Home Health:  Outcome and Assessment Information Set (OASIS) Update

PDF Version of BQA 01-044 (PDF, 15 KB)

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Date: October 30, 2001 DSL-BQA-01-044

To: Home Health Agencies HHA 20

From: Jan Eakins, Chief, Provider Regulation and Quality Improvement Section

cc:  Sue Schroeder, Director, Bureau of Quality Assurance

The purpose of this memorandum is to provide you with information related to:

• Diagnosis coding guidelines for Medicare home health (HH).

• Modified guidance for OASIS data item M0825.

Diagnosis Coding Guidelines for Medicare HH

The Bureau of Quality Assurance (BQA) received notification that the Centers for Medicare and Medicaid Services (CMS) developed coding guidelines for home health agencies (HHAs) to use under the prospective payment system (PPS).

The 28-page document titled "Correct Diagnosis Coding Practices" can be accessed at either:

• The CMS web site at: http://www.hcfa.gov/medicare/hhmain.htm [replaced by http://www.cms.hhs.gov/providers/hhapps/ (exit DHFS)] under Home Health Prospective Payment System Policy Issues and Regulations, or
• The State OASIS System Welcome Page under Bulletins.

The document was developed to assist HHAs in understanding correct diagnosis coding practices for Medicare HH and is divided into the following three sections:

1. Information on general coding principles, with discussion of coding issues pertinent to HH.
2. Case scenarios for illustration.
3. Frequently asked questions on coding.

Questions

Address specific questions about this document to CMS Home Health Main at: hhc@hcfa.gov.

Questions about specific cases HHAs encounter in their clinical practice should be referred to the agency’s Medicare fiscal intermediary or national/local coding authorities such as the American Health Information Management Association (AHIMA).

Modified Guidance for OASIS Data Item M0825

CMS provides guidance on OASIS through a series of questions and answers on their website at: http://www.hcfa.gov/medicaid/oasis/oasishmp.htm. [replaced by http://www.cms.hhs.gov/oasis/hhoview.asp (exit DHFS)]. On 9/26/01, information on the correction policy for OASIS data item M0825 was modified. The current information on question #24 of Category 12: PPS/OASIS is printed below.

Q24: What are the HHA's options if they originally answered "No" to M0825 but subsequently performed 10 or more patient visits? Can they cancel the RAP that they originally filed or must they submit a SCIC? What if the HHA answered "Yes" to M0825 but subsequently performed less than 10 patient visits over the course of the episode?

A24: If the therapy need was under-estimated and there is no clinical change in the patient's health status, the HHA may cancel the original RAP and resubmit it. The HHA should make a note in the patient's record as to the difference between therapy originally estimated and therapy actually delivered and correct the original assessment at M0825 (i.e., change the No to a Yes) that will update the HHRG. Agencies can make this non-key field change to their files and retransmit the corrected assessment. HHAs should refer to the correction policy found on the OASIS web site at: www.hcfa.gov/medicaid/oasis/datasubm.htm [no longer operable, see http://www.cms.hhs.gov/oasis/hhoview.asp (exit DHFS)].

If the therapy need was over-estimated at the beginning of the episode and there is no clinical change in the patient's health status, the HHA should make a note in the patient's record as to the difference between therapy originally estimated and therapy actually delivered. However, it is not necessary to correct the original assessment at M0825 (i.e., change the Yes to a No) to update the HHRG. The HHA's payment for the episode will automatically be adjusted to reflect that the therapy threshold was not met.

If there is an unexpected change in the patient's clinical condition due to a major decline or improvement in health status that warrants a change in plan of treatment, an Other Follow-up Assessment (RFA 5) is expected to document the change. This is in keeping with the regulations at 42 CFR 484.55(d) (exit DHFS), Update of the comprehensive assessment and 484.20 (b), Accuracy of encoded data. The OASIS assessment must accurately reflect the patient's status at the time of the assessment. For payment purposes, the RFA 5 is the basis for the SCIC adjustment when no hospitalization is involved. It is necessary to have one consistent document for the patient's assessment, so if therapy visits are increased there should be concurrent OASIS and clinical record documentation. (Added 02/22/01/Modified 9/26/01)

Resources for OASIS and Home Health

Please direct questions regarding OASIS and HH issues to the resource contacts listed below:

Software and OASIS data transmission

• Chris Benesh, OASIS Automation Coordinator, 608/266-1718 or benesce@dhs.state.wi.us
• Cindy Symons, OASIS Technical Analyst [no longer available, see Chris Benesh]

OASIS clinical issues

• Andrea Henrich, OASIS Education Coordinator, 608/267-3807 or henriam@dhs.state.wi.us

HH regulations/interpretive guidelines

• Barbara Woodford, HH Education Coordinator [replaced by Marianne Missfeldt, (715) 836-4036]

Pharmacy/medication issues

• Douglas Englebert, Pharmacy Practice Consultant, 608/266-5388 or engleda@dhs.state.wi.us

Medicare payment and billing issues

• Medicare Provider Relations at United Government Services, 1-877-309-4290.

Please check What’s New on the CMS OASIS website (exit DHFS), and Bulletins on the State OASIS System Welcome Page often for timely OASIS-related announcements, corrections, and updates.

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