NAVIGATING THE OASIS C2 OUTCOMES. Data Elements: Standardization. Standardized Patient Assessment Data. Standardization: Ideal State

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1 NAVIGATING THE OASIS C2 OUTCOMES Selman Holman & Associates, LLC Lisa Selman Holman, JD, BSN, RN, HCS D, COS C, HCS O, HCS H Home Health Insight Consulting, Education and Products CoDR Coding Done Right CodePro University 5800 N. I 35 Suite 301 Denton, Texas fax Lisa@selmanholman.com Data Elements: Standardization Standardized Patient Assessment Data Currently the main reason for revising OASIS is to increase standardization with assessment item sets for other post acute settings and to enable calculation of standardized, cross setting quality measures, pursuant to the provisions of the Improving Medicare Post Acute Care Transformation (IMPACT Act of 2014) HH SNF Skilled Nursing Facility (Minimum Data Set) IRF Inpatient Rehab Facility (Patient Assessment Instrument) LTCH Long Term Care Hospital (Continuity Assessment Record and Evaluation (CARE) Data Set) Use of Standardized Assessment Data no later than Functional status HHA: January 1, 2019 Cognitive status and mental function Special services, treatments and interventions Medical conditions and comorbidities 3 Other categories Impairments 4 Standardization: Ideal State 5

2 OASIS Data Timepoints The Definition of an Episode Can Be D I f f e r e n t OASIS data are collected at the following time points: Start of care. Resumption of care following inpatient facility stay. Recertification within the last 5 days of each 60 day recertification period. Other follow up during the home health episode of care. Transfer to inpatient facility. Discharge from home care. Death at home. Payment Episode: SOC to Recert to Recert to 7 SOC ROC Quality Episode AKA Outcome Episode Transfer Discharge Death at Home 8 Ramifications Resumption of Care is as important as SOC Discharge is as important as SOC or ROC Unplanned discharges without a visit to the home for assessment can be disastrous to your outcomes SOC, FU, FU, FU, FU, DC not good for your Home Health Compare outcomes Outcomes Outcomes are health status changes between two or more time points, where the term health status encompasses physiologic, functional, cognitive, emotional, and behavioral health. Outcomes are changes that are intrinsic to the patient. Outcomes are changes that result from care provided, or natural progression of disease and disability, or both. Outcomes are positive, negative, or neutral changes in health status Example At SOC, Mr. Brown was marked as a 3. At DC, Mr. Brown was marked as a 2 as he had been trained by therapy to use a 2 handed device, but he still needed occasional assistance. X X 11 12

3 No Longer Included on the HH Quality Measures Table Removed from Home Health Compare Will be on HHC preview reports for several quarters Removed in January 2018 CASPER reports Still can be used for internal purposes through Tally Reports IMPACT Act Measure Domains Began reporting with OASIS C2 Skin Integrity and Changes in Skin Integrity. Medication Reconciliation. Resource Use Measures, i.e. Total estimated Medicare Spending Per Beneficiary. Discharge to Community. All Condition Risk Adjusted Potentially Preventable Hospital Readmission Rates New or worsened pressure ulcer M1313a M1313b M1313c Risk adjusters GG0170c (Assistance) M1620 (Bowel) (Not new) M1028 (Diabetes) M1060a (BMI) M1060b (BMI) New Measure/New Items Three new items Covariates Drug Regimen Review Conducted with Follow Up for Identified Issues Claims Based Measures Resource Use Measure: Total Estimated Medicare Spending per Beneficiary. Outcome Measure: Discharge to Community. Outcome Measure: Potentially Preventable 30 Day Post Discharge Readmission Measure

4 SOC ROC M1028 Active Diagnoses 19 This item identifies whether two specific diagnoses are present, and active. These diagnoses influence a patient's functional outcomes or increase a patient's risk for development or worsening of pressure ulcer(s). - means unable to assess Leave blank if the patient doesn t have either diagnosis. 20 M1028 Response Specific Instructions Select Response 1, Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) if the patient has an active diagnosis of PVD or PAD. 21 M1028 Response Specific Instructions PVD or PAD is indicated by any of the following diagnosis codes that start with the first four characters of: I70.2 Atherosclerosis of native arteries of the extremities. I70.3 Atherosclerosis of bypass graft(s) of the extremities. I70.4 Atherosclerosis of autologous vein bypass graft(s) of the extremities. I70.5 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities. I70.6 Atherosclerosis of nonbiological bypass graft(s) of the extremities. I70.7 Atherosclerosis of other type of bypass graft(s) of the extremities. I70.91 Generalized atherosclerosis. I70.92 Chronic total occlusion of artery of the extremities. PVD or PAD is indicated by the following diagnosis code that start with the first three characters of: I73. Other peripheral vascular diseases. 22 M1028 Response Specific Instructions Select Response 2, Diabetes Mellitus (DM) if the patient has an active diagnosis of DM. M1028 RESPONSE-SPECIFIC INSTRUCTIONS DM is indicated by any of the following diagnosis codes that start with the first three characters of: E08. Diabetes mellitus due to underlying condition. E09. Drug or chemical induced diabetes mellitus. E10. Type 1 diabetes mellitus. E11. Type 2 diabetes mellitus. E13. Other specific diabetes mellitus. Home Health: OASIS C2 May

5 CODING CONVENTION When diabetes and PVD/PAD are documented as diagnoses and no other cause is documented for the PVD/PAD, the classification assumes diabetes as the cause. So if the patient has Type 2 diabetes and also has PVD, it is coded as E11.51 Type 2 DM with peripheral angiopathy. Do NOT add a code from I73. Because the patient has both diagnoses documented, should both 1 and 2 be checked on M1028, even though no I70 or I73 is used? DIABETIC PVD When a patient has diabetic peripheral vascular disease (PVD) or peripheral artery disease (PAD), should both items be checked (as yes) even though these are combination codes (Ecodes) and no I-code is included? Yes. If a diabetic patient has either PAD or PVD, both the diabetes mellitus item (2) and the PAD/PVD (1) items are checked in item M1028, Active Diagnoses STEPS FOR ASSESSMENT DOCUMENTATION REQUIRED Transfer documents, Progress notes H&P DC Summary Step 1Identify Diagnosis Step 2 Determine if Diagnosis is Active Documentation states dx is active OR Active intervention 27 Item requires documentation in the medical record by: Physician Nurse Practitioner Physician Assistant Clinical Nurse Specialist Other Authorized Licensed Staff, If Allowable Under State Licensure Laws 28 STEP 1: IDENTIFY DIAGNOSES Diagnoses communicated verbally should be documented in the medical record by the physician (or other licensed staff if allowable under State licensure laws) to ensure follow-up and coordination of care. Only diagnoses confirmed and documented by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under State licensure laws) should be considered when coding this item. M1028 Is the diagnosis active? Active diagnoses are diagnoses that have a direct relationship to the patient s current functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of assessment. Not resolved 29 30

6 M1028 IS THE DIAGNOSIS ACTIVE? Do not include diseases or conditions that have been resolved or do not affect the patient s current functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of assessment. Note: Diabetes and conditions in I70 and I73 will usually affect pain, treatments, monitoring. 31 DIAGNOSIS DURING THE TIMEFRAME-- EXAMPLE Patient s admitting diagnosis is prediabetes. The assessing clinician finishes the assessment on the second day after SOC. On the 4 th day the PA calls and states further tests indicate patient has a diagnosis of diabetes and provides orders. The assessment should be updated and the M0090 date changed. This is only true if new information is obtained within the assessment time frame. 4b Q EXAMPLES OF ACTIVE DIAGNOSES Example 1: Mr. A is prescribed insulin for diabetes mellitus. He requires regular blood glucose monitoring to determine whether blood glucose goals are achieved by the current medication regimen. The physician progress note documents diabetes mellitus. Response 2: Diabetes Mellitus would be checked. Rationale: This would be considered an active diagnosis because the physician progress note documents the diabetes mellitus diagnosis, and because there is ongoing medication management and glucose monitoring. 33 EXAMPLES OF ACTIVE DIAGNOSES Example 2: Mrs. I underwent a below the knee amputation due to gangrene associated with peripheral vascular disease. She requires dressing changes to the stump and monitoring for wound healing. In addition, peripheral pulse monitoring is ordered. The nurse practitioner s progress note documents peripheral vascular disease and left below the knee amputation. Response 1: Peripheral Vascular Disease (PVD) would be checked. Rationale: This would be considered an active diagnosis because the nurse practitioner s note documents the peripheral vascular disease diagnosis, with peripheral pulse monitoring and recent below the knee amputation, with dressing changes and wound status monitoring. 34 ANOTHER EXAMPLE (PT ONLY) Patient admitted for PT after joint replacement. The patient takes care of diabetes. Diabetes could affect her rehab prognosis so is reported in M1023. PT will be monitoring patient holistically to identify problems but has no active interventions related to diabetes. Diabetes could be affected by limited mobility, impact the healing of the surgical wound. Monitoring the patient and wound considering diabetes makes it an active diagnosis. 4bQ46.4 PRACTICE SCENARIO Mr. B has Type 2 Diabetes Mellitus (DM) and takes metformin and glypizide daily. His healthcare regimen also includes regular blood glucose monitoring, exercise, and a diabetic diet. The physician progress note documents an active diagnosis of both DM with peripheral neuropathy and Peripheral Vascular Disease (PVD)

7 PRACTICE SCENARIO Mr. J is admitted to home care services after surgery for a left total knee replacement. His medical record documents current active diagnoses of asthma and arthritis. How should the admitting clinician complete M1028? a. 1 b. Dash c. Leave blank 37 SOC ROC M1060 HEIGHT AND WEIGHT Self-report or paperwork from another setting is not acceptable 4bQ62.9 Use mathematical rounding M1060 These items support calculation of the patient s body mass index (BMI) using the patient s height and weight. Diminished nutritional and hydration status can lead to debility that can adversely affect wound healing and increase risk for the development of pressure ulcers. Height and weight measurements (and BMI calculation) assist staff in assessing the patient s nutrition and hydration status by providing a mechanism for monitoring stability of weight and BMI over a period of time. The measurement of height and weight for the calculation of BMI is one guide for determining nutritional status. Weight measurement is also used in assessment of heart failure Cannot Use Weight Obtained Somewhere Else IIf a patient does not have a scale and we do not have a weight from the discharging facility, is it better that we estimate the weight or should we enter a dash? The guidance for obtaining the weight indicates that the clinician must obtain the weight directly, following agency policies/procedures (not utilizing data from the referral source). Cannot Use Weight Obtained Somewhere Else Must we weigh the patient on SOC, or can the information be obtained from the MD or hospital? At SOC, the patient should be weighed. M1060b should not be obtained from the MD or hospital records.

8 POLICIES AND PROCEDURES FOR HEIGHT AND WEIGHT HEIGHT Measuring height of bedbound and chairbound patients Contractured patients WEIGHT Scales for admissions and ROC Patient scales Calibration May not be able to weight patients who cannot stand Dash Top of head to waist Waist to behind knees Knees to bottom of heels Write down numbers Add together 44 MOST RECENT MEASURE IN 30 DAYS M1060b says you can record the most recent weight in the last 30 days. If my agency weighs the patient at SOC, then the patient is transferred and care resumed, on the ROC can the agency use the same weight from the SOC if taken within 30 days? As per the OASIS-C2 Guidance Manual, Chapter 3: C-26, Steps for Assessment for M1060b, Weight, Item 3, If a patient cannot be weighed, for example, because of extreme pain, immobility, or risk of pathological fractures, enter a dash value ( ) and document the rationale on the patient's medical record. At ROC, an attempt to weigh the patient should be made. If this is not possible and the previous agency-obtained weight in M1060b is within the 30-day window, the weight can be used at ROC. WHAT IS THE ANSWER? Mrs. G has congestive heart failure and advanced osteoporosis. She is at risk for pathological fractures. She is pain free at rest but experiences severe pain when she moves. Daily weights have been discontinued as part of her prescribed medical care due to pain management. What can be done for best practices and what is the answer to M1060? 46 WHAT IS THE ANSWER? As part of the SOC comprehensive assessment, the registered nurse (R.N.) needs to obtain a height for Mr. B. Mr. B has had bilateral lower extremity amputations due to complications from diabetes. His legs are now uneven in length. Using a tape measure, the R.N. measures the patient s current height while the patient is lying in bed. She obtains two measurements: 64.4 inches and 60.8 inches. a. 64 b. 65 c. 61 d. Dash (the patient is unable to stand) M1060 Practice Scenario (3) During the SOC home visit, the R.N. completes the comprehensive assessment. The agency s policy states that a patient s weight is to be obtained with footwear removed. The R.N. assists the patient to remove his shoes and obtains his weight. The R.N. records the weight as pounds

9 M1060 Practice Scenario (4) On Day 20 of his home health quality episode, Mr. Y is transferred to acute care and remains hospitalized for 3 days. On Day 24, home health services resume. During the ROC assessment, the clinician attempts to weigh Mr. Y, but he is unable to stand on the scale due to shortness of breath. The clinician locates the following information: From the most recent SOC assessment (24 days ago), Mr. Y has a documented weight of 175 pounds. This weight was obtained by a different clinician from the same agency. Hospital medical records from his latest hospitalization indicate a recent weight of 177 pounds. Home Health: OASIS C2 May SOC ROC FU DC M1620 Bowel Incontinence Frequency M1620 BOWEL INCONTINENCE FREQUENCY Response 4 On a daily basis Indicates that the patient experiences bowel incontinence once per day. Response NA Patient has an ostomy for bowel elimination. Unknown Not an option at follow-up or discharge Bowel program no assumed incontinence 4b-Q TIME FRAME FOR BOWEL INCONTINENCE The timeframe under consideration is day of assessment and relevant past. This timeframe is directed by Response options "0- Very rarely or never has bowel incontinence" and "1-Less than once weekly." Considering these two options, the assessing clinician would need to consider bowel incontinence that was experienced beyond the past 7 days. The assessing clinician must use clinical judgment to determine how far into the past would be relevant to this home care admission. The assessing clinician may elect to re-assess bowel incontinence within the allowed timeframe and change her/his original response as well as M0090, Date Assessment Completed. 4bQ M1620 BOWEL INCONTINENCE FREQUENCY Review the bowel elimination pattern Difficulty controlling stools Diarrhea Note cleanliness Around the toilet Clothing At F/U may ask the aide Consider Physiologic reasons Cognitive impairments Mobility problems 54

10 GG0170c Mobility Usual sleeping surface 55 GG0170C1 SOC/ROC Performance Coding Instructions Code 06, Independent: if the patient completes the activity by him/herself with no human assistance (includes independent use of an assistive device). For example: The patient can independently retrieve and use a belt to lift legs to the side of the bed or independently place a step stool for use. GG0170C1 SOC/ROC Performance Coding Instructions Code 05, Setup or clean up assistance: if the caregiver SETS UP or CLEANS UP; patient completes activity. Caregiver assists only prior to or following the activity, but not during the activity. For example: The patient requires assistance putting on a shoulder sling prior to the transfer, or requires assistance removing the bedding from his/her lower body to get out of bed. GG0170C1 SOC/ROC Performance Coding Instructions Code 04, Supervision or touching assistance: if the caregiver provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. For example: The patient requires verbal cueing, coaxing, or general supervision for safety to complete activity; or patient may require only incidental help such as contact guard or steadying assistance during the activity. GG0170C1 SOC/ROC Performance Coding Instructions Code 03, Partial/moderate assistance: if the caregiver must provide LESS THAN HALF the effort. Caregiver lifts, holds, or supports trunk or limbs, but provides less than half the effort.

11 GG0170C1 SOC/ROC Performance Coding Instructions Code 02, Substantial/maximal assistance: if the caregiver must provide MORE THAN HALF the effort. Caregiver lifts or holds trunk or limbs and provides more than half the effort. GG0170C1 SOC/ROC Performance Coding Instructions Code 01, Dependent: if the caregiver must provide ALL of the effort. Patient is unable to contribute any of the effort to complete the activity; or the assistance of two or more caregivers is required for the patient to complete the activity. GG0170C1 SOC/ROC Performance Coding Instructions Code 07, Patient refused: if the patient refused to complete the activity. GG0170C1 SOC/ROC Performance Coding Instructions Code 09, Not applicable: if the patient did not perform this activity prior to the current illness, exacerbation, or injury. GG0170C1 SOC/ROC Performance Coding Instructions Key Coding Questions Code 88, Not attempted due to medical condition or safety concerns: if the activity was not attempted due to medical condition or safety concerns. Code 07, Patient refused: if the patient refused to complete the activity. Code 09, Not applicable: if the patient did not perform this activity prior to the current illness, exacerbation, or injury. Code 88, Not attempted due to medical condition or safety concerns: if the activity was not attempted due to medical condition or safety concerns.

12 GG0170C1 SOC/ROC Performance Coding Instructions Code 88 Not attempted due to medical or safety concerns. New condition related to current illness, exacerbation, or injury preventing activity from being performed safely on this assessment. Example: New compression fracture requiring bed rest. Code 09 Not applicable. Patient did not perform this activity prior to the current illness, exacerbation, or injury. Examples: Quadriplegic patient; patient with preexisting and ongoing need of Hoyer lift. GG0170C1 SOC/ROC Performance Coding Instructions If no information is available or assessment is not possible for other reasons, enter a dash ( ) for SOC/ROC Performance. A dash ( ) value is a valid response for this item. A dash ( ) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged, or dies before assessment of the item could be completed. CMS expects dash use to be a rare occurrence. Sleeping Surface If the patient is not allowed to lay in a bed due to shoulder surgery but instead sleeps in a recliner, would we use code 88 or assess them in the recliner? If the patient s usual sleep surface is a recliner, the recliner can be considered the patient s bed for GG0170C. You would assess the patient's mobility in the recliner, treating the recliner as the bed. Assistive Device If the patient sleeps in an electric recliner (which we are assessing as the patient s bed), and the patient pushes a button for the chair to return to a sitting position, is this considered assistance? If patients are able to use an assistive device themselves, the response code entered on the OASIS would be coded as a 06, Independent. Assistive Device Does Not Count If a patient uses a belt to go from lying to sitting on the side of the bed, but someone had to hand the belt to the patient, would that still be considered independent? For GG0170C, the use of an assistive device does not affect the scoring of the measure if the patient is able to perform the activity independently. If the patient usually requires a caregiver to hand them the assistive device to perform the activity, this would be scored as Code 5, Setup or clean up assistance, because the patient requires setup assistance prior to performing the activity. Do we consider safety when answering GG0170C? Yes, safety is always a concern. GG0170C states the ability to SAFELY move from lying on the back to sitting on the side of the bed, with feet flat on the floor, and with no back support.

13 Feet on the Floor? How would a patient with below knee amputation (BKA) be coded to perform lying to sitting position with feet on the floor? If any patient can perform the activity independently and safely, sitting on the side of the bed with no back support, and their feet do not touch the floor, they can be scored as a 06, Independent. For a BKA patient, the score would be based on the amount of assistance required to complete the activity. If the patient was able to safely complete the activity independently, moving from lying to sitting on the side of the bed with one foot touching the floor or not, with no back support, the patient would be scored as a 06, Independent. Please be aware that a BKA patient can wear lower extremity prosthetic(s) with attached foot to complete this activity. Must See the Transfer The patient can be assessed by report by the patient or caregiver/family. If the patient refuses to do the activity but verbally tells you what he/she is capable of doing, can you code 01 through 06 or do you have to code 07? The patient s functional status requires a functional assessment by a clinician. Information to support functional status can be supplemented by patient or caregiver report. If the patient refuses to complete the activity to allow a clinical functional assessment, the score entered on the OASIS C2 would be Code 07, Patient refused. Hoyer Lift If a patient uses a Hoyer or other lift, would the response be 09 and then a dash for the discharge goal? If prior to the current illness, exacerbation, or injury, the patient did not perform this activity with a Hoyer lift for transfers, the patient would be scored as Code 09 (Not applicable, if the activity was not applicable to the patient prior to the current illness, exacerbation, or injury). If the need for the Hoyer lift was new and/or temporary, the code would be Code 88, not attempted due to medical condition or safety concerns. If the patient is expected to gain function, then you would score the discharge goal accordingly using the scale of 01 to 06. If it is not expected that the patient will regain this function by discharge, the Discharge Goal for GG0170C2 would be a dash ( ). Progress or Not? The agency admits a patient that was bedbound prior to this SOC/ROC. The nurse scores GG0170C1 ROC/SOC Performance score as 09 Not applicable. For discharge goal, GG0170C2, what is the appropriate score? If Code 09 is not an option for GG00170C2, would the correct code to use be a dash ( )? Assuming the patient is expected to stay at his/her SOC/ROC functional level and will remain bedbound, enter a dash ( ) for GG0170C2 indicating the assessing clinician is not establishing a Discharge Goal for the patient s mobility task. If the patient is expected to make functional progress allowing the activity to be performed, report the discharge goal using the six point scale. Purpose of DC Goal For GG0170C2, what is the discharge goal being used for? Does it impact/increase the risk adjustment as a covariate for Risk for Pressure Ulcer Quality Measure (QM)? Is it not included in the Discharge Assessment, because we are not measuring improvement in mobility? The SOC/ROC Performance score and the Discharge Goal score for GG0170C are standardized in all post acute assessment instruments. The SOC/ROC Performance Score will be available for use as a risk covariate for the quality measure, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened. The Discharge Goal is not expected to impact any of the home health quality measures in 2017 but may be used directly or indirectly in future quality measure calculation. Foresight is not 20/20 When the clinician chooses an answer for the goal on GG0170C2, is this just an opinion based on the assessment? Will it affect any outcomes if the goal chosen is not reached? The Discharge Goal score for GG0170C2 is a standardized item that is included in all postacute care patient/resident assessment instruments. It is determined by the assessing clinician based on findings from the comprehensive assessment. The Discharge Goal is not expected to impact any of the home health quality measures in 2017, but may be used directly or indirectly in future quality measure calculation.

14 DC Goal Mrs. Peabody is bedbound at Admission/SOC, so you code her as 88, (Not attempted due to medical condition or safety concerns). What do you code them at discharge if you cannot use codes 07, 09, or 88? If prior to the current illness, exacerbation, or injury, the patient did not perform this activity because he/she was bedbound, the patient would be scored as Code 09, Not applicable. If the bedbound status was new and/or temporary, and the activity was not attempted, the not attempted response code for the activity would be Code 88, Not attempted due to medical condition or safety concerns. For DC Column: If the patient is expected to gain function, then you would score the discharge goal accordingly using the scale of 01 to 06. If it is not expected that the patient will regain this function by discharge, the Discharge Goal for GG0170C2 would be a dash ( ). DC Goal If GG0170C for SOC/ROC was scored 07, 09, or 88, is dash the correct scoring for GG0170C2 discharge? If the patient refused, should we use clinical judgment to determine a discharge goal? If the patient is expected to gain function, the assessor would score the discharge goal accordingly using the scale of 01 to 06. If it is not expected that the patient will regain this function by discharge, the Discharge Goal for GG0170C2 would be a dash ( ). GG0170C Practice Scenario (1) When asked to demonstrate lying to sitting on the side of the bed, Ms. A states that, while improved, it still requires much effort to get up. She does not want to get up again today. She states that she needs a lot of help moving in bed, getting her feet off the side of the bed, and coming to a sitting position. Her son states he must do most of the work. Based on patient/family input and observation of the patient s weakness and pain, the assessing clinician concurs that the patient likely requires considerable assistance to move from lying to sitting on the side of the bed. Based on patient/family input on recent progress, observation of Ms. A s general bed mobility, and the expected home care length of stay, the clinician determines that Ms. A will be able to independently perform the activity of sitting to lying on the side of the bed by discharge. HOME HEALTH: OASIS-C2 M A Y GG0170C Practice Scenario (2) Mr. B pushes up on the bed to attempt to get himself from a lying to a seated position as the occupational therapist (OT) provides much of the lifting assistance necessary for him to sit upright. The OT provides assistance as Mr. B scoots himself to the edge of the bed and lowers his feet to the floor. Overall, the OT must provide more than half of the effort to complete the task. GG0170C Practice Scenario (3) Mrs. Y is obese and recovering from surgery for spinal stenosis with lower extremity weakness. The caregiver partially lifts Mrs. Y s trunk to a fully upright sitting position on the bed and minimally lifts each leg toward the edge of the bed. Mrs. Y then scoots toward the edge of the bed, placing both feet flat onto the floor. She completes most of the activity herself

15 GG0170C Practice Scenario (4) Mr. W states he wishes he could get out of bed himself rather than depending on his wife to help. At the SOC, the patient requires his wife to do most of the effort. Based on the patient s prior functional status, his current diagnoses, the expected length of stay, and his motivation to improve, the clinician expects that by discharge, the patient would likely only require assistance helping his legs off the bed to complete the supine to sitting task. GG0170C Practice Scenario (5) Mrs. M is a quadriplegic admitted to home health services following a skin graft for a Stage 4 pressure ulcer. Prior to this home health admission, she was bedbound, and her caregivers used a Hoyer lift to transfer Mrs. M from her bed to her wheelchair. Based on the patient s prior functional status and current diagnoses, the home health clinician does not expect that Mrs. M s dependence on a Hoyer lift for transfer will change by discharge GG0170C Practice Scenario (6) Mr. W is recovering from shoulder surgery and usually sleeps in an electric recliner every night. When demonstrating lying to sitting, Mr. W pushes the button on the side of the recliner to return the chair to an upright position and sits unassisted with his feet flat on the floor. Based on the patient s prior functional status, his current diagnosis, and his motivation to improve, the clinician expects Mr. W will be independent in performing the activity by discharge. Summary GG0170C is a risk adjustment covariate for the Pressure Ulcers That Are New or Worsened Quality Measure. GG0170C is a new item added to OASIS C2, requiring observation and assessment. Assesses patient s usual status at SOC/ROC using the 6 point scale and three activity not attempted codes. A dash ( ) value is a valid response for this item. 67 Action Plan Review current assessment processes and tools and revise as needed to reflect the addition of GG0170C. Develop an education plan for clinicians for GG0170C. Practice coding a variety of scenarios with staff. Annual Performance Improvement Plan Consider a review of items to ensure accuracy in data collection.

16 SOC ROC FU DC M1306 Yes Stage 2 or higher and unstageables No Stage 1 and all healed ulcers or no pressure ulcers New in OASIS C2 Stage 3 and 4 (full thickness) pressure ulcers heal through a process of granulation (filling of the wound with connective/scar tissue), contraction (wound margins contract and pull together), and reepithelialization (covers with epithelial tissue from within wound bed and/or from wound margins). Once the pressure ulcer has fully granulated and the wound surface is completely covered with new epithelial tissue, the wound is considered closed, and will continue to remodel and increase in tensile strength M1306 Agencies should be aware that the patient is at higher risk of having the site of a closed pressure ulcer open up due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed full thickness pressure ulcer is only 80% of normal skin tensile strength. Agencies should pay careful attention that preventative measures are put into place that will mitigate the re opening of a closed ulcer. Implications Closed stage 3 and stage 4 pressure ulcers will no longer provide points. Not the code, but how you answer the OASIS items. Closed stage 3 and stage 4 pressure ulcers do require skilled intervention. Assessment Prevention M M1306 Mr. Ross has been on service before and it took several months to heal up his stage 4 ulcer. Mr. Ross is being admitted back to your agency. The assessing clinician notes the shiny pink divot on the right hip. Only ulcer is a closed stage 4 then answer to M1306 is NO. (Note skip pattern.) OASIS response no pressure ulcer Clinical documentation epithelialized stage 4 ulcer located at M1350 Yes (skin lesion requiring ongoing assessment/intervention) Code according to stage? Up to you Continue to code them? Guidance to not include them as pressure ulcers applies to the OASIS responses Section III of the official coding guidelines For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. Pressure Ulcer Guidelines But if documented as completely healed then do not code (by the provider)

17 NO Stage 1 pressure ulcers. Healed Stage 2 pressure ulcers (once epithelialized no longer considered a pressure ulcer) Healed Stage 3 pressure ulcers (healed for the purposes of scoring OASIS continue to be at risk) Healed Stage 4 pressure ulcers (healed for the purposes of scoring OASIS continue to be at risk) M1306 Synopsis 97 Stage 2 pressure ulcers Stage 3 Unhealed Stage 4 Unhealed YES Unstageable presence of non removable dressing/device presence of necrotic tissue that obscures visualization of stage 4 structures (bone, muscle, tendon or joint capsule) presence of eschar/slough Suspected deep tissue injury in evolution 98 Stage 2 Stage 2 Pressure Ulcer A stage 2 ulcer also may present as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. * Bruising indicates suspected deep tissue injury. Red, pink wound bed No granulation Without slough No bruising Intact or open/ruptured blister NOT solely from friction Epidermolysis Bullosa vs Pressure Ulcers We have a patient with epidermolysis bullosa. I had been categorizing his blisters and open wounds as pressure ulcers. Is this correct? If not, what would I call them? Pressure ulcers are defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. If pressure is not the primary cause of an identified skin ulcer, it does not meet the definition of a pressure ulcer. Epidermolysis bullosa is a disease that causes blistering of the skin. The etiology of these blisters is not as a result of pressure (as defined above) and therefore would not be reported as pressure ulcers. However, someone with epidermolysis bullosa can certainly develop pressure ulcers, and the clinician responsible for skin assessment should be skilled enough to know the difference in etiology. The blisters identified as part of the disease process of epidermolysis bullosa should be clearly identified as blisters associated with this disease process. Please consult with your agency related to documentation requirements. Bone, tendon or muscle is NOT exposed Slough may be present Stage 3 Undermining and tunneling may be present Granulation indicates healing 102

18 Stage 3 Pressure Ulcer The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage 3 ulcers in these locations can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Stage 3 on Ankle Stage 4 Stage 4 Pressure Ulcer Exposed bone, tendon or muscle May be slough or eschar present, but not obstructing wound bed Undermining or tunneling Granulation indicates healing Osteomyelitis does not equate The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage 4 ulcers in these locations can be shallow. stage 4 ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule); osteomyelitis is possible. Exposed bone/tendon is visible or directly palpable Stage 4 Staging Tips Unstageable: Non removable dressing Granulation and no exposed bone, tendon or muscle Stage based on previous documentation Include those that are sutured Exposed bone, tendon or muscle Slough or eschar Still a stage 4 Slough or eschar without exposed bone, tendon or muscle Unstageable (even if previously staged) 107 Non removable dressing/device includes, for example, a primary surgical dressing that cannot be removed, an orthopedic device, or cast. Every effort should be made to assess the wound if possible, unless there is clear direction that the dressing/device should not be removed. 108

19 Unstageable: Eschar Slough Unstageable Coverage of bed by slough and/or eschar Slough: Non viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Scab obscuring tissue loss Eschar: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound The true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. The pressure ulcer stage can be determined only when enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage. Deep Tissue Injury Suspected DTI Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. Bruised appearance The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue. Thin blister over dark wound bed intact skin or blood filled blister SOC ROC M1311 Current Number of Unhealed Pressure Ulcers FU DC M1311 Current Number of Unhealed Pressure Ulcers

20 Healed vs Unhealed Determining Present on Admission Terminology referring to healed vs. unhealed ulcers refers to whether the ulcer is closed vs. open. Recognize, however, that Stage 1 pressure ulcers and Suspected Deep Tissue Injury (sdti), although closed (intact skin), would not be considered healed. Unstageable pressure ulcers, whether covered with a non removable dressing or eschar or slough, would not be considered healed. For the OASIS, Present on Admission and Present at SOC/ROC have equivalent meanings. For each pressure ulcer, determine whether the pressure ulcer was present at the time of the most recent SOC/ROC, and did not form during this home health quality episode M1311 Guidance For each line 1, report the number of pressure ulcers according to stage or definition of unstageable. At FU or DC, report if that pressure ulcer was present at the same stage at the most recent SOC/ROC. Example: The patient had a stage 3 pressure ulcer at SOC. The pressure ulcer is granulating at the time of recert. Row b would be marked 1 in line 1 and 1 in line 2. The pressure ulcer is still a stage 3, is current at the time of assessment (line 1) and is at the same stage as it was at the most recent SOC/ROC (line 2). Example: The patient had a stage 3 pressure ulcer at ROC. The pressure ulcer is a stage 4 at recert. The follow up assessment should indicate: Row b (stage 3) line 1 would be marked 0 and line 2 is skipped. (No current stage 3.) Row c (Stage 4) line 1 is marked 1 and line 2 is marked 0. Even though it is the same pressure ulcer that was marked a stage 3 at ROC, it is not at the same stage as it was at ROC. 117 Determining Present on Admission If the pressure ulcer was unstageable at SOC/ROC, but becomes numerically stageable later, when completing the Discharge assessment, its Present on Admission stage should be considered the stage at which it first becomes numerically stageable. If it subsequently increases in numerical stage, do not report the higher stage ulcer as being present at SOC/ROC when completing the Discharge assessment. Example: The pressure ulcer is covered with eschar and slough with no visualization of stage 4 structures at SOC. The second week of care the pressure ulcer is debrided and is staged as a pressure ulcer stage 3. The patient is now being recertified. The pressure ulcer is still a stage 3. The assessing clinician should report the current stage 3 in row b line 1. To determine how to answer line 2, walk forward from the SOC/ROC if the pressure ulcer was unstageable at that time until the clinical record mentions a stage. That is the stage that should be considered present at the SOC/ROC when answering line Practice Practice The The pressure ulcer is covered with eschar and slough with no visualization of stage 4 structures at SOC. The second week of care the pressure ulcer is debrided and is staged as a pressure ulcer stage 3. The patient is now being recertified. The pressure ulcer is still a stage 3. The The pressure ulcer at ROC was covered by a nonremovable dressing. The first documentation noted of stage during the episode is stage 2. At discharge the pressure ulcer is stage

21 Determining Present on Admission The general standard of practice for patients starting or resuming care is that patient assessments are completed beginning as close to the actual time of the SOC/ROC as possible. If a pressure ulcer that is identified on the SOC date increases in numerical stage (worsens) within the assessment time frame, the initial stage of the pressure ulcer would be reported in M1311 at the SOC. Cannot Change Assessment on M1311 Does the instruction to code based on assessment as close to admission as possible, mean that if the ulcer is unstageable on Day 1 but debrided on Day 2, do we still report it as unstageable at SOC and leave it? Example: Pressure ulcer is covered with eschar and slough. Ulcer is debrided on day 3 of episode and ulcer is staged at 4. M1311 CANNOT be updated to stage Example: Pressure ulcer is covered with a nonremovable dressing at SOC. Patient returns to clinic on day 3 and nurse documents on day 4 that it is a stage 3. M1311 CANNOT be updated to stage 3. Non Removable Dressing at SOC If the pressure ulcer is identified as a Stage 3 in the SNF documentation but is under a dressing that cannot be removed at the SOC, for M1311 do I identify a Stage 3 or unstageable pressure ulcer due to non removable dressing? The only way you can report a pressure ulcer as unstageable due to nonremovable dressing/device is by having documentation that there is indeed an ulcer underneath the dressing/device. In this case, since there is documentation of a Stage 3 pressure ulcer under the non removable dressing/device, you would report the ulcer as unstageable due to nonremovable dressing/device. Once the dressing is removed, the ulcer would need to be assessed and staged. The SOC M1311 response of unstageable due to non removable dressing/device should not be changed to Stage 3, since that was the pressure ulcer s status when first assessed upon admission. Rationale The initial clinical assessment that was conducted on the patient should be consistent with what is reported on the SOC. If the initial skin assessment completed on admission to home health services identifies a pressure ulcer, the stage of the pressure ulcer as identified on that initial clinical assessment is what should be reported on the SOC OASIS. Any subsequent changes in numerical staging would be reported on subsequent OASIS assessments. Therefore, if an unstageable pressure ulcer is identified as part of the initial skin assessment at SOC, this ulcer should be reported as unstageable on the SOC OASIS, regardless of whether it is subsequently debrided and stageable after the initial skin assessment (i.e., by Day 2). Implications Case mix scoring comes from the answer to M1311 and M1324. No case mix points available for unstageable pressure ulcers in M1311. Cannot update M1311 during the first 5 days according to new instructions. The purpose of this policy is to get better information for outcome purposes. Q and A did NOT mention the same policy for M1324. Can the correct stage be updated in M1324??? Not a Change A muscle flap, skin advancement flap, or rotational flap (defined as full thickness skin and subcutaneous tissue partially attached to the body by a narrow strip of tissue so that it retains its blood supply) performed to surgically replace a pressure ulcer is a surgical wound. It should not be reported as a pressure ulcer on M

22 Change A pressure ulcer treated with a skin graft (defined as transplantation of skin to another site) should not be reported as a pressure ulcer and until the graft edges completely heal, should be reported as a surgical wound on M1340. Implications Pressure ulcers with skin grafts no longer count as pressure ulcers on the OASIS. Count them as surgical wounds. Coding guidelines state to code pressure ulcers with skin grafts as unstageable. Question: What do we code once the skin graft has healed? More Practice More Practice At SOC, patient has three small stage 2 pressure ulcers on sacrum At DC, sacral area is assessed: two of the stage 2 pressure ulcers have merged, and the third ulcer has increased to a stage More Practice At the SOC, patient admitted with four stage 2 pressure ulcers and one stage 3 pressure ulcer More Practice At recert, three of the stage 2 ulcers healed, however patient developed one additional new stage 3 pressure ulcer

23 Practice At the SOC, Ms. P was admitted with a diagnosis of cerebrovascular accident with right hemiparesis and assessed to have a 1 cm x 1 cm x < 0.1 cm Stage 2 pressure ulcer on her coccyx. Ms P continued Ms. P continued to decline at home, with decreased appetite, frequent transient ischemic attacks, and a wish not to be hospitalized again. After a palliative care consult, the patient and family agreed to hospice care. Upon discharge from home care, Ms. P was noted to have a pressure ulcer completely covered with eschar on her left heel and a Stage 3 pressure ulcer 3 cm x 2 cm x 0.4 cm on her coccyx DC M1313 Response Specific Instructions 135 Review the history of each current pressure ulcer. Specifically, compare the current stage at Discharge to past stages to determine whether any pressure ulcer currently present is new or at an increased numerical stage (worsened) when compared to the most recent SOC/ROC. Then, for each current stage, count the number of current pressure ulcers that are new or have increased in numerical stage since the last SOC/ROC was completed. This allows a more accurate assessment than simply comparing total counts at Discharge and most recent SOC/ROC. If a pressure ulcer increased in numerical stage from SOC (or ROC) to Discharge, it is considered worsened and would be included in counts of worsened pressure ulcers on M1313 at Discharge. 136 Response Specific Instructions Do not reverse stage pressure ulcers as a way to document healing as it does not accurately characterize what is physiologically occurring as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Clinical standards require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has healed. Once the pressure ulcer has fully granulated and the wound surface is completely covered with new epithelial tissue, the wound is considered healed, and should no longer be reported as an unhealed pressure ulcer. A previously closed Stage 3 or Stage 4 pressure ulcer that breaks down again should be staged at its worst stage

24 M1313 Continued Practice Stage 4 on the coccyx at SOC and a stage 2 on the elbow. Stage 4 underwent a skin rotational flap. Stage 2 now a stage Practice Stage 2 at ROC. At DC it is 80% covered with slough no stage 4 structures visible. New stage 2 at different location. Unstageable If the pressure ulcer was unstageable at SOC/ROC, but becomes numerically stageable later, its Present on Admission stage should be considered the stage at which it first becomes numerically stageable. Scenario: At SOC, the pressure ulcer was unstageable. At a routine visit after SOC, it was staged as a stage 3. At discharge it is a stage 3. It is NOT worsened. Worsened means the pressure ulcer has increased in numerical stage. It does not mean other deterioration of the decubitus wound, such as infection or an increase in measurable size M1313 Quiz M1313 Practice Scenario 1: You are completing Mrs. Sanchez s discharge comprehensive assessment. While assessing her skin, you determine she has two pressure ulcers. One is a stage 4 on her left buttock, and is 50 percent covered in slough, with observable muscle. The other is on her left elbow and is completely covered with eschar. You review her chart and find that at SOC the left elbow was a stage 2 and the buttock ulcer was a stage 3. How would you respond to M1313 Worsening in Pressure Ulcer Status since SOC/ROC?

25 M1313 Quiz M1313 Practice Scenario 2: You are completing Mr. Stone s discharge comprehensive assessment. When assessing his skin, you discover a stage 2 pressure ulcer on his right heel and a suspected deep tissue injury on his left heel. When you review the chart, you discover that he had no pressure ulcers at SOC. How would you respond to M1313 Worsening in Pressure Ulcer Status since SOC/ROC? SOC and ROC Transfer and DC Medications SOC ROC M2001 A potential clinically significant medication issue is an issue that in the care provider s clinical judgment, requires physician/physician designee notification by midnight of the next calendar day (at the latest). The drug regimen review includes all medications, prescribed and over the counter (including TPN and herbals), administered by any route (for example, oral, topical, inhalant, pump, injection, intravenous and via enteral tube). 149 Defining Clinically Significant Potential or actual clinically significant medication issues may include but are not limited to: adverse reactions to medications (such as a rash), ineffective drug therapy (analgesic that does not reduce pain), side effects (potential bleeding from an anticoagulant), drug interactions (serious drug drug, drug food and drug disease interactions), duplicate therapy (generic name and brand name equivalent drugs are both prescribed), omissions (missing drugs from an ordered regimen), dosage errors (either too high or too low), and nonadherence (regardless of whether the nonadherence is purposeful or accidental). 150

26 Bottom Line Any of these circumstances listed above must reach a level of clinical significance that warrants notification of the physician/physician designee for orders or recommendations by midnight of the next calendar day, at the latest. Any circumstance that does not require this immediate attention is not considered a potential or actual clinically significant medication issue. 3 Levels Drug regimen review activities we can address ourselves without physician intervention Drug regimen review activities we need to address with the physician, but not necessary by midnight of next calendar day Those issues which require physician input asap Your Judgment Upon discharge from the hospital, on the discharge summary the medication list is frequently documented. They are listed in sections under start taking these medications, continue taking these medications, and stop taking these medications. They have been reviewed by a physician. If the patient is taking any medications that have the potential to cause a significant issue, such as two different blood pressure medicines or pain medications, do we still notify the physician, even though the specific medications are documented on the discharge summary, and that has been reviewed already by a physician? As part of the OASIS assessment, it is the responsibility of the clinician to conduct the review on SOC/ROC and notify the responsible physician of any potential clinically significant issues. M2001 Not Just Med Rec The drug regimen review in post acute care is generally considered to include medication reconciliation, a review of all medications a patient is currently using and review of the drug regimen to identify, and if possible, prevent potential clinically significant medication issues. Collaboration is allowed 154 SOC ROC M2003 Definition

27 M2003 YES Two way communication AND completion of the prescribed/recommended actions must have occurred by midnight of the next calendar day after the potential clinically significant medication issue was identified No new orders or instruction in response to timely reported potential clinically significant medication issue(s) (still 2 way communication) Multiple potential clinically significant medication issues identified all must be communicated to the physician/physician designee, with completion of all prescribed/recommended actions occurring by midnight of the next calendar day. If the physician/physician designee recommends an action that will take longer than the allowed time to complete, as long as by midnight of the next calendar day the agency has taken whatever actions are possible to comply with the recommended action. 157 M2003 Examples of recommended actions that would take longer than the allowed time to complete might include: physician instruction to agency staff to continue to monitor the issue over the weekend and call if problem persists, or the physician instructs the patient to address the concern with his PCP on a visit that is scheduled in two days The actual type of actions recommended should be considered in determining if the agency has taken whatever actions are possible by midnight of the next calendar day. 158 M2003 NO If two potential clinically significant medication issues are identified at the SOC/ROC, both are communicated to the physician/physiciandesignee timely, and the physician/physician designee provides a recommended action for each issue (for example, patient education for one medication, and a new dosage for another), if both recommended actions could have been addressed by midnight of the next calendar day, but only one was addressed. If a potential clinically significant medication issue was identified, and the clinician attempted to communicate with the physician, but did not receive communication back from the physician/physician designee until after midnight of the next calendar day 159 Physician does not respond If we are unable to resolve a medication issue before midnight of the next calendar day due to no physician reply, how is that reflected within the reporting structure for M2003 and M2005? How does it differentiate a no physician reply vs. no agency action? Moreover, what are the implications, if any, for the agency and/or the physician for a pattern of non adherence to this best practice? M2001 does not offer the option of Drug regimen review not done. To answer M2003 and M2005, the review must be done. M2003 asks if the physician was contacted and the actions completed. If no issues were identified, there is no need to contact the physician; if issues were found, the communication and response are both needed. Selecting No for M2003 and M2005 indicates that the best practice of identifying a medication issue, reporting it to the physician, and completing the recommended/prescribed actions possible by midnight of the next calendar day was not accomplished. The item response choices for M2003 and M2005 do not identify the reason why the best practice was not met. Missing a RX On the SOC or ROC assessment, if the patient is missing a prescribed medication and unable to obtain it from the pharmacy (for example, due to the pharmacy being closed or a transportation issue), do you still notify the doctor of a potential issue? Is a follow up phone call to the patient sufficient enough to ask if they did indeed obtain the medicine, or would a visit need to be made? Depending on the situation, the assessing clinician might determine that absence of a medication is a clinically significant issue appropriate for timely physician contact. A potential clinically significant medication issue is an issue that in the care provider s clinical judgment requires physician/physician designee notification by midnight of the next calendar day (at the latest). Any circumstance that does not require this immediate attention is not considered a potential or actual clinically significant medication issue. If a medication related problem is identified and resolved by the agency staff (not requiring physician/physician designee contact by midnight of the next calendar day), the problem does not need to be reported as an existing clinically significant problem in M2001. The manner in which the agency validates the resolution is a clinical practice question for the agency to determine. Practice An issue regarding the refusal to take a medication is found during the drug regimen review, and in the assessing clinician s judgment she can resolve the problem with teaching. On the third day after SOC, the issue is not resolved. She then calls the physician who changes the medication on the 4 th day. How should M2001 be marked? A No issues found during the review B Issues found during the review C Patient is not taking any medications What about M2003? A No B Yes 162

28 MidMidnightht Does midnight of the next calendar day refer to the date of SOC or ROC or the date of completion as indicated in M0090? The cited timeframe does not refer to either specifically, but rather to the time period from the identification of the medication issue to the notification of the physician and through the completion of the requested actions. Midnight Comes Early at ROC ROC OASIS must be completed within 48 hours of patient discharge from facility or the agency being aware of the patient being discharged from a facility. If the OASIS assessment is done on the second day (hours 25 48) and a medication issue is identified, does the clinician still have until midnight of the following day to resolve the issue, or does the issue need to be resolved before the 48th hour is complete? M2003, Medication Follow up must also be answered within the timeframe allowed at the SOC/ROC to ensure compliance with the Conditions of Participation regarding the completion of the comprehensive assessment. If a medication problem is identified at SOC or ROC, physician communication and completion of prescribed/recommended actions must occur by midnight of the next calendar day after identification and before the end of the allowed assessment timeframe. Timeframe How does the 5 day rule for completion of the comprehensive assessment at SOC impact this item? If the assessing clinician identifies the clinically significant medication issue on Day 2, does this reset the clock for the midnight of the next calendar day? M2003 and M2005 ask if a two way communication and completion of any prescribed/recommended actions occurred by midnight of the next calendar day when a clinically significant issue is identified. For M2003, the timeframe is by midnight of the next calendar day from the time the potential clinically significant medication issue was identified and within the SOC or ROC comprehensive assessment timeframe. For M2005, the timeframe is by midnight of the next calendar day each time a potential clinically significant medication issue was identified at the time of, or at any time since, the most recent SOC/ROC assessment. Practice An issue regarding the refusal to take a medication is found during the drug regimen review, and in the assessing clinician s judgment she can resolve the problem with teaching. On the third day after SOC, the issue is not resolved. She then calls the physician who changes the medication on the 4 th day. How should M2001 be marked? A No issues found during the review B Issues found during the review C Patient is not taking any medications What about M2003? A No B Yes 166 TRN DC DAH M2005 Example SOC ROC Issue resolved by nurse Issue Physician responded Issue Physician did not respond TRN DC DAH 167 Each time that an issue is found and rises to the level which requires physician intervention, was the physician notified, and did the physician respond (each time). 168

29 M2005 states since SOC/ROC. Does that mean at the time of or since SOC/ROC? If the intent of the question was to go back to the SOC, why would ROC be in the question? Quality episodes can be calculated from a start of care or a resumption of care to the end of the care episode (transfer to an inpatient facility, discharge from the agency, or death). In completing M2005 at Transfer, Death or Discharge, you must review the documentation from that time point back to the time of or at any time since the most recent Start of Care or Resumption of Care. Quality Episodes SOC ROC Quality Episode DC DAH Transfer Use Your Judgment How do we answer this item for a compliant degenerative joint disease patient who was noted to have pain symptoms of 4/10 (per patient) on SOC, who already is on a new narcotic analgesic during the past week? With this symptom, can we answer 0 = No, no issues found during review if we think this issue does not necessitate notifying the physician by midnight of the next business day? A potential clinically significant medication issue is an issue that in the care provider s clinical judgment requires physician/physiciandesignee notification by midnight of the next calendar day (at the latest). Any circumstance that does not require this immediate attention is not considered a potential or actual clinically significant medication issue. RN or Therapist?? Is it required that an RN do the drug regimen review in cases of therapy only home health episodes? The RN is not required to do the drug regimen review in therapy only home health episodes. The comprehensive assessment must include a review of all medications the patient is using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Each agency must determine the capabilities of current staff members to perform comprehensive assessments, taking into account professional standards or practice acts specific to your State. No specific discipline is identified as exclusively able to perform this assessment. According to Federal guidelines, only RNs, physical therapists (PTs), occupational therapists (OTs), and speech and language pathologists (SLPs) are qualified to perform comprehensive assessments and collect OASIS data. In cases of therapy only services, where the scope of practice for the therapist is limited by State, agency, or other policies/restrictions, the agency may instruct that the therapist collaborate with nursing to complete the drug regimen review. RN or Therapist Please clarify the difference between the national and State level requirements regarding whether therapists are qualified to conduct medication reviews. The requirements presented in the OASIS and OASIS Guidance are Federal requirements. The comprehensive assessment must include a review of all medications the patient is using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Each agency must determine the capabilities of current staff members to perform comprehensive assessments, taking into account professional standards or practice acts specific to your State. States may have more stringent guidance, and State specific queries should be addressed to the appropriate State agency. No specific discipline is identified as exclusively able to perform this assessment. According to Federal guidelines, only RNs, PTs, OTs, and SLPs are qualified to perform comprehensive assessments and collect OASIS Data. Drug Regimen Review Conducted with Follow Up for Identified Issues Adopted as a patient assessment based, cross setting quality measure to meet the Improving Medicare Post Acute Care Transformation (IMPACT) Act requirements, with data collection beginning January 1, This measure assesses whether home health agencies (HHAs) are responsive to potential or actual clinically significant medication issue(s) when such issues are identified. This measure will be applied uniformly across the Post Acute Care (PAC) settings.

30 Drug Regimen Review Conducted with Follow Up for Identified Issues Quality Measure Description Reports the percentage of patient care episodes in which a drug regimen review was conducted at the time of Start of Care (SOC) or Resumption of Care (ROC) and timely followup with a physician occurred each time potential clinically significant medication issues were identified throughout that care episode. Drug Regimen Review Conducted with Follow Up for Identified Issues Drug Regimen Review Conducted with Follow Up for Identified Issues Denominator Exclusions This measure has no denominator exclusions. Risk Adjustment This measure is not risk adjusted or stratified. M2003 Practice Scenario (1) During the SOC comprehensive assessment visit, the RN completes a drug review and identifies that the patient is taking two antihypertensives; one that was newly prescribed during her recent hospital stay, and another that she was taking prior to her hospitalization. During the home visit, the RN contacts the physician s office and leaves a message with office staff providing notification of the potential duplicative drug therapy and a request for clarification. The next day, the RN returns to the home to complete the comprehensive assessment and again contacts the physician from the patient s home. The physician s office nurse reports to the agency and patient that the physician would like the patient to continue with only the newly prescribed antihypertensive and discontinue the previous medication. Home Health: OASIS C2 May M2003 Practice Scenario (2) During the comprehensive assessment visit, the RN completes the drug review and identifies that the patient is taking an anticoagulant and low dose aspirin. During the visit, the RN calls the physician s office and leaves a message with the office staff providing notification of the potential drug interaction with these two medications and requests clarification on the medication regimen. The physician does not return the phone call until after midnight of the next calendar day. M2003 Practice Scenario (3) During the comprehensive assessment visit, the RN identifies that the patient s medication regimen review includes an antihypertensive medication. His current blood pressure (BP) is 136/78. The patient reports that he sometimes feels dizzy when he stands up. The RN calls the physician s office to report the patient s symptoms. The physician instructs the RN to reassess the patient daily for 2 days and call if symptoms continue. The RN makes the two additional visits ordered. The patient s symptoms have resolved and BP remains stable. Home Health: OASIS C2 May Home Health: OASIS C2 May

31 M2005 Practice Scenario (1) During the SOC comprehensive assessment, the RN completes the drug regimen review and identifies a potential clinically significant medication issue. On that day of admission, the RN calls and leaves a message with the physician s office related to the medication issue. The physician does not return her call until after midnight of the next calendar day. No other medication issues arise during the episode, and the patient is discharged from home health. M2005 Practice Scenario (2) During the Discharge assessment visit, the RN reviews the patient s medication list and confirms that no potential clinically significant medication issues are present. In reviewing the clinical record, there is documentation that a drug regimen review was conducted earlier in the episode, and no potential clinically significant medication issues were identified. There is no other documentation to indicate that potential clinically significant medication issues occurred during the episode of care. Home Health: OASIS C2 May Home Health: OASIS C2 May M2005 Practice Scenario (3) During the SOC comprehensive assessment, the RN completing the drug regimen review, identified a clinically significant issue, contacted the physician, and resolved the issue by midnight of the next calendar day. On Day 35 of the episode, the patient is transferred to acute care. Home care services resume on Day 40. The ROC assessment identified no clinically significant medication issues. During the discharge assessment visit, the RN reviewing the patient s medication list finds no potentially clinically significant medication issues. Summary M2001, M2003, and M2005 are included in the calculation of the Drug Regimen Review Conducted with Follow Up for Identified Issues Quality Measure. A Drug Regimen Review (M2001) is completed at SOC/ROC to identify potential or actual clinically significant medication issues. Medication Follow up (M2003) is completed at SOC/ROC to determine if issues identified in M2001 were addressed with the physician (or physician designee) by midnight of the next calendar day. Medication Intervention (M2005) is completed at transfer, death at home, or discharge to identify if medication issues identified at the time of or any time since the SOC/ROC were addressed with the physician or physiciandesignee. Home Health: OASIS C2 May Home Health: OASIS C2 May Action Plan Review/revise policies and procedures for items M2001. Drug Regimen Review, M2003. Medication Follow up, and M2005. Medication Intervention. Develop an education plan for clinicians. Practice coding a variety of scenarios with staff. Annual Performance Improvement Plan Consider a review of items to ensure accuracy in data collection. Resources OASIS Educational Coordinators: Initiatives Patient Assessment Instruments/OASIS/downloads/OASISeducationalcoordinators.pdf Quality Measures: Home Health Quality Reporting Program HomeHealthQualityQuestions@cms.hhs.gov OASIS Items & Payment Policy: Home Health Policy Mailbox HomehealthPolicy@cms.hhs.gov Data Submission & CASPER: QTSO Help Desk o Telephone: (800) help@qtso.com Website: Home Health: OASIS C2 May Home Health: OASIS C2 May

32 Payment Case mix variables table Case mix diagnoses Case mix manifestation Non Routine Supplies Case Mix Coding Concepts Only one diagnosis from each case mix group can earn points If the patient has an AMI and ASHD and CHF, points can only be earned once. Case mix manifestation codes can only earn points if an acceptable etiology is placed in the space preceding the manifestation. If the number of therapy visits is more or less than estimated at the beginning of the episode, then the scoring may shift. If a Z code is primary, and the next code down is case mix, then that diagnosis is counted as primary. Case Mix System Mrs. Rose is admitted to home care after a CABG following a heart attack 3 weeks ago. Other co morbidities include hypertension (stable with new medications), diabetes and right fractured hip she sustained at the same time as her heart attack. Aftercare is the focus of care along with rehab for the fracture. Her diabetes is also of concern. Her doctor documents her blood sugars are too high ( ), so her insulin dosage had increased. Her surgical wound is not epithelialized yet. There is one area of incisional separation 4 cm long. Dressing changes are ordered. She has 14 therapy visits ordered and it is an early episode. Other OASIS items have been answered like this: M1240 (Pain) 3 M1830 (bathing) 2 M1342 (surgical wound status) 3 M1840 (toileting) 2 M1810 (upper body dressing) 1 M1850 (transferring) 2 M1820 (lower body dressing) 2 M1860 (ambulation) 3 Z Aftercare circulatory I25.10 ASHD I21.3 Acute MI E11.65 Diabetes with hyperglycemia S72.001D Traumatic fracture hip, right, subsequent episode Z48.01 surgical dressing change Her coding

33 Did you get 8? Add up the functional points Now determine the score Now change it up 2 nd episode: Mrs. Rose gets 7 therapy visits because her doctor decides she needs to go to outpatient therapy. The MI is no longer acute and the diabetes is more important than it was the first episode. The incision is still not healed but there is some granulation tissue in that area of incisional separation so the RN marks it early granulation. The coder leaves off the ASHD because the nurse said it was resolved. Other OASIS items have been answered like this: M1240 (Pain) 2 M1830 (bathing) 2 M1342 (surgical wound status) 2 M1840 (toileting) 2 M1810 (upper body dressing) 1 M1850 (transferring) 2 (device & assist) M1820 (lower body dressing) 1 M1860 (ambulation) 2 Her coding Z Aftercare circulatory E11.65 Diabetes with hyperglycemia S72.001D Traumatic fracture hip, right, subsequent episode Z48.01 surgical dressing change????

34 Did you get 2? 2 Add up the functional points Now determine the score Lisa@selmanholman.com Teresa@selmanholman.com