review of Chapter 3 OASIS M items/clinical Questions M0030-M JLU Health Record Systems 1

2 OASIS Manual The OASIS Guidance Manual provides information about the completion of assessment items that require coding. Assessment- Instruments/HomeHealthQualityInits/HHQIOASISUserM anual.html Read Appendix D Selection & Assignment of OASIS Diagnosis Read Chapter 3 Section C Patient History & Diagnosis 3 Selection & Assignment of OASIS Diagnoses From OASIS Guidance Manual HHAs are expected to understand the patient s specific clinical status before selecting and assigning the diagnosis. Each patient s overall medical condition and care needs must be comprehensively assessed before the HHA selects and assigns the OASIS diagnoses. CMS expects HHAs to complete the patient s comprehensive assessment before assigning the home health diagnoses to M1020/M1022 and M1024 (optional) to the OASIS-C JLU Health Record Systems 2

3 ICD-9-CM Coding Appendix D Selection & Assignment of OASIS Diagnosis 5 Important Definitions Outcome and Assessment Information Set (OASIS): A group of standard data elements which provide a comparative measurement of home health care patient outcomes at two points in time. The OASIS is part of the comprehensive clinical assessment of the patient. The patient s condition and care needs are comprehensively assessed and OASIS diagnoses are then assigned. Case Mix Diagnosis: A specific list of diagnoses determined by Center for Medicare & Medicaid Services (CMS) which increase revenues if listed as on the of the first six (6) diagnoses on the OASIS form JLU Health Record Systems 3

4 Important Definitions Prospective Payment System (PPS): The general term for the payment system under which home health is paid for Medicare patients. PPS uses episodic payment which is based on the case mix diagnosis and specific OASIS information. Home Health Resource Grouping (HHRG): The calculated payment category for home health. 153 Payment Groupings where payment is per episode & is based on 21 OASIS data elements. It Includes the cost of the 6 disciplines & NRS. 7 HHRG C1F1S1 Clinical is the first level of the decision tree and is composed of 14 M items. Functional is the second level of the decision tree and is composed of 6 M items. Service level dimension is based on 1 item: M2200 Therapy Services A patient is assigned into four equations: 1 st or 2 nd episode low therapy 1 st or 2 nd episode high therapy 3 rd + episode low therapy 3 rd + episode high therapy JLU Health Record Systems 4

5 21 Items Used to Calculate HHRG M1020 Primary Diagnosis M1022 Other Diagnoses M1024 Payment Diagnosis M1030 Therapies (IV, parenteral) M1200 Vision M1242 Frequency of Pain M1308 Multiple Pressure Ulcer M1324 Most Problematic Pressure Ulcer M1334 Stasis Ulcer M1342 Surgical Wound M1400 Shortness of Breath M1620 Bowel Incontinence M1630 Ostomy for Bowel Elimination M2030 Injectable Drug Use M1810 Ability to Dress Upper Body M1820 Ability to Dress Lower Body M1830 Bathing M1840 Toilet Transferring M1850 Transferring M1860 Ambulation/Locomotion M2200 Therapy Visits Diagnostic Case Mix Categories Blindness/low vision Ortho 1 &2 Blood CA Diabetes Dysphagia GI Heart/HTN Neuro 1, 2, 3, 4 Psych 1 &2 Pulmonary Skin 1 Skin 2 Tracheostomy Urostomy/Cystostomy JLU Health Record Systems 5

6 HH PPS Grouper Software Logic Calculating Case Mix Points If both primary & secondary diagnosis from the same diagnostic category then the primary diagnosis score is recognized Not eligible to earn points from the same diagnosis group If diagnoses are from different diagnostic groups points from each different diagnostic group is assigned Up to 6 diagnoses are recognized Codes identified with M (manifestation) must be preceded by underlying etiology to receive points 11 OASIS Coding Items Inpatient Diagnosis M1010 Inpatient Diagnosis ICD-9 Code M1012 Inpatient Procedure ICD-9 Code M1016 Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days JLU Health Record Systems 6

7 M1010 Inpatient Diagnosis List each Inpatient Diagnosis and ICD-9-CM code at the level of highest specificity for only those conditions treated during an inpatient stay within the last 14 days (no E-codes, or V-codes): OASIS ITEM Inpatient Facility Diagnosis ICD-9-CM Code a. _. b. _. c. _. d. _. e. _. f. _ M1010 Inpatient Diagnoses Selection Identifies diagnoses for which patient was receiving treatment in an inpatient facility within the past 14 days The term past fourteen days is the two-week period immediately preceding the start/resumption of care For purposes of counting the 14-day period, the date of admission is day 0 and the day immediately prior to the date of admission is day 1. This list of diagnoses is intended to include only those diagnoses that required treatment during the inpatient stay and may or may not correspond with the hospital admitting diagnosis. This expanded list allows for a more comprehensive picture of the patient s condition prior to the initiation or resumption of home care JLU Health Record Systems 7

8 M1010 Inpatient Diagnoses Selection Record only those diagnoses that required treatment during inpatient stay If not treated, do not list Actively treated: defined as receiving something more than the regularly scheduled medications and treatments necessary to maintain or treat an existing condition If a diagnosis was not treated during an inpatient admission, it should not be listed. (Example: The patient has a long-standing diagnosis of osteoarthritis, but was treated during hospitalization only for peptic ulcer disease. Do not list osteoarthritis as an inpatient diagnosis.) May include up to 6 inpatient diagnoses No V-codes or E-codes. List the underlying diagnosis No surgical codes. List the underlying diagnosis that was surgically treated 15 Comparison Inpatient Diagnosis Acute CVA Hemiplegia dominant side Two Codes Required Side of hemiplegia specified Home Health Admission Late Effect CVA with Hemiplegia dominant side One Code Required Combines diagnosis and sequelae Side of hemiplegia specified JLU Health Record Systems 8

9 M1012 Inpatient Procedure List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care. Inpatient Procedure Procedure Code a.. b.. c.. d.. NA - Not applicable UK - Unknown 17 M1012 Inpatient Procedure Selection List each Inpatient procedure and the associated ICD-9-CM procedure code relevant to the plan of care Include only those procedures that occurred during the inpatient stay that are relevant to the home health plan of care Example: Mastectomy Example: CABG Do not include inpatient procedures that are not relevant to the home health plan of care. i.e. diagnostic procedure (CT scan) Identifies medical procedures that the patient received during an inpatient facility stay within the past 14 days that are relevant to the home health plan of care JLU Health Record Systems 9

10 M1012 Inpatient Procedure Selection It is no longer necessary to enter Inpatient Procedures as M1012 is not used for quality or payment functions. The item may not be left blank. Any response of NA, UK, or procedure codes represents an acceptable response 19 M1016 Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days List the patient's Medical Diagnoses and ICD-9-CM codes at the level of highest specificity for those conditions requiring changed medical or treatment regimen within the past 14 days (no surgical, E-codes, or V- codes): Changed Dx ICD-9-CM Code a. _. b. _. c. _. d. _. e. _. f. _. NA - Not applicable (no medical or treatment regimen changes within the past 14 days) JLU Health Record Systems 10

11 M1016 Diagnoses Requiring Medical or Treatment Regimen Change within past 14 days Purpose is to identify the patient s recent past history Allows for up to 6 diagnoses (a-f) Surgical, V codes and E codes are not allowed Identify any change in treatment, health care services or medications by diagnosis New or diagnoses that have exacerbated Mark NA if changes in medical or treatment regime were made because of a diagnosis improvement 21 M1016 Diagnoses Requiring Medical or Treatment Regimen Change within past 14 days Question 4. Please provide clarification and guidance related to M1016 and the Response specific Instructions to "Mark NA if changes in the medical or treatment regimen were made because a diagnosis improved." If we admit a patient following a hospital stay for exacerbation of CHF and at SOC, the patient s CHF is still a current diagnosis that requires monitoring, evaluation, and/or active treatment by the agency to prevent readmission of the patient to the hospital; can we list CHF in M1016 even though it improved? JLU Health Record Systems 11

12 M1016 Diagnoses Requiring Medical or Treatment Regimen Change within past 14 days Answer 4. M1016 is utilized in the risk adjustment of outcomes. The Ch. 3 Item Intent explains, "The purpose of this question is to help identify the patient s recent history by identifying new diagnoses or diagnoses that have exacerbated over the past 2 weeks. This information helps the clinician develop an appropriate plan of care, since patients who have recent changes in treatment plans have a higher risk of becoming unstable. The intent of the item is not to identify diagnoses where all medical or treatment regimen changes in the last 14 days were related to improvements in a condition. If at any time in the last 14 days the patient requires a medical or treatment regimen change due to development of a new condition or lack of improvement or worsening of an existing condition, the diagnosis should be reported in M1016, even if the condition also showed improvement or stabilization during that time, or is improved at the time of the SOC (M1020) Primary Diagnosis & (M1022) Other Diagnoses (M1024) Case Mix Diagnoses (OPTIONAL) (1) (2) (3) (4) ICD-9-CM and symptom control rating for each condition Complete only if a V code in Column 2 is reported in place of a case mix diagnosis. Complete only if the V code in Column 2 is reported in place of a case mix diagnosis that is a multiple coding situation (e.g., a manifestation code). Description ICD-9-CM / Symptom Control Rating Description/ ICD-9-CM Description/ ICD-9-CM (M1020) Primary Diagnosis (V codes are allowed) (V or E codes NOT allowed) (V or E codes NOT allowed) ( ) a. D0 D1 D2 D3 D4 a. a. ( ) ( ) (M1022) Other Diagnoses (V or E codes are allowed) (V or E codes NOT allowed) (V or E codes NOT allowed) b. b. b. ( ) D0 D1 D2 D3 D4 ( ) ( ) JLU Health Record Systems 12

13 M1020 Primary Diagnosis Selection M1020 line a: (Columns 1 & 2) PRIMARY DIAGNOSIS (485 #11) Definition: the diagnosis most related to current home health plan of care The condition established after study to be the chief reason for the admission. The diagnosis that represents the most acute condition and requires the most intensive services should be entered. Specifically, why the agency is treating the patient. May be different from hospital diagnosis (M1010). V-Codes may be the appropriate primary diagnosis. Example: Attention to Colostomy V55.3 Example: Encounter for change or removal of surgical wound dressing V58.31 Example: Rehab Only Case V M1022 Other Diagnosis M1022 lines b-f (Columns 1 & 2) OTHER DIAGNOSES (485 #13) Definition: all conditions that coexisted at the time the plan of care was established, or which developed subsequently, or affect the treatment or care of the patient. Ensure that the secondary diagnosis under consideration includes not only conditions actively addressed in the patient's plan of care but also any co morbidity affecting the patient's responsiveness to treatment and rehabilitation prognosis, even if the condition is not the focus of any home health treatment itself. The order that secondary diagnoses are entered should be determined by the degree that they impact the patient s health and need for home health care, rather than the degree of symptom control. V & E Codes may be listed as other diagnoses. Example: Therapeutic Drug Monitoring V58.83 Example: Long Term (Current Use) Drug Use V58.6x Avoid excessive assigning of V codes JLU Health Record Systems 13

14 M1024 Payment Diagnosis Instructions Effective January 1, 2014 only fracture codes are allowed in M1024 for payment Leave M1024 blank if M1020 or M1022 is not a V-code Resolved conditions may be included in M1024 for risk adjustment purpose only If a V code is utilized in M1020 for Case Mix Categories of Diabetes, Neuro 1 or Skin 1, the grouper will read the next line and award the higher payment category Assignment of OASIS Codes Q Can anyone other than the assessing clinician enter the ICD codes? A Coding may be done in accordance with agency policies and procedures, as long as the assessing clinician determines the primary and secondary diagnoses and records the symptom control ratings. The clinician should write-in the medical diagnoses requested in M1010, M1016, and M1020/1022/1024, if applicable. A coding specialist in the agency may enter the actual numeric ICD-9 codes once the assessment is completed JLU Health Record Systems 14

15 Assignment of OASIS Codes Q36: Can we have the SOC Clinician defer to the agency certified coder for all coding in the document? Does this affect the date that the OASIS assessment is completed? A36: Regulation does allow for a coding specialist to enter the ICD-9 Codes after the assessment is completed so therefore it does not change the M0090 date Test Your Knowledge Which of the following is a case mix diagnosis? a. Hypertension b. Atrial Fibrillation c. Late Effect CVA with hemiplegia d. Acute bronchitis JLU Health Record Systems 15

16 Chapter 3 OASIS M items 31 OASIS C Numbering System M Items Patient Tracking Items M0010-M0069, M0140-M0150 Clinical Record Items M0080-M0110 Patient History & Diagnosis M1000s Living Arrangements M1100 Sensory Status M1200s Integumentary Status M1300s Respiratory Status M1400s Cardiac Status M1500s Elimination Status M1600s Neuro/Emotional/Behavioral M1700s ADLs/IADLs M1800s +M1900s Medications M2000s Care Management M2100s Therapy Need & POC M2200s Emergent Care Data Collected at TNR/DC M2300s 32 M2400,M0903-M JLU Health Record Systems 16

17 Clinical Record Items M0080-M SOC/ROC M0030 Start of Care Date Specifies the start of care date, which is the date that the first reimbursable service is delivered. M0032 Resumption of Care Date Specifies the date of the first visit following an inpatient stay by a patient receiving service from the home health agency JLU Health Record Systems 17

18 M0090 Date Assessment Completed SOC, ROC, follow-up and discharge assessments must be completed by a face-to-face encounter with the patient May take more than one day to complete Usually this date is associated with the visit, however if the clinician needs to follow up off site with MD, family, collaboration of other disciplines (to complete specific clinical items), M0090 will reflect the date the assessment is completed For transfer or death at home assessments document the date the agency learns of the event 35 Test Your Knowledge We have 5 calendar days to complete the admission/start of care assessment. What date do we list on OASIS for M Date Assessment Completed March 1 st when information is gathered on day 1, 3 and 5? JLU Health Record Systems 18

19 Timeliness of Care (QM) (M0102) Date of Physicianordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. / / month / day / year (Go to M0110, if date entered) NA No specific SOC date ordered by physician (M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA. / / month / day / year 37 Timeliness of Care Tips M0102 Physician-ordered SOC Date Enter date of SOC Communication from D/C planner on behalf of MD is physician-ordered SOC If delayed due to MD request or patient s physical condition enter that date Enter NA if initial orders do not specify SOC date M0104 Date of Referral Enter date of referral Verbal, written or electronic authorization Do not count date to prepare for possible admission Updated information on a delayed admission use date of updated information JLU Health Record Systems 19

20 Test Your Knowledge The home health agency received a referral on June 1st, and then on June 2nd received a faxed update with additional patient information that indicates a possible delay in the patient s hospital discharge date. What is the referral date for M0104? 39 Patient History & Diagnosis M1000s JLU Health Record Systems 20

21 M1000 Was patient discharged from Inpatient Facility? From which of the following Inpatient facilities was the patient discharged during the past 14 days? (Mark all that apply) 1. Long Term Nursing Facility 2. Skilled Nursing Facility (SNF/TCU) 3. Short - stay Acute Hospital (IPPS) 4. Long Term Care Hospital (LTAC) 5. Inpatient Rehab hospital or unit (IRF) 6. Psychiatric Hospital or Unit 7. Other (specify) NA Patient was not discharged from an inpatient facility (Go to M1016) 41 M1000 TIPS Indicate ALL the facilities the patient was in during the past 14 days (the 14 days excludes the SOC date). If the patient has been in both a hospital and SNF; mark both responses. Determine past 14 days by counting the days the day of admission is day 0. Ask patient if he was in more than one facility, moved from one floor to another and identify facility by name Hospitals may have a separately licensed facility on the same grounds: TCU, Rehab Note: If M1000 is NA then skip to M JLU Health Record Systems 21

22 M1000 Test Your Knowledge A client who was admitted to an inpatient facility for less than 24 hours. We did not do a Transfer OASIS because the criteria for it were not met. Two days later the patient was discharged from our agency and we completed a discharge comprehensive assessment. Approximately 1 week later, the client developed a wound and was readmitted to our agency. When completing the new SOC comprehensive assessment, how do we mark M1000 regarding Inpatient Facility Discharge in the Past 14 Days? 43 Next Session: March 19, :00 3:00PM EST Some Highlights: Review of Chapter 3 OASIS M items/clinical M M1700s JLU Health Record Systems 22