Part 2: OASIS C2 Accuracy

Transcription

1 Part 2: OASIS C2 Accuracy Presented by: Sharon Molinari, RN, HCS D, HCS O For: HealthCare Synergy Patient Tracking Items M0010 M0150 Completed at SOC and updated when a change occurs in the episode. 1

2 11/30/2016 Tracking Data: 17 Items M0010: CMS Certification number (HHA) M0014: Branch State M0016: Branch ID Number M0018: NPI # for attending MD who signs POC M0020: Patient ID # M0030: SOC Date M0032: ROC Date M0040: Patient Name M0050: Patient State of Residence M0060: Patient Zip Code M0063: Medicare Number M0064: Social Security # M0065: Medicaid Number M0066: Birth Date M0069: Gender M0140: Race/Ethnicity M0150: Current Payment Source 3 Data Entry of Tracking Items o Computer or administrative staff may enter data, which identifies: Agency information Certification Number, Branch State and ID Number NPI for attending physician Patient demographics and identifiers Verify patient name is spelled as on Medicare or other insurance card to avoid claim rejection. Medicare and Social Security Numbers Clinician should verify with patient and look at cards. Do NOT enter a Medicare HMO ID number. NA = No Medicare or Medicare HMO and no Medicare number. If there are fewer digits than boxes provided, leave boxes at the end blank. 4 2

3 Timely Initiation of Care o Home Health Compare Quality Process Measure How often the home health team began their patients care in a timely manner. o OASIS items that contribute to the measure: M1005 Inpatient Discharge Date M0030 SOC Date M0032 ROC Date M0102 Date of Physician ordered SOC (ROC) M0104 Date of Referral But, what s a timely manner? 5 Timely Initiation of Care o If physician has specified SOC/ROC date, then the SOC/ROC should be on or before that date. o If no SOC/ROC date has been specified by physician, then the SOC/ROC should be: Within two days of referral OR If the inpatient discharge is later than the referral, within two days of inpatient discharge. o For a resumption of care, per the Medicare CoPs, the patient must be seen within two days of inpatient discharge, even if the physician specifies a later date. 6 3

4 (M0030) 7 o The start of care date is the date of the first billable visit and is maintained until the patient is discharged. o A reimbursable (skilled) service must be delivered to be considered the start of care. A physician must specifically / order that a covered service be furnished on the SOC date. (42 CFR ) Accuracy of this date is essential since many other aspects of data collection are based on this date. Note: For all items requiring a date, if the month or day is only one digit, that digit is preceded by a 0. Enter all four digits for the year. e.g., September 1, 2016 = 09/01/ Therapy Only Admits o When the agency s policy is for RN to perform the SOC assessment in a therapy only case, the nursing assessment visit must be made the same day OR within five days after the therapist s first visit. RN visit is NOT billable! o The first billable visit may be an unskilled one made by a home health aide, once need and eligibility are established. o For PT or SLP to perform the SOC visit for a Medicare patient: No orders may be present for nursing at the start of care. HHA must have orders from the patient s physician indicating the need for physical therapy or SLP prior to the initial assessment visit. The patient s need for skilled PT or SLP service establishes program eligibility for the Medicare home health benefit. (42 CFR (a)(2) 8 4

5 SOC Date when Late F2F Encounter o A late F2F encounter (did not occur within 90 days prior to SOC or within 30 days after SOC) = payer change. o Create new SOC OASIS with SOC date 30 days prior to date of late F2F encounter (day 0). o A prior OASIS can be used to generate new SOC OASIS. If more than one, use OASIS closest to that date. It may be necessary to change the response originally reported for (M0110) Episode Timing, and/or (M2200) Therapy Need, to exclude therapy visits provided before the date of eligibility. o Delete any OASIS assessments already submitted. o Maintain both in patient record and document circumstances. 9 (M0032) 10 o The ROC date is the date of the first visit following an inpatient stay and may be conducted by any person providing a service under the agency s home health plan of care may be made by an aide, therapy assistant, or LPN. o There must be orders for the ROC and the visit performed. If physician orders are not received within the 48 hour time frame, the ROC date would be out of compliance. 10 5

6 o At SOC, mark NA. M0032: Guidance (cont.) o The most recent ROC date should be entered. o The ROC comprehensive assessment must be completed within 48 hours of discharge following a qualifying inpatient stay or within 48 hours of knowledge of the qualifying inpatient stay. o There is no regulatory allowance for ROC date beyond 48 hours of inpatient facility discharge. If physician ordered ROC is within allowed 48 hours, enter date. If not, select NA and enter date of referral in M How would you answer these? Your patient was released from the hospital and needed an injection that evening (November 1 st ). The case manager was unavailable and planned to do the ROC assessment the following day (November 2 nd ). Could the on call nurse visit and give the injection before the ROC assessment is done? Can an LPN do the ROC visit? The assessment? M0032 (ROC date) is. M0090 (Date assessment completed) is. 12 6

7 Answers Your patient was released from the hospital and needed an injection that evening (November 1 st ). The case manager was unavailable and planned to do the ROC assessment the following day (November 2 nd ). Could the on call nurse visit and give the injection before the ROC assessment is done? Yes Can an LPN do the ROC visit? Yes The assessment? No M0032 (ROC date) is November 1 st. M0090 (Date assessment completed) is November 2 nd. 13 (M0150) 6 Title programs (e.g., Title III, V, or XX) 7 Other government (e.g., TriCare, VA, etc.) 8 Private Insurance 9 Private HMO/managed care 10 Self pay 11 Other (specify) Note: Only responses #1, 2, 3, and 4 (Medicare and Medicaid) require OASIS to be submitted. 14 7

8 M0150: Guidance o This item is limited to identifying payers to which any services provided during this home care episode and included on the plan of care will be billed by your home health agency. o Mark all that apply those that may be billed by the agency whether considered primary or secondary. o Exclude pending payment sources. o Do not consider any equipment, medications, or supplies being paid for by the patient, in part or in full. 15 MEDICARE as Payer o If the payer is Medicare as primary or secondary, then Medicare must be checked. o If the payer changes to Medicare, there must be a new SOC date. o If the payer changes from Medicare to another payer, change M0150 at the next OASIS time point, unless the payer has other requirements. See the response specific instructions in Chapter 3 for selection of the payment sources. 16 8

9 How would you mark M0150? o Your patient sustained injuries in an auto accident and the liability insurance is paying for home health. Most of the insurance money was spent on the hospitalization, though. Your patient has traditional Medicare and is eligible for the home health benefit (homebound, etc.). What response(s) will you check on M0150? 17 Answer o Your patient sustained injuries in an auto accident and the liability insurance is paying for home health. Most of the insurance money was spent on the hospitalization, though. Your patient has traditional Medicare and is eligible for the home health benefit (homebound, etc.). What will you check on M0150? 1 Medicare (traditional fee for service) and 8 Private insurance 18 9

10 Clinical Record Items M0080 M0110 (M0080) o Specifies the discipline of the clinician completing the comprehensive assessment during an actual visit to the patient s home at the specified OASIS time point or the clinician reporting the transfer to an inpatient facility or death at home

11 M0080: Guidance o Only one individual may complete and record the assessment, even when two disciplines are seeing the patient at the time of the assessment. o When both the RN and PT/SLP are ordered on the initial referral, the CoPs ( ) require the RN must perform the initial and comprehensive assessment at SOC. An RN, PT, SLP, or OT may perform subsequent assessments. o The RN is allowed up to 5 days at SOC and 2 days at ROC to complete the comprehensive assessment. o The PT/SLP may visit after the initial RN visit, even if the RN has not completed the SOC comprehensive assessment. o OT alone is not a qualifying skill at SOC for Medicare. 21 M0080: Guidance (cont.) o Collaboration is allowed on some items (e.g., medication items), but the assessing clinician is the accountable clinician. The one clinician rule! o LPNs, PTAs, COTAs, MSWs, and HHAs are not allowed to perform the comprehensive assessment or collect OASIS data. o If allowed by agency policy, a social worker may perform quality reviews/audits of OASIS data and comprehensive assessment and provide education/instruction

12 M0080: Guidance (cont.) o Clerical (office) staff may enter demographic data and agency ID items, but the assessing clinician must verify accuracy. o When both the RN and qualified therapist are scheduled to conduct discharge visits on the same day, the last qualified clinician to see the patient is responsible for conducting the discharge comprehensive assessment. 23 (M0090) o Specifies the actual date the assessment is completed. o This date cannot be before the SOC date! 24 12

13 M0090: Guidance (cont.) o If consulting with another discipline, or completing the OASIS over multiple visits, use the latest applicable date within range: Up to 5 days after SOC (day 0); By day 60 for Recertification; Within 48 hours of inpatient discharge (or knowledge of) for ROC. o For Transfer and Death at home assessments: Record the date the agency completes the data collection after learning of the event. A visit may not be associated with these events. o Do not change for OASIS corrections due to audits. o If payer change requires re creating a SOC OASIS, M0090 will be out of range: Disregard warning at OASIS submission; and Document circumstances in patient record. 25 (M0100) o Identifies the time point the reason why the assessment data are being collected and reported. Only SOC and Follow up (Recertification) assessments are used for determining payment based on a HHRG. No Discharge OASIS assessment is required when only a single visit is made in an episode

14 RFA 1: Start of Care further visits planned o Start of Care (SOC) Comprehensive Assessment Requires home visit Must be completed within 5 days after SOC (day 0) RFA = Reason for Assessment o When inpatient stay extends beyond current certification period (patient returns to agency after day 60): Complete internal agency paperwork not DC OASIS, before doing new SOC assessment. Complete SOC assessment M0100 = RFA 1 See OASIS Considerations for Medicare PPS Patients. 27 RFA 3: Resumption of Care o Resumption of Care (ROC) comprehensive assessment: Conducted when patient care resumes after an inpatient stay of 24 hrs. or longer for reasons other than diagnostic testing Requires home visit Must be completed within 48 hours of the patient s discharge from inpatient facility (or knowledge of the patient s discharge) If no physician order to resume care within the 2 day timeframe, agency should document efforts to obtain order and complete ROC visit when order obtained. ROC during the last 5 days of an episode fulfills both the ROC and recertification requirements. M0110 (Episode Timing) and M2200 (Therapy Need) must be projected for upcoming episode for calculation of HHRG

15 Late ROC and Process Measures o If the ROC assessment is late (> 48 hours after qualifying inpatient stay), Yes may still be selected for the best practices in M2250, Plan of Care Synopsis), if the relevant orders were present within the 48 hour ROC time frame. o If orders are not present within this time frame, M2250 responses would be answered No, unless the best practice is not applicable to the patient. e.g., Row b, diabetes best practice, the patient does not have a diagnosis of diabetes or has no lower extremities), in which case the response would be NA. 29 Late ROC and Standardized Assessments o Mark Yes for M1240 (Pain Assessment), M1300 (Pressure Ulcer Risk Assessment), M1730 (Depression Screening), and/or M1910 (Fall Risk Assessment): If the relevant standardized assessments were completed within the 48 hour time frame, even if the ROC comprehensive assessment was done late. Documentation should support that the tool was administered within the 48 hour time frame. o If the standardized assessments were completed late, M1240, M1300, M1730, and M1910 must be answered No. o The M0090 date is the date the ROC assessment is completed

16 RFA 4: Recertification (follow up) reassessment o Recertification comprehensive assessment Must be done within the last 5 days of the 60 day cert period Requires home visit May be completed over multiple days (56 60) by one clinician o If Recertification assessment is not done during required time frame, and agency still provides care: Do not discharge and readmit. Make visit the and complete Recertification assessment as soon as the oversight is identified. M0090 = date the assessment completed. Warning message will result. Document circumstances in the medical record. 31 RFA 5: Other follow up o Comprehensive assessment (reassessment) due to a major decline or improvement in patient s condition not envisioned in the original plan of care Requires home visit Completed at time other than last 5 days of episode, when there has been no inpatient stay May indicate need to update patient s plan of care Policies regarding criteria for RFA 5 determined by agency o Must be completed within 2 days of identifying a major improvement or decline in patient s health status 32 16

17 RFA 6: Transfer to Inpatient Facility patient not discharged from agency o Transfer to inpatient facility includes planned admissions Transferred and admitted to inpatient bed of inpatient facility Stay of 24 hours or longer For reasons other than diagnostic tests Does not require home visit Must be completed within 2 days of transfer date (M0906) or knowledge of transfer that meets criteria If discovered later, complete RFA 6 within 2 days then RFA 3 (ROC). Complete RFA 6 for Medicare PPS patients you feel will return to agency. Other payers may have different requirements. If patient does not return to agency, do internal agency DC (no DC OASIS). o M0906 (Transfer Date) = date patient admitted to inpatient bed, not the ER. 33 RFA 7: Transfer to Inpatient Facility patient discharged from agency o Requirements for completing a transfer to inpatient facility with discharge from agency are the same as a RFA 6, except an RFA 7 is completed when a patient will NOT return to the agency e.g., patient needs higher level of care, moves out of service area, etc. Do internal agency discharge (no discharge OASIS required). o If patient dies in ER, outpatient surgery/recovery room, while under outpatient observation status, within 24 hours of admission to an inpatient facility, the usual transfer requirements are waived

18 RFA 8: Death at Home o Patient died somewhere other than inpatient/outpatient facility or ER. For example: At home At church In an ambulance Pronounced dead on arrival (DOA) in ER o Ahome visit is not required. o Complete within 2 days of death date (M0906). o M0906 (Death Date) = date patient actually died. 35 Completing Transfer and Death at Home o Can someone in the office who has never seen the patient complete the Transfer and Death at Home OASIS? Yes Transfer and Death at home require data collection, not a visit. Includes no assessment findings Any RN, PT, OT, or SLP familiar with OASIS data collection practices may collect the data, per agency policy. Data may be collected by phone and through record review. Guidance applies only to the Transfer and Death at Home OASIS not SOC, ROC, Follow Up (Recertification), Other Follow up, and Discharge

19 RFA 9: Discharge from Agency o Requires home visit o Does not include: Death in an inpatient facility Death in an ambulance Dead on arrival (DOA) in ER o Complete within 2 days of discharge date (M0906) or knowledge of need to discharge 37 Unplanned or Unexpected Discharge Per CMS, should not happen often, but when it does: o A qualified clinician must complete OASIS assessment: RN, PT, SLP, OT Must accurately reflect patient status during that clinician s most recent home visit Do not collect this OASIS data by telephone. o Clinical record documentation must match OASIS data submitted to CMS

20 Unplanned or Unexpected Discharge Dates When a clinician completes the DC OASIS, based on the last visit, the dates should be: o M0090 (Date assessment completed) Actual date agency completed assessment o M0903 (Date of last [most recent] home visit) Made by any agency staff that is included on the Plan of Care o M0906 (Discharge/Transfer/Death date) Discharge date: determined by agency policy or physician order Transfer date: actual date patient admitted to inpatient facility Death date: actual date of death 39 P (M0102) Completed at SOC/ROC links to M0030 and M0032. o The physician has ordered home health covered services to start on a specific date, regardless of type of services (e.g. therapy only). o If only a range is provided, the initial assessment visit must be conducted within 48 hrs. of referral or the patient s return home from an inpatient facility admission. o If the physician orders the resumption of care to be done more than 2 days after an inpatient facility discharge, select NA for M0102 and enter the referral date for the resumption of care in M

21 Question to CMS We received a referral for home care but were unable to reach the patient for several days. We notified the physician of the problem. When we finally reached the patient he requested we start care a week after the original order date. We sent a fax to the MD 5 days after the original order was received requesting a delay in the SOC with a specific date 3 days from then. If we received the order back from the MD prior to that new date, how do we answer M0102 and M0104? 41 CMS Answer Question: OASIS C1/ICD 10 Guidance Manual, Chapter 3, Response Specific instructions state: If the originally ordered start of care is delayed due to the patient s condition or physician request (e.g., extended hospitalization), then the date specified on the updated/revised order to start home care services would be considered the date of physician/ordered start of care (resumption of care). Answer: In order to report this new updated/revised physician s ordered start of care date in M0102, it must have been received before the end of the 48 hour initial assessment time frame (or before the date of the previous physician ordered start of care date, if one was provided). If the order to extend the physician s ordered start of care date is received after the 48 hour initial assessment time frame (or after the previous physician ordered start of care date, if one was provided), report NA for M0102 and report the original referral date in M

22 P (M0104) o Skip, if date is reported in M0102. o For a faxed referral, the date stamp on the fax is the referral date. o It is NOT the date the agency receives a call or documentation from a facility or from the family. o A verbal, written, or electronic referral must be received. o It is NOT the date the authorization was received from the patient s payer, such as Medicare Advantage. Remember, The initial assessment must be within 48 hours of referral or the patient s return home from an inpatient facility or notification. 43 M0102/M0104: Guidance o Referrals from hospital/snf discharge planners on behalf of the physician may be considered when determining the SOC or referral date. (This should generate a verbal order.) o There must be an order or change in patient condition to change the date. The request of the patient, family, or ALF staff to delay SOC is not included as a reason for delay of SOC/referral date. o If the original SOC date is delayed due to patient condition or physician request (order), the date the agency receives the updated/revised referral order is the new referral date. o To be considered a physician ordered SOC date, the physician must give a specific date to initiate care, not a range of dates. o If only a date range is provided, the initial assessment visit must be conducted within 48 hours of referral or patient s return home from IP facility

23 Consider this situation o The hospital discharge planner notified your agency on 11/14 that Mrs. L was being discharged from the hospital that day. However, she developed a fever and remained hospitalized. On 11/18, the discharge planner called and said Mrs. L was going home that afternoon and needed a nursing visit that evening to administer IV antibiotics for a postoperative wound infection. The RN performed the initial assessment and started the comprehensive assessment and OASIS that evening, but the patient was too tired for the nurse to complete the assessment. The nurse decided that the case manager could finish it the following morning, 11/19. PT was ordered for strengthening, and the eval was done on 11/21. The MD confirmed the nursing POC on 11/20 and the therapy POC on 11/ Which of the following is true? a) The nurse who made the initial visit on 11/18 must complete the SOC OASIS on that day. M0030 and M0090 = 11/18; M0102 = NA; M0104 = 11/14 b) The RN who made the visit on 11/19 may complete the SOC OASIS that was started the evening before. M0030 = 11/18; M0090 = 11/19; M0102 = 11/18; skip M0104 c) The RN who visited on 11/19 must complete a new SOC OASIS. M0030 and M0090 = 11/19; M0102 = NA; M0104 = 11/18 d) The RN who visited on 11/19 must complete a new SOC OASIS. M0030 = 11/18; M0090 = 11/21; M0102 = 11/18; skip M

24 Answer a) The nurse who made the initial visit on 11/18 must complete the SOC OASIS on that day. M0030 and M0090 = 11/18; M0102 = NA; M0104 = 11/14 b) The RN who made the visit on 11/19 may complete the SOC OASIS that was started the evening before. M0030 = 11/18; M0090 = 11/19; M0102 = 11/18; skip M0104 c) The RN who visited on 11/19 must complete a new SOC OASIS. M0030 and M0090 = 11/19; M0102 = NA; M0104 = 11/18 d) The RN who visited on 11/19 must complete a new SOC OASIS. M0030 = 11/18; M0090 = 11/21; M0102 = 11/18; skip M What constitutes a valid referral? o The patient must be under the care of a physician. o A valid referral exists if the referring physician, or another physician, will provide for the plan of care and ongoing orders and has provided adequate information regarding the patient. o When the referring physician (i.e., hospitalist) is not going to provide a plan of care and ongoing orders and follow the patient, this is not a valid referral. The HHA must contact an alternate or attending physician who agrees to follow the patient and provide ongoing orders. The M0104 date is the date of the following physician s agreement to provide a plan of care and ongoing orders for the patient

25 More on Valid Referrals o A general order to Evaluate for Home Care services (no discipline(s) specified) is a valid order if: It is received from a physician who will be following the patient and provide ongoing orders. Per CoP , the RN must conduct the initial assessment to determine immediate care and support needs and eligibility for the HH Benefit for Medicare patients. 49 M0104 Date When Late F2F Encounter M0104 = day before new SOC date: Where a new Start of Care date is established based on the completion of a late face to face encounter for Medicare eligibility, report M0102 Date of Physician ordered SOC as NA and report M0104 Date of Referral, as the day prior to the new Start of Care date

26 Scenario Your agency received a written order for a resumption of care for Mrs. X on 2/1. This is the same day the patient was discharged from the hospital. The written physician order specified that the patient s care should be resumed on 2/4. 1. To comply with the CoPs ( ), when must the agency resume services for this patient? 2. What is the appropriate response to M0102 and M0104? 51 Answer Your agency received a written order for a resumption of care for Mrs. X on 2/1/16. This is the same day the patient was discharged from the hospital. The written physician order specified that the patient s care should resume on 2/4. 1. To comply with the CoPs ( ), when must the agency resume services for this patient? Services must be resumed no later than 2/3. 2. What is the appropriate response to M0102 and M0104? M0102 = NA (Physician ordered date not within 48 hours) M0104 = 02/01/

27 $$$ (M0110) o Identifies the placement of the current Medicare PPS payment episode in the patient s current sequence of adjacent Medicare PPS payment episodes. o A sequence of adjacent Medicare home health payment episodes is a continuous series of Medicare PPS payment episodes, whether or not the same agency provided care for all episodes. Low utilization payment adjustment (LUPA) episodes (< 5 visits) are counted. Adjacent = no gap of > 60 days between Medicare covered episodes. Time when a patient is on service with a different payer, such as HMO, Medicaid, or private pay, are gap days. $$$ M0110 = 2 53 M0110: Guidance o Early includes the only PPS episode in a single episode case OR the first or second PPS episode in a sequence of adjacent PPS episodes. o Later means the third or later PPS episode in a sequence of adjacent episodes. o Enter UK Unknown if the placement of this PPS payment episode in the sequence of adjacent episodes is unknown. For the purposes of assigning a case mix code to the episode, this will have the same effect as entering the Early response. o Enter NA if no Medicare case mix group is to be defined for this episode. o If no Medicare case mix group is to be defined for this episode (ROC and Other Follow up), select NA. o If a non Medicare FFS payer requires an HHRG for payment, select UK. o If a Medicare FFS is secondary payer in M0150, complete M0110 as if Medicare is primary

28 History and Diagnosis M1000 M1025 (M1000) o Identifies whether the patient has been discharged from an inpatient facility within the 14 days (two week period) immediately preceding the Start of Care/Resumption of Care date

29 M1000: Guidance o A patient may have been discharged from more than one facility within the 14 days prior to SOC/ROC. o An inpatient discharge on the day of assessment (day 0) falls within the 14 day period. o The facility type is determined by the facility s state license. See Chapter 3 of the Guidance Manual for specifics regarding the responses. 57 How would you mark M1000? Mr. E was admitted to the hospital on 7/26 and discharged to rehab on 8/1. He was discharged from rehab on 8/8 to an assisted living facility. After 6 days in the ALF, he went to stay with his son, because he didn t like living there. He was admitted to your agency on 8/16. Which response(s) would you select for M1000? 1 Long term nursing facility 2 Skilled nursing facility 3 Short stay acute hospital 4 Long term care hospital 5 Inpatient rehabilitation 6 Psychiatric hospital 7 Other (specify) NA Patient was not discharged from an inpatient facility 58 29

30 Answer Mr. E was admitted to the hospital on 7/26 and discharged to rehab on 8/1. He was discharged from rehab on 8/8 to an assisted living facility. After 6 days in the ALF, he went to stay with his son, because he didn t like living there. He was admitted to your agency on 8/16. Which response(s) would you select for M1000? Select the correct response: 1 Long term nursing facility 2 Skilled nursing facility 3 Short stay acute hospital 4 Long term care hospital 5 Inpatient rehabilitation 6 Psychiatric hospital 7 Other (specify) NA Patient was not discharged from an inpatient facility 59 (M1005) 60 o Enter the date of only the most recent discharge: From an inpatient facility identified at M1000, Within 14 days of SOC/ROC

31 (M1018) ddd THINK Are responses consistent with cognitive behavioral items: M1700 and M1740? Did the patient have intractable pain prior to surgery? 61 Intractable Pain Characteristics o Is often chronic and persistent o Occurs at least daily o Is not easily relieved o Can be psychogenic in origin If patient had a joint replacement for DJD, was there intractable pain prior to the inpatient stay? If so, mark it in M1018. o Affects the patient s sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity o Refers to pain that is not relieved by ordinary medical, surgical, and nursing measures 62 31

32 Documentation, Compliance, Diagnoses and Coding 63 That the word documentation is stated 72 times and that querying for additional information is noted 23 times in the ICD 10 CM Guidelines? Do you know??? 64 32

33 Do you worry about documentation? 65 Importance of Documentation o Documentation is one of the central elements that underlies: The quality and skilled nature of patient care; Coding and billing for the care provided; and An effective compliance plan. o Specificity of diagnosis code assignment is essential in creating an accurate and compliant medical record

34 Creating a Compliant Record o Begins at referral/intake with requests for: F2F and/or the reason for referral to home care Dates and places of recent inpatient stays/surgeries Copies of the H&P, consultations, operative report, if applicable, discharge summary, etc. If referral from MD office H&P, current medication list, and visit notes o Continues with review of the documentation, then 67 A complete and thorough Comprehensive Assessment! 68 34

35 Assessment Strategies Per the OASIS Guidance Manual, Chapter 3 o Interview patient/caregiver to obtain past health history. Additional information may be obtained from the physician. o Review current medications and other treatment approaches. o Determine if additional diagnoses are suggested by the current treatment regimen. o Verify this information with the patient/caregiver and physician. 69 What s new or different? o Look for problems and changes in treatment. Remember, CHANGE IS YOUR FRIEND! o For patients referred from physician, ask what s worsened or changed. What prompted the referral NOW? 70 35

36 Important Questions to Ask Why was the patient referred for home care? What problems are unresolved? Resolved conditions and acute fractures may NEVER be coded! Are there any co morbidities that may impact the outcome? Is there more than one problem targeted for intervention? If more than one discipline is ordered, is there a diagnosis common to multiple disciplines? What services are needed to achieve the goals/outcomes? Are there coding conventions that require additional codes or listing diagnoses in a specific order? Often, the most challenging question of all is 71 What is the focus of care? 72 36

37 Comorbidities add complexity! o Comorbidity is the presence of one or more additional disorders (or diseases) co occurring with a primary disease or disorder, that can worsen the course of both, even if the condition is well managed, and is associated with: Worse health outcomes; More complex clinical management; and Increased health care costs. o Identifying comorbidities that are relevant to the current POC helps support medical necessity! 73 Identifying the Diagnoses o Go beyond the checkmarks on the assessment. How is the patient functioning now? How about 3 6 months ago? o Dig deep into the medications. Are there related diagnoses or a clue that there may be others? o Consider what other illnesses or conditions the patient has that may impact the care plan

38 Identifying the Diagnoses (cont.) o Determine the level of the patient s knowledge of his/her health conditions? o Identify goals that are measurable, attainable, and appropriate for the patient, so the POC can be focused on what needs to be done and why. o Collaborate with other disciplines who will be providing services to the patient. o Select and sequence the diagnoses according to their seriousness related to the care plan. 75 Determining Diagnoses for the POC o Diagnoses must support that services provided are reasonable and necessary. o Select only those diagnoses that: Comply with the coding guidelines and sequencing requirements; Are relevant to the POC; Are unresolved; Are verified by current treatment regimen and the physician; and Are supported by documentation in the medical record

39 Assignment of Diagnoses o Assignment of the diagnosis must be based on: Physician documentation or verification of ALL diagnoses; Findings of the comprehensive assessment; Official coding guidelines; and OASIS guidance. o The assessing clinician is responsible for: Selecting and sequencing the diagnoses, in conjunction with the physician; and Assigning the symptom control ratings (0 4). 77 More o Onset and exacerbation dates are not mandated by CMS. If used, they must be supported by the medical record. o A coder may assign the codes. o The assessing clinician must agree with any changes. o Documentation of collaboration with the clinician is imperative! 78 39

40 Clinician/Coder/Physician Communication o A joint effort between the provider and the clinician/coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. o Queries made to physicians are part of the communication process. Think collaboration! Improve specificity of documentation Allow the coder to obtain information needed to accurately assign diagnosis codes, which impacts: Reimbursement; Outcomes; and Risk adjustment. o The process is also critical in the development of a relevant and meaningful patient centered POC. 79 The Provider The term provider is used throughout the guidelines to mean physician or any qualified heath care practitioner who is legally accountable for establishing the patient s diagnosis. o For home health, orders may ONLY be accepted by a: Doctor of Medicine (MD); Doctor of Osteopathic Medicine (DO); or Doctor of Podiatric Medicine (DPM)

41 11/30/2016 Physician MUST Verify POC! o Physician verification is imperative! Verify diagnoses, medications, or treatments not documented or unclear. Confirm specific wound type and complications. Clarify cause of condition. Is the patient s anemia due to CKD or a vitamin deficiency? Approve interventions (M2250). DOCUMENT all communication with the physician! 81 Diagnoses must paint the picture of your patient s condition! 41

42 83 Official Coding Guidance Justify your diagnosis and coding choices by going straight to the official sources! 84 42

43 o Official Coding Guidelines o Coding Conventions Official Sources o OASIS C2 Guidance Manual Chapter 1: Conventions Chapter 3: Item by Item guidance o Coding Clinic Quarterly publication by the American Hospital Association, whose guidance is approved by CMS o Other CMS Guidance Annual Final Rule Quarterly CMS Q&As January, April, July, and October OASIS Guidance 86 43

44 OASIS, Coding, and Relationship to PPS o 6 OASIS coding items: M1011, M1017, M1021, M1023, M1025, M1028 o All diagnoses must match on: OASIS, Plan of Care (POC), and final claim (UB 04) RAP (Request for Anticipated Payment) and Final Claim o Coding is governed by the ICD 10 CM Coding Conventions and Guidelines and by the response specific guidance in Chapter 3 of the OASIS C2 Guidance Manual. 87 (M1011) Note: Skip instruction If M1000 = NA, [Go to M1017] 88 44

45 M1011: Guidance o List only diagnoses actively treated during inpatient stay. Active treatment means receiving something more than the regularly scheduled medications and treatments necessary to maintain or treat an existing diagnosis. Treatment must be supported by documentation. If not actively treated, do not code. o Avoid coding symptoms, if there is a definitive diagnosis. o Within the last 14 days refers to discharge from an inpatient facility during that time frame. SOC/ROC date is counted as day zero. Consider which facility the patient was discharged from. 89 (M1017) 90 45

46 M1017: Guidance o Identifies if any change has occurred to the patient s treatment or medication regimen within the 14 days immediately preceding the start or resumption of care. o A diagnosis reported in M1011 (Inpatient Diagnosis) may also be reported in M1017 if, within the 14 days prior to the SOC/ROC date, the condition was new or exacerbated, required changes in the treatment regimen, AND the patient was discharged from an inpatient facility where the condition was actively treated. o A physician appointment or referral to home care, by itself, is NOT a change in the treatment regimen. o A change occurring on the day of assessment, as a result of the assessment, does count. 91 M1017: Guidance (cont.) o All treatments/disciplines ordered at SOC do not count as a change, but changes to these during the episode do count. For example, discontinuation of therapy services when goals are not met o Mark "NA" if no medical or treatment regimen changes were made within the past 14 days OR all changes in the medical or treatment regimen were made because a diagnosis improved (e.g., discontinuation of an antibiotic for pneumonia). May include an improved diagnosis if it is pertinent to the POC and required a change in the medical or treatment regimen. For example, chronic conditions such as CHF or exacerbated COPD 92 46

47 What would you list in M1017? o Mr. J went to his doctor yesterday with complaints of painful urination. During the visit, the physician diagnosed a UTI and found his blood pressure to be high. He ordered an antibiotic and made a referral to home health nursing for management of the UTI and for blood pressure monitoring daily for 5 days. Mr. J had a fungal infection on his right hand, which had been treated for the past 3 weeks, which is now resolved. So, the physician discontinued his anti fungal medication. Which diagnosis(es) would be reported in M1017? (M1017) Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days: a) UTI, fungal infection b) UTI, hypertension c) UTI, hypertension, fungal Infection d) UTI 93 Answer: M1017 d) UTI Rationale: M1017 identifies if any change has occurred in the patient s treatment regimen, health care services, or medications within the past 14 days not diagnoses that solely improved during this timeframe. There was no diagnosis of hypertension noted, nor was the high blood pressure treated. The fungal infection was diagnosed 3 weeks ago and resolved during the past 14 days. Therefore, it is not coded in M

48 M1021/M1023/M M1021/M1023 Diagnoses & Symptom Control o List each diagnosis for which the patient is receiving home care in Column 1. V, W, X, and Y codes Never use at M1021 as Primary Diagnosis. Use in M1023 as Other Diagnoses

49 M1021/M1023 Diagnoses & Symptom Control o List diagnoses in the order that: Best reflects the patient s condition Supports the POC Disciplines Services 97 M1021/M1023 Diagnoses & Symptom Control o Enter the ICD 10 code for each diagnosis in Column 2. At highest level of specificity No V, W, X, or Y codes allowed in M1021a. Z codes may be used. Both a Z code and the code for its underlying condition can be used in Column 2, if the condition is active and impacts home care. Assign the Symptom Control Rating (0 4). Sequencing not based on rating

50 $$$ M1021: Primary Diagnosis The chief reason for skilled home care services, which may or not be related to most recent hospital stay Appropriate o Current diagnosis The focus of care Requires the most intensive skilled services (nursing or therapy) and interventions o Z codes Aftercare for Attention to Encounter for Use for routine care, except for certain joint complications! NOT Appropriate o Resolved diagnosis o Surgical codes List underlying condition o V, W, X, Y codes External cause of injury, adverse effect, or poisoning Report the injury, effect, or poisoning code 99 $$$ M1023: Other Diagnoses Pertinent diagnoses that are relevant to the current care plan, which require treatment or may impact or be impacted by the POC Appropriate o Current diagnoses Actively addressed in the POC May affect response to treatment or rehab prognosis May have impact on care plan, or be impacted by it, such as: Diabetes, HTN, heart failure, CAD, PVD, neuro conditions Parkinson s, Alzheimer s, MS depression, amputation status, blindness (if impacts POC), history neoplasm (if current one) o V, W, X, Y, and Z codes NOT Appropriate o Resolved diagnoses o Surgical codes List underlying condition o Diagnoses with no impact on current POC e.g., stable: Anemia GERD Hypercholesterolemia Hypothyroidism

51 $$$ M1025: Optional Diagnoses o If a Z code is reported in Column 2 and the underlying condition for the Z code is resolved, then the resolved condition may be reported in Columns 3 and 4 at the agency s discretion. o No V, W, X, Y, or Z codes are allowed. Code the relevant medical diagnosis. o If placed in M1025, these diagnoses will not earn case mix points and will not impact payment. 101 (M1028) Impact Act o Item Intent: 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). o The diseases and conditions in this item require a physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) documented diagnosis at the time of assessment

52 M1028: Guidance o Diagnostic information, including past medical and surgical history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity, follow up and coordination of care. o It is also essential that diagnoses communicated verbally be documented in the medical record by the physician to ensure follow up and coordination of care. o If patient does not have an active diagnosis of PVD, PAD, or diabetes within the assessment timeframe, leave boxes in M1028 unchecked. (CMS Quarterly Q&A #6 7, 10/16) o Use a dash ( ) if information is not available or could not be assessed. (CMS Quarterly Q&A #5, 10/16) 103 M1028: Guidance (cont.) o Active diagnoses: those 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. 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. Nurse monitoring: includes clinical monitoring by a licensed nurse (e.g., serial blood pressure evaluations, medication management). A diagnosis may not be inferred by association with other conditions (i.e., weight loss inferred to mean malnutrition ). o Leave M1028 blank if no active diagnoses of PVD, PAD, or DM. Do not use a dash ( )

53 11/30/2016 M1028: Active Diagnoses o Select Response 1 if the patient has an active diagnosis of: Peripheral Vascular Disease (PVD) Codes that start with the first 3 characters of I73 Peripheral Arterial Disease (PAD) Codes that start with the first 4 characters of: I70.2, 170.3,170.4, 170.5, 170.6, 170.7, and and I70.92 Excludes I70.90 (Unspecified atherosclerosis) o Select Response 2 if the patient has an active diagnosis of Diabetes Mellitus (DM) indicated by any one of the following diagnosis codes that start with: 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 specified diabetes mellitus 105 M1028: Tips o There must be specific documentation in the medical record by a physician of the disease or condition being an active diagnosis. o The physician may specifically indicate that a diagnosis is active. Specific documentation areas in the medical record may include, but are not limited to, progress notes, admission history and physical, transfer notes, and the hospital discharge summary. o The physician may, for example, document at the time of assessment that the patient has inadequately controlled diabetes and requires adjustment of the medication regimen. This would be sufficient documentation of an active diagnosis and would require no additional confirmation because the physician documented the diagnosis and also confirmed that the medication regimen needed to be modified

54 M1028: 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. Response 2: Diabetes Mellitus would be checked. Rationale: Diabetes Mellitus is considered an active diagnosis because the physician progress note documents the diagnosis and there is ongoing medication management and glucose monitoring. 107 M1028: Example 2 Mrs. B is admitted to home health for physical therapy following a hip replacement. She has type 2 diabetes, which is controlled by diet, and she independently monitors her blood sugars. She is knowledgeable about diabetic foot care and checks her feet daily using a mirror. The PT will be monitoring the patient holistically to identify problems and to modify the POC as appropriate with physician collaboration. Orders do not list any active interventions related to her diabetes. Response 2: Diabetes mellitus would be checked. Rationale: Diabetes Mellitus is considered an active diagnosis since the patient s change in activity could affect her blood sugar levels and diabetes could affect the healing of her surgical wound. Monitoring of the patient/wound healing with specific knowledge that the patient is a diabetic, would make diabetes an active diagnosis for this patient. (CMS Quarterly Q&A #8, 10/16)

55 M1028: Example 3 Mr. C is referred to home health for speech language pathology interventions related to his dysphagia. He also has PAD, which is documented by the physician in the medical history. However, there are no interventions associated with the PAD, nor is it felt that this diagnosis will have an impact on the patient s prognosis related to his dysphagia. M1028 would be blank. Rationale: Since the PAD is not addressed in the POC and isn t felt to have the potential to affect the patient s responsiveness to treatment, it does not appear to have a direct relationship to the patient s current functional, cognitive, mood or behavior status, medical treatment, nurse monitoring or risk of death at the time of assessment. Therefore, PVD would not be reported as an Active Diagnosis in M It s your turn!

56 Scenario #1 o Patient has SOC assessment done on Monday. The H&P does not indicate a diagnosis of Diabetes, PVD or PAD, and M1028 is left blank. On Thursday, the RN is notified that the patient was given a new diagnosis of PAD during her physician visit on Wednesday. Since this is within the 5 day window, should M1028 be changed? Scenario #1 Answer o Patient has SOC assessment done on Monday. The H&P does not indicate a diagnosis of Diabetes, PVD or PAD, and M1028 is left blank. On Thursday, the RN is notified that the patient was given a new diagnosis of PAD during her physician visit on Wednesday. Since this is within the 5 day window, should M1028 be changed? No. Per the Guidance Manual, the OASIS should NOT be changed, and M1028 would remain blank. The OASIS should reflect what was known and documented at the time of the assessment. 56

57 Scenario #2 o Your patient underwent a below the knee amputation due to gangrene associated with PVD. She requires dressing changes to the stump and monitoring for wound healing. In addition, peripheral pulse monitoring is ordered. The physician s progress note documents PVD and a left below the knee amputation. How should M1028 be answered? 113 Scenario #2 Answer o Your patient underwent a below the knee amputation due to gangrene associated with PVD. She requires dressing changes to the stump and monitoring for wound healing. In addition, peripheral pulse monitoring is ordered. The physician s progress note documents PVD and a left below the knee amputation. How should M1028 be answered? Response 1: Peripheral Vascular Disease (PVD) should be checked. Rationale: Consider PVD an active diagnosis because the physician s note documents the diagnosis, which is associated with the below the knee amputation, and there is an order for peripheral pulse monitoring

58 Supporting physician documentation and compliance with OASIS and coding guidance are crucial to an agency s survival! For Part 3: History and Diagnosis: M Living Arrangements: M1100 Sensory Status: M1200 M1242 Medications: M2001 M2040 Tuesday, December 6 th 1:00 3:00 EST

59 Thank you for attending! Sharon Molinari, RN, HCS D, HCS O Home Health Consultant and Educator sharon.molinari@gmail.com