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OASIS Toolkit

OASIS-D Toolkit

© 2019 – Home Care Institute, LLC

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Table of Contents

CMS OASIS Resources ............................................................................................................................. 2

OASIS Conventions .................................................................................................................................. 3

Assessment Time frames ........................................................................................................................ 16

OASIS Timepoint Requirements ............................................................................................................ 25

Transfer to Inpatient Facility (RFA 7) or Death at Home (RFA 8)? ................................................... 36

OASIS-D Data Elements that Accept a Dash Value ............................................................................ 37

Home Health Compare ........................................................................................................................... 39

Timely Initiation of Care ........................................................................................................................ 45

Diagnosis Coding .................................................................................................................................... 52

OASIS Surgical Wounds ......................................................................................................................... 64

Best Practices for Coding GG Items ..................................................................................................... 66

When is a Fall a Fall for J1800 and J1900? ........................................................................................... 72

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CMS OASIS Resources

The following resources can be used to support completion of the OASIS Comprehensive Assessment. When there is conflicting guidance between one or more CMS sources, clinicians should follow the most recent guidance. When the clinician is unable to find specific guidance, clinical judgment should be used.

CMS Resource Web Link

OASIS-D Data Set https://go.cms.gov/2TMoeOX

OASIS-D Guidance Manual (includes OASIS-D data sets) https://go.cms.gov/2thJSyO

CMS Quarterly OASIS Q&As https://bit.ly/2RXIGea

CMS OASIS Q&As (By Category) https://bit.ly/2UWeZM7

CMS OASIS Mailbox (To submit Questions) [email protected]

OASIS Educational Coordinators https://go.cms.gov/2dvCNjU

WOCN Guidance on OASIS-D Integumentary Items: Best Practice for Clinicians https://bit.ly/2GEAj4V

NPUAP Pressure Injury Stages https://bit.ly/2aY9hV0

Home Health Conditions of Participation https://bit.ly/2kq2szx

Home Health Interpretive Guidelines https://go.cms.gov/2NN1GKX

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OASIS Conventions

The following conventions or general rules apply to completion of the OASIS assessment:

Day of Assessment

When assessing the patient, report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. The day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.

Examples of other time periods under consideration include:

l At the time of or at any time since the most recent SOC/ROC OASIS assessment.

l Within the last 14 days

l Day of assessment and recent pertinent past (clinicians should use clinical judgment to determine the recent pertinent past)

l Prior to the current illness, exacerbation or injury

l Daily

l During the past week

l During the past month

l Time of assessment through midnight of the next calendar day

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Usual Status

If the patient’s ability or status varies on the day of the assessment or the time frame under consideration, report the patient’s “usual status” or what is true greater than 50% of the assessment time frame, unless the item specifies differently.

Prior Status

When a data element refers to the patient’s status prior to the current illness, exacerbation, or injury, clinicians must determine a point in the past when the patient was at a steady-state that is different from the patient’s current status. if a patient has had two or more recent illnesses, exacerbations or injuries, clinicians should use clinical judgement to determine the patient’s status prior to the onset of the current illness, exacerbation, or injury (whichever is most recent) that initiated this episode of care. It is possible that he patient’s current illness, exacerbation, or injury

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may incorporate more than one condition that affected the patient at different times in the recent past.

Current Status

Unless a data element requests the review of the patient’s condition over the care episode, responses to items documenting a patient’s current status should be based on observation of the patient’s condition and ability at the time of the assessment without referring back to prior assessments or documentation of status from a prior care setting.

Assessment Technique

Combine observation, interview, collaboration with other agency staff and other relevant strategies to complete any and all OASIS items as needed, unless otherwise noted in guidance. Direct observation of the patient’s condition typically provides the most accurate assessment of the patient’s true ability.

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Collaboration

Collaboration involves obtaining feedback from other knowledgeable about the patient’s condition. This includes other agency staff (including contract staff) acting within their scope of practice, family and caregivers, the patient’s physician, and other healthcare providers (e.g., pharmacist).

Collaboration may also include considering available input from other sources, such as referral remarks, discharge summaries, phone calls, photographs, video monitoring devices, etc. Collaboration may be used to complete any and all OASIS items as needed, unless otherwise noted in guidance. When collaborating with other agency staff, they should have had in-person contact with the patient.

Although collaboration is acceptable, only one clinician takes responsibility for completing a comprehensive assessment. (M0090) Date Assessment Completed should be the last day the assessing clinician gathered or received any input to complete the comprehensive assessment document.

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Collaboration Time Frames Specific to Each Comprehensive Assessment Timepoint

Collaboration can be used to support the assessing clinician’s comprehensive assessment during the following time frames for each OASIS timepoint:

l Start of Care (SOC) – the SOC date (first billable visit) and the next 5 days.

l Resumption of Care (ROC) – Within 48 hours of being notified of a patient’s discharge from an inpatient facility or knowledge of the discharge. When a physician-ordered ROC date is given, collaboration may occur over the next 48 hours.

l Recertification (Follow-up) – During the last 5 days of the current episode.

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l Other Follow-up – Within 48 hours of identifying an unanticipated significant change in the patient’s condition.

l Discharge – The date of the patient’s last visit and the 4 preceding days.

Assessment Time Frame

The assessment time frame is the maximum number of days to complete each OASIS timepoint. The assessment time frame corresponds to the collaboration time frames (listed above).

Quality (Care) Episode

Many OASIS data elements refer to the quality episode. The quality episode spans from SOC or ROC (whichever is most recent) to the next Transfer to Inpatient Facility or Discharge.

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In contrast to a quality episode, a billing episode is a 60-day period beginning with the Start of Care date. There may be multiple quality episodes in a billing episode if a patient is admitted to an inpatient facility. Or a quality episode may extend beyond one or more billing episodes if the patient is not admitted to an inpatient facility. Quality episodes are used to calculate outcomes, while a billing episode is used to determine payment.

Minimize the use of NA and Unknown

While it may be unavoidable and appropriate in certain situations, clinicians should minimize the selection of NA and Unknown responses. Although NA responses may be appropriate based on the item, it is rare that Unknown should be selected. These responses fail to provide important

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information about the patient and should be avoided unless there is no ability to obtain the data. Responding with Unknown may also negatively impact outcomes, since outcome data cannot be computed unless a measurable response is selected.

If a patient refuses to answer an item, clinicians should not automatically select NA or Unknown. Further research should be done, including contacting the referral source, physician or authorized family member.

Dash Value

Some items allow a dash response. A dash (–) value indicates that no information is available. It should not be used when a patient is unable to perform an activity. CMS expects dash use to be a rare occurrence.

Assistance

When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited to physical contact and can include necessary verbal cues and/or supervision. Clinicians should note item instructions when determining whether the use of assistive devices impact performance of the activity.

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Examples

The OASIS assessment provides examples to assist clinicians in completing certain data elements.

l When “specifically” is used, only the examples listed should be considered.

l When “for example” is used, the items listed are only a subset of a larger set of items that can be considered.

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l Other data elements provide you with only the examples that can be considered without using the word, “specifically.”

l If the words, “Such as” are used, the clinician should note that these are only two items to consider and others may apply.

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Ability vs. Preference

Report the patient’s physical and cognitive ability to perform a task. Do not report on the patient’s preference or willingness to perform a specified task.

Safe Ability and Assistance

The level of ability refers to the level of assistance (if any) that the patient requires to safely complete a specified task. If the patient can perform a task independently but is unsafe doing so, he/she should be coded as requiring assistance to perform the task or not being able to perform the task independently.

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Presence of a Caregiver

While the presence or absence of a caregiver may impact the way a patient carries out an activity, it does not impact the clinician’s ability to assess the patient in order to determine and report the level of assistance that the patient requires to safely complete a task.

Multi-Task Items

If the patient’s ability varies between the different tasks included in a multi-task item, report what is true in a majority of the included tasks, giving more weight to tasks that are more frequently performed.

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Consider Medical Restrictions

Consider medical and environmental restrictions when determining ability. If the physician has restricted activity, such as orders not to climb stairs or a non-functioning shower, the patient should be coded as not being able to perform the associated activity.

Look-Back Process Measures

Certain OASIS data elements request a review of the care episode. For these items that state, “since the previous OASIS assessment," the patient’s status refers to a review of the time period “at the time of or at any time since the most recent SOC/ROC assessment” was completed. For these look-back data elements, the previous OASIS assessment that should be referred to must be a SOC or ROC assessment and not any other assessment timepoint.

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Assessment Time frames

When assessing specific OASIS data elements, the assessment time frame, or the period under which assessment of the item takes place, varies based on the data element. This job aid reviews and defines common assessment time frames specified within the OASIS Guidance Manual:

Time of Assessment

The time of assessment is the specific time that the data element is assessed. While in most situations, a data element may be updated during the assessment time frame for the timepoint being assessed, the item is coded at the time that the assessment details are obtained. Many of the general data elements are assessed at the specific time of assessment. Examples include:

l (M0030) Start of Care Date

l (M0063) Medicare Number

l (M0140) Race/Ethnicity

l (M1021) Primary Diagnosis and (M1023) Other Diagnoses

l (M1033) Risk for Hospitalization

l (M1100) Patient Living Situation

l (M1200) Vision

Other data elements involve obtaining measurements. These items use the time of assessment to report the results. Examples include:

l (M1060) Height and Weight

l (M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

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l (M1332) Current Number of Stasis Ulcer(s) that are Observable

l (M1730) Depression Screening (when the screening is performed, which can be during the assessment time frame for the timepoint being assessed)

l (M1910) Falls Risk Assessment (when the screening is performed, which can be during the assessment time frame for the timepoint being assessed)

Day of Assessment

May OASIS data elements use the Day of Assessment as the time frame to determine the response to be coded. The Day of Assessment Day of is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.

During the Day of Assessment, the clinician reports the patient’s “usual status” or what is true greater than 50% of the assessment time frame, unless the item specifies differently. This status that is reported may not be the patient's current status.

Examples of data elements that use the Day of Assessment to capture OASIS results include:

l (M1400) When is the patient dyspneic or noticeably Short of Breath?

l (M1700) Cognitive Functioning

l (M1720) When Anxious

l ADL and IADL data elements: (M1800) Grooming - (M1870) Feeding or Eating

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l (M2020) Management of Oral Medications

l (M2030) Management of Injectable Medications

l (M2102) Types and Sources of Assistance

Within the Past 14 Days

Certain OASIS data elements report details from within the past 14 days. When calculating this time frame, the start of care, resumption of care or the first day of the new certification period (for recert assessments) is considered day 0. The clinician should count backward with the day before being day 1 until reaching day 14. The 14th day begins the 14-day window.

Using a simpler formula, the clinician can note the day of the week the assessment is being completed, for example a Friday, and go back two Friday’s before for the day that begins the 14-day period.

Examples of data elements that refer to the past 14 days include:

l (M1000) Inpatient Facilities

l (M1600) Urinary Tract Infection

l (M1630) Ostomy for Bowel Elimination

l (M1710) When Confused

l (M1720) When Anxious

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Review of the Care Episode

Certain OASIS data elements request a review of the care episode. For these items that state, “at the time of or since the most recent start of care or resumption of care," the patient’s status refers to a review of the time period since and including the most recent SOC/ROC assessment was completed.

Process items collected at transfer and discharge time points include documentation of interventions implemented as part of patient care at the time of or since the most recent start of care or resumption of care. For these look-back data elements, the previous OASIS assessment that should be referred to must be a SOC or ROC assessment and not any other assessment timepoint. Examples of data elements that refer to a review of the care episode include:

l (M1041) Influenza Vaccine Data Collection Period

l (M1046) Influenza Vaccine Received – For patients with any part of the home health episode (SOC/ROC to Transfer/Discharge) occurring between October 1 and March 31, did the patient received an influenza vaccine for this year’s flu season.

l (M1306) Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher (unstageable due to dressing or device may be later reported if occurred during the care episode)

l (M1307) The Oldest Stage 2 Pressure Ulcer

l (M2005) Medication Intervention

l (M2016) Patient/Caregiver Drug Education Intervention

l (M2301) Emergent Care

l (M2310) Reason for Emergent Care

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l (M2401) Intervention Synopsis

Prior to the Current Illness, Exacerbation, or Injury

Several data elements compare the patient’s current status with his or her status prior to the current illness, exacerbation, or injury. Since a set point is not indicated on the assessment, clinicians must determine a point in the past when the patient was at a steady-state that is different from the patient’s current status.

Examples of data elements that refer to the time prior to the current illness, exacerbation, or injury include:

l GG0100. Prior Functioning: Everyday Activities

l GG0110. Prior Device Use

l GG0130. Self-Care

l GG0170. Mobility

Time Frame for Completion of the Comprehensive Assessment for the Specific OASIS Timepoint Being Completed

Certain data elements specify that the results reported may be obtained during the maximum number of days within which to complete the comprehensive assessment for the specific timepoint being completed. This is defined as follows for each timepoint:

l Start of Care (SOC): 5 days after the first billable visit or start of care date.

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l Resumption of Care (ROC): within 2 calendar days of the facility discharge, knowledge of the discharge, or the resumption of care date requested by the physician.

l Recertification (Follow-up): the last 5 days of every 60-day billing episode.

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l Discharge: the last five days the agency provided visits. The last qualified clinician who made a visit completes the comprehensive assessment, with collaboration allowed between this clinician and any clinician who visited the patient during this time period.

For unplanned discharges, the last qualified clinician to see the patient completes the comprehensive assessment, with collaboration allowed by any clinician who made a patient visit within the last 5 days of care.

Examples of data elements that allow assessment results to come from the time frame for completion of the comprehensive assessment include:

l (M0090) Date Assessment Completed

l (M1021) Primary Diagnosis & (M1023) Other Diagnoses

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l (M1730) Depression screening (although reported results should be from the point that the screening is administered)

l (M1910) Falls Risk Assessment (although reported results should be from the point that the screening is administered)

l (M1800 – M1870) Functional Assessment ADL/IADL Data Elements (although reported results should encompass the day of assessment)

l (M2001) Drug Regimen Review

l (M2010) Patient/Caregiver High-Risk Drug Education

l (M2200) Therapy Need

l (GG0130) Self-Care

l (GG0170) Mobility

Other Time frames as Specified Within the Item Stem and/or Response Verbiage

Several data elements list varying time frames in which assessment results are reported. Examples include:

l (M1028) Active Diagnoses – which specifies the active diagnoses known on the “day of assessment” but instructs agencies to update (via a correction to the OASIS if necessary) any active diagnoses that are discovered after the assessment is completed

l (M1030) Therapies – includes therapies the patient is receiving on the day of assessment, as well as therapies that are ordered and will begin to be administered in the home at a date in the future. PRN medications that aren’t needed on the day of assessment should not be reported for this item

l (M1051) Pneumococcal Vaccine – the patient’s entire history

l (M1242) Frequency of Pain Interfering – clinicians assess frequency of pain interfering with activity or movement: less than daily, daily, all of the time

l (M1610) Urinary Incontinence or Urinary Catheter Presence – while assessment of this item encompasses the “Day of Assessment,” if a catheter is removed or inserted and removed during the assessment visit, the urinary catheter would not be considered for the item

l (M1620) Bowel Incontinence Frequency – Within the past week

l (M1740) Cognitive, behavioral, and psychiatric symptoms – Within the past week

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l (M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) – Within the past month

l (M2003) Medication Follow-up – Time of assessment through midnight of the next calendar day following identification of clinically significant medication issue

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OASIS Timepoint Requirements

This job aid reviews regulatory requirements for each OASIS timepoint:

Initial Assessment Visit

Although the initial assessment visit is usually associated with the Start of Care visit, it has a unique purpose and may be made before the Start of Care visit.

Purpose:

l Determine eligibility for home care services and the home health benefit.

l Determine the patient’s immediate care needs.

Requirements:

l Must be the first patient visit.

l Must be made by an RN if skilled nursing is ordered within the SOC referral/orders.

l If skilled nursing is not ordered within the SOC referral/orders and agency policy allows, may be made by a PT, SLP or OT. Occupational therapy may not establish program eligibility and make the initial assessment visit for patients with Medicare Fee-for-Service but may for other payers as allowed.

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Time Frame for Completion:

l Must be made within 48 hours of referral OR within 48 hours of return home from an inpatient visit OR on the Physician-ordered Start of Care date.

Comprehensive Assessments

l Must be completed at various timepoints for all home health patients.

l Must be patient-specific.

l At start of care, must be completed by an RN if nursing is ordered within the referral; otherwise it may be completed by a qualifying therapist (OT won’t qualify for Medicare FFS patients)

l Discipline is not mandated for comprehensive assessments other than SOC.

l Must include:

l The patient's current health, psychosocial, functional, and cognitive status

l The patient's strengths, goals, and care preferences

l The patient's continuing need for home care

l The patient's medical, nursing, rehabilitative, social, and discharge planning needs

l Drug regimen review

l The patient’s primary caregivers and any designated representative(s)

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l OASIS items for patients with Medicare fee-for-service, Medicare Advantage and Medicaid payors

Updates to Comprehensive Assessments

Comprehensive assessments (including OASIS) must be updated and revised at the following times:

l Within 5 days of the first billable visit (SOC)

l With any unanticipated decline or improvement in the patient’s health status (Other Follow-up)

l The last five days of every 60-day episode beginning with the SOC date (Days 56-60 of each 60-day billing episode)

l Within 48 hours of patient’s return home, knowledge of the patient’s return home, or on the physician-ordered ROC date from an inpatient facility admission of 24 hours or more for reasons other than diagnostic testing (ROC)

l At discharge

Start of Care (SOC) Comprehensive Assessment (RFA 1)

The SOC comprehensive assessment is a patient-specific assessment that must be completed for all patients at the start of care regardless of payor source. This assessment is often combined with the Initial Assessment visit.

Requirements:

l Cannot be completed before the Start of Care Date / First Billable Visit.

l A plan of care (485) is required.

l If skilled nursing is not ordered within the SOC referral/orders and agency policy allows, the SOC Comprehensive Assessment may be completed by a PT, SLP or OT. Occupational therapy may not establish program eligibility and complete the Start of Care assessment for patients with Medicare Fee-for-Service but may for other payers as allowed.

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l It’s not permissible for LPNs, therapy assistants, social workers or home health aides to complete OASIS assessments, however, they may collaborate with the assessing clinician.

Time Frame for Completion and Collaboration:

l Must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. Day 0 is the first billable visit.

l If the patient is transferred to an inpatient facility and returns home after day 60 of the previous certification period, a new SOC comprehensive assessment must be completed. An internal agency discharge without a Discharge OASIS is completed.

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Resumption of Care (ROC) Comprehensive Assessment (RFA 3)

The ROC comprehensive assessment is completed following an inpatient stay of 24 hours or longer for reasons other than observation or diagnostic testing. This timepoint starts a new quality episode.

Requirements:

l May be completed by any discipline qualified to complete OASIS assessments.

l As long as the time frame for completion of the assessment is achieved, the agency may bill for other discipline (including aides and LPNs) visits made before the ROC assessment.

l The (M0032) Resumption of Care Date would be the date the first clinician made a visit.

l A ROC assessment is the only assessment required if a patient resumes services during the last 5 days of the current 60-day billing episode. A Recertification assessment is not required.

l New comprehensive verbal orders for continued care are required, although a new Plan of Care (485) is not generated unless the ROC is completed during the last 5 days of the current 60-day billing episode.


l Must be completed within 48 hours of discharge from an inpatient facility or knowledge of discharge from an inpatient facility, or on the physician-ordered ROC date.

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l If the physician orders a specific ROC date, a visit must be made on that date and then the agency has 2 calendar days to complete the assessment documentation.

Recertification (Follow-Up) Comprehensive Assessment (RFA 4)

The purpose of the Recertification assessment is to provide a comprehensive assessment of the patient and generate new orders, a new plan of care, and a new episode payment for the forthcoming 60-day certification period.

Requirements:

l Completed during the last 5 days of the current certification period.

l May be completed by any clinician qualified to perform a comprehensive assessment.

l The visit is only billable if it can be combined with a skilled service. A physician order is not required to make a nonbillable visit to complete the assessment.

l A patient who undergoes a recertification assessment during the last 5 days of the certification period but then is admitted to the hospital before a visit can be made in the new certification period should have an agency D/C completed (no D/C OASIS) and a new start of care assessment completed upon return home.

l If an agency misses the recertification window (early or late) and still provides care, the patient should not be discharged and readmitted. A visit should be made ASAP and the

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Recertification assessment completed. (M0090) Date Assessment Completed is the date that the Recertification assessment is completed.


l Must be completed during the last 5 days of the current certification period (Days 56 – 60).

Other Follow-Up (Follow-up) Comprehensive Assessment (RFA 5)

The Other Follow-up assessment is completed when the patient has an unanticipated significant decline or improvement in condition, indicating a possible need to update the plan of care. It is not completed if another comprehensive assessment is indicated (e.g., ROC, Recert, D/C).

Timeframe for Completion and Collaboration:

l Must be completed on or within 48 hours of becoming aware of the significant change in condition.

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Discharge from Agency (D/C) Comprehensive Assessment (RFA 9)

The Discharge from Agency Comprehensive Assessment is completed when the patient has a planned or unplanned discharge from the agency for reasons other than transfer to an inpatient facility or a death at home.

Requirements:

l A visit is required to complete the D/C assessment.

l For an unplanned discharge, a nonbillable visit may be made to complete the assessment or the visit from the last discipline qualified to perform comprehensive assessments may be used (RN, PT, SLP, OT).

l If more than one qualified discipline visits the patient on the discharge date, the last clinician visiting the patient should complete the D/C Comprehensive Assessment

l The assessing clinicians may collaborate with other disciplines who visited the patient during the last 5 calendar days the patient received visits if agency policy allows.

OASIS Discharge Dates:

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Timeframe for Completion and Collaboration:

l Must be completed within 48 hours of being notified of the need to discharge the patient.

l The assessing clinician may supplement the discharge assessment with information from patient visits by other agency staff that occurred within the last 5 calendar days the patient received visits (date of last visit is counted as day 5). Planned Discharge:

Unplanned Discharge

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Timepoints That Do Not Require a Comprehensive Assessment All OASIS timepoints require completion of a patient visit and comprehensive assessment except Transfer to Inpatient Facility – Not Discharged from Agency (RFA 6), Transfer to Inpatient Facility –Discharged from Agency (RFA 7), and Death at Home (RFA 8).

Transfer to Inpatient Facility (RFA 6 and 7)

The Transfer to Inpatient Facility timepoint is completed when the patient is admitted to an inpatient facility bed for a period longer than 24 hours for reasons other than diagnostic testing or observation. This timepoint ends the quality episode.

Requirements:

l Transfer to Inpatient facility – Not Discharged from Agency (RFA 6) is completed when the patient is expected to return to the agency or it is unknown if the patient will return.

l If it’s expected that the patient will not return to the agency, Transfer to Inpatient Facility –Discharged from Agency (RFA 7) is completed.

l If the patient doesn’t return to the agency, even if RFA 6 is completed, a Discharge OASIS assessment is not required. Clinicians should complete an internal agency discharge.

l (M0906) Transfer Date should be the date the patient is admitted to an inpatient bed and not the date admitted to the emergency room or observation bed.

Time Frame for Completion:

l Must be completed within 48 hours of knowledge of transfer to an inpatient facility.

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Death at Home (RFA 8)

The Death at Home assessment is completed when the patient dies somewhere other than an inpatient facility, outpatient facility or emergency room.

Requirements:

l Involves data collection. A patient visit or comprehensive assessment is not required.

l (M0906) Death Date should be the date the patient died.

Time Frame for Completion

l �Must be completed within 48 hours of death or knowledge of death.

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Transfer to Inpatient Facility (RFA 7) or Death at Home (RFA 8)?

This table provides guidelines for determining which OASIS Timepoint should be completed based on where a patient dies:

Complete Transfer to Inpatient Facility (RFA 7) Complete Death at Home (RFA 8)

Patient dies:

o In an inpatient facility, even if there less than 24 hours

o In the emergency room o During outpatient surgery or the

outpatient recovery room o While under outpatient observation

(even if in an inpatient facility if only receiving observation or diagnostic testing)

Patient dies:

o At home o At church o At a physician’s office o In the wound clinic o Receiving outpatient therapy o In a dialysis center o In the community o In an ambulance o In the emergency room if arrives dead

on arrival (DOA)

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OASIS-D Data Elements that Accept a Dash Value

A dash (–) value is an OASIS convention used with several data elements. A Dash (–) Value indicates that no information is available, or an item could not be assessed. CMS expects use of the dash value to be a rare occurrence. When a dash is entered for a data element, the clinician should document the reason the item could not be assessed. CMS warns that overuse of the dash may result in missed risk adjustment and outcome opportunities.

The following OASIS-D data elements accept use of the dash value:

l �(M1028) Active Diagnoses

l �(M1060) Height and Weight

l �(M2001) Drug Regimen Review

l �(M2003) Medication Follow-up

l �(M2005) Medication Intervention

l �(GG0100) Prior Functioning: Everyday Activities

l �(GG0110) Prior Device Use

l �(GG0130) Self-Care

l �(GG0170) Mobility

l �(J1800) Any Falls Since SOC/ROC

l �(J1900) Number of Falls Since SOC/ROC

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Note: While a dash value is allowed for the Discharge Goal in (GG0130) Self-Care and (GG0170) Mobility, at Start of Care and Resumption of Care, the Home Health (HH) Quality Reporting Program (QRP) requires a minimum of one self-care or mobility goal to be coded without a dash value. Use of a dash is permissible for any remaining self-care or mobility goals that were not coded.

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Home Health Compare

The following measures are publicly reported on the Home Health Compare website:

Measure Star Rating? Source / Comments

Managing Daily Activities

HHC: How often patients got better at walking or moving around Measure: Improvement in Ambulation/Locomotion

OASIS: Outcome Measure

HHC: How often patients got better at getting in and out of bed Measure: Improvement in Bed Transferring


HHC: How often patients got better at bathing Measure: Improvement in Bathing


Managing Pain and Treating Symptoms

HHC: How often patients had less pain when moving around Measure: Improvement in Pain Interfering with Activity


HHC: How often patients’ breathing improved Measure: Improvement in Dyspnea


HHC: How often patients’ wounds improved or healed after an operation Measure: Improvement in Status of Surgical Wounds

OASIS: Outcome Measure Proposed for removal from HHC January 2021

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HHC: How often patients developed new or worsened pressure ulcers Measure: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

OASIS: Outcome Measure To be added to HHC January 2021

Preventing Harm

HHC: How often the home health team began their patients’ care in a timely manner Measure: Timely initiation of care

OASIS: Process Measure

HHC: How often the home health team taught patients (or their family caregivers) about their drugs Measure: Drug education on all medications provided to patient/caregiver

OASIS: Process Measure Proposed for removal from star rating

HHC: How often patients got better at taking their drugs correctly by mouth Measure: Improvement in Management of Oral Medications

(To be added 4/2019)


HHC: How often the home health team checked patients’ risk of falling Measure: Multifactor fall risk assessment conducted for all patients who can ambulate

OASIS: Process Measure Proposed for removal from HHC January 2021

HHC: How often the home health team checked patients for depression Measure: Depression assessment conducted


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HHC: How often the home health team made sure that their patients have received a flu shot for the current flu season Measure: Influenza immunization received for current flu season


HHC: How often the home health team made sure that their patients have received a pneumococcal vaccine (pneumonia shot) Measure: Pneumococcal polysaccharide vaccine ever received

OASIS: Outcome Measure Proposed for removal from HHC January 2021

HHC: For patients with diabetes, how often the home health team got doctor’s orders, gave foot care, and taught patients about foot care Measure: Diabetic foot care and patient education implemented


HHC: How often physician-recommended actions to address medication issues were completed timely Measure: Drug Regimen Review

Preventing Unplanned Hospital Care

HHC: How often home health patients had to be admitted to the hospital Measure: Acute Care Hospitalization During the First 60 Days of Home Health

Claims: Utilization Outcome

HHC: How often patients receiving home health care needed any urgent, unplanned care in the


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hospital emergency room – without being admitted to the hospital Measure: Emergency Department Use without Hospitalization During the First 60 days of Home Health

HHC: How often home health patients, who have had a recent hospital stay, had to be readmitted to the hospital Measure: Rehospitalization during the first 30 days of home health


HHC: How often home health patients, who have had a recent hospital stay, received care in the hospital emergency room without being readmitted to the hospital Measure: Emergency department use without hospital readmission during the first 30 days of home health


HHC: How often patients remained in the community after discharge from home health Measure: Discharge to community


Payment and Value of Care

HHC: How much Medicare spends on an episode of care at this agency, compared to Medicare spending across all agencies nationally Measure: Medicare Spending per Beneficiary (MSPB)


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Patient Survey

How often the home health team gave care in a professional way

HHCAHPS

How well did the home health team communicate with patients

HHCAHPS

Did the home health team discuss medicines, pain, and home safety with patients

HHCAHPS

How do patients rate the overall care from the home health agency

HHCAHPS

Would patients recommend the home health agency to friends and family

HHCAHPS

For Future Addition to Home Health Compare

Measure: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury


Measure: Application of Percent of Patients Experiencing One or More Falls with Major Injury


Measure: Application of Percent of Patients experiencing one or more falls with major injury


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Home Health Compare results may be viewed based on agency name, city, zip code and state at: https://www.medicare.gov/homehealthcompare/search.html.

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Timely Initiation of Care

Timely initiation of care is a process measures that is reported on the Home Health Compare website and used in the calculation of star ratings. Because of this, it’s important to understand the clinician’s requirements related to the measure and how it’s calculated.

Measure Name

Reporting Description OASIS-D Data

Elements Timely Initiation of Care

HH Compare Star Rating

Percentage of home health quality episodes in which the start or resumption of care date was on the physician-ordered SOC/ROC date (if provided), otherwise was within 2 days of the referral date or inpatient discharge date, whichever is later

(M0102) Date of Physician-ordered SOC/ROC (M0104) Date of Referral (M0030) Start of Care Date (M0032) Resumption of Care Date (M0100) Reason for Assessment (M1000) Inpatient Facility discharge (M1005) Inpatient Discharge Date

The Home Health Conditions of Participation require that a registered nurse conduct an initial assessment visit to determine the immediate care and support needs of the patient and determine eligibility for the Medicare home health benefit. If the patient is returning home from a qualifying inpatient facility stay, a resumption of care (ROC) must be made.

These visits must occur at the following times to meet the Timely Initiation of Care process measure and comply with the Home Health Conditions of Participation:

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1. Within 48 hours of referral

2. Within 48 hours of the patient's return home from an inpatient facility stay, or

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3. On the physician-ordered start of care (SOC) or resumption of care (ROC) date.

Change in Conditions of Participation (CoPs)

Prior to the release of the new CoPs, agencies were required to make a visit within 48 hours of a patient’s return home (or knowledge of their return home) from an inpatient facility stay that was 24 hours or more for reasons other than diagnostic testing or observation. If a physician ordered a ROC visit after this 48-hour period, agencies were out of compliance with this CoP. With the new CoPs that went into effect in January 2018, the CoPs were changed, allowing a visit to be made on the physician-ordered ROC date, even if that date was more than 48 hours after the patient’s return home.

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Calculating the Measure

The following OASIS-D data elements are used to calculate the Timely Initiation of Care process measure:

l (M0102) Date of Physician-ordered SOC/ROC

l (M0104) Date of Referral

l (M0030) Start of Care Date

l (M0032) Resumption of Care Date

l (M0100) Reason for Assessment

l (M1000) Inpatient Facility discharge

l (M1005) Inpatient Discharge Date

Rules for a Positive Process Measure Outcome – Timely Initiation of Care:

v If the patient has a specific physician-ordered SOC date (M0102), the SOC date (M0030) or ROC date (M0032) must be on this date, depending on the Reason for Assessment (M0100).

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v If a physician-ordered SOC or ROC date was not given, then the referral date (M0104) and inpatient facility discharge date (M1005) are used to calculate the measure. The SOC date (M0030) or the ROC date (M0032) must be within 48 hours of the later of these two dates. For ROCs, the referral date (M0104) is the date the agency becomes aware of the inpatient facility discharge and confirms orders for resumption.

v

Example: the agency receives a referral to admit a patient on Friday, May 6th. However, the patient is not discharged until Sunday, May 8th. Because the discharge date is later than the referral date, the agency has 48 hours from Sunday the 8th to see the patient.

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Physician-Ordered Start of Care vs. Date of Referral

In order to respond to (M0102) Date of Physician-ordered SOC/ROC for a start of care assessment, the physician must specifically state the date that services should be started. Examples would include:

More general requests to start services would be considered the date of referral. The date the referral is received would be entered in (M0104) Date of Referral. Examples include:

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It’s important to note that referrals that give “permission” to start services on a future date, like “Home health services to begin next week,” do not remove the requirement for an initial assessment visit to occur within 48 hours of referral.

The referral date would be the date that the physician ordered home care; not the date that services are permitted to begin. An exception would be if the physician

specifically stated for home health services to begin on a specific date.

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Diagnosis Coding

Home care coding requires that coding be documented on the Plan of Care (485), OASIS assessment and billing claim (UB-04). Coding must be consistent amongst these documents and supported by the clinical record.

Locators 11, 12 and 13 of the 485 Plan of Care are used to capture the patient’s principle or primary diagnosis, surgical procedures and pertinent or secondary diagnoses.

Within the OASIS assessment (M1021) and (1023) Diagnoses and Symptom Control are used to capture each medical diagnosis and ICD-10-CM code for which the patient is receiving home care. This job aid provides best practices for selecting the best diagnoses and how to sequence them.

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Determining the Patient’s Diagnoses

When determining the patient’s diagnoses, guidance states that diagnosis assignment should be based on the physician’s statement that the diagnosis exists and not necessarily on clinical criteria. This includes the physician or other qualified healthcare practitioners legally accountable for establishing the patient's diagnosis. For example, if the physician states that the patient has morbid obesity (E66.01), but the patient does not meet the BMI criteria for morbid obesity (BMI > 40), it would be appropriate to assign a diagnosis of morbid obesity.

If there is conflicting medical record documentation, either from the attending physician, clinician performing the assessment, or clinical data, the attending

physician is responsible for determining the patient’s diagnoses.

The Primary Diagnosis

The patient’s primary diagnosis is entered in column 1 of M1021 (a) and the associated ICD-10-CM code is entered in column 2 of M1021 (a).

The primary diagnosis:

l Most drives the patient’s home care needs

l Correlates to the chief reason for home care

l Is the most acute condition for which the agency provides the most intensive service impacting the plan of care

l May or may not be related to a recent hospital stay

l Must relate to the agency’s skilled service and plan of care

l Should not include surgical or procedure codes or external cause codes (ICD-10-CM codes beginning with V, W, X, or Y)

If more than one diagnosis meets the criteria of an acceptable primary diagnosis for a patient, the diagnosis that represents the most acute condition and requires the most intensive services should be selected as the primary diagnosis. It should be the chief reason for home care and represent the most acute condition.

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Secondary Diagnoses

Up to five secondary diagnoses are entered in column 1 of M1023 (b-f) and their associated ICD-10-CM codes are entered in column 2 of M1023 (b-f).

Secondary diagnoses:

l Include co-morbid conditions that exist at the time of assessment and that are treated within the plan of care

l Have the potential to affect the patient’s responsiveness to treatment and rehabilitative prognosis

l Should be sequenced in an order that reflects the seriousness of the patient’s condition

l Do not need to be the focus of home care

l Should not include conditions of a mere historical value

l May include external cause codes (ICD-10-CM codes beginning with V, W, X, or Y)

Resolved Conditions

Resolved conditions should not be reported as a primary or secondary diagnosis unless the condition still impacts the plan of care. While they should not be documented in locator’s 11 and 13 of the Plan of Care, they may need to be added to locator 21 (services and treatments) of the 485 to help explain the need for other services. In these situations when a condition is resolved but still impacts the patient’s care, a personal history code (categories Z80-Z87) may be used as a secondary code to support the ordered care.

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For example, it may be appropriate to include the Z code, “personal history of pathological fracture” (V13.51) to help explain the need for nursing visits to administer Calcitonin® or Forteo® in a patient with postmenopausal osteoporosis.

Conditions that Should be Consistently Coded as Secondary Diagnoses

Certain conditions, even if they are not the focus of home care, should be coded because they have the potential to impact the patient’s status and/or response to treatment. Examples include:

l Diabetes

l Hypertension

l Coronary artery disease

l Peripheral vascular disease

l Chronic obstructive pulmonary disease

l Chronic neurological diseases (Parkinson’s, MS, ALS)

l Blindness

l Morbid obesity

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Follow Sequencing Guidelines

Diagnoses should be sequenced in an order that supports home care services, justifies the ordered disciplines, and reflects the seriousness of the patient’s condition. Sequencing of diagnoses may not correlate with the patient’s symptom-control rating as documented in column two of M1021 and M1023.

Etiology and Manifestation Codes

Certain conditions have both an underlying etiology (primary illness) and multiple body system manifestations (associated illnesses) due to the underlying etiology. Coding conventions require that the underlying condition be sequenced first, followed by the manifestation. In these situations, the etiology code will include the statement: “use additional code” and a “code first” note will appear at the manifestation code. Often, the manifestation codes will have state “in diseases classified elsewhere” in the code title. Codes with this title are a component of the etiology/manifestation convention. These codes may never be used before the etiology code (underlying condition) or as the primary diagnosis.

It’s important to note that “Code first” diagnoses are not always manifestation codes. They may be due to an underlying condition that is not a specific etiology code. When there is a “code first” note and an underlying condition is present, the underlying condition should be sequenced first, if known.

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“Use Additional Codes”

Certain codes include a “use additional code” note at the etiology code and a “code first” note at the manifestation code. The rules of sequencing also apply to these codes.

“Code Also”

A “code also” note instructs that two codes may be required to fully describe a condition. However, unlike the etiology and manifestation codes, this notation does not provide sequencing guidance. The sequencing should depend on the needs of the patient.

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Code to the Highest Specificity

Diagnoses should be entered to the highest specificity, indicating a code that most reflects the patient’s condition and is as specific as possible. The highest specificity equates to the highest number of characters available for the diagnosis code. ICD-10-CM diagnosis codes are composed of 3, 4, 5, 6 or 7 characters. Codes with 3 characters are used as the heading of a category of codes that may be further subdivided using 4-7 additional characters. Although 3-character codes may be appropriate, the more characters that can be added supports greater specificity. A three-character code should only be used if it cannot be further subdivided.

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Avoid Unspecified Codes

Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. Clinicians should make every effort to identify the most specific code for the patient and avoid unspecified codes.

Signs and Symptoms

Signs and symptoms, as opposed to disease-specific diagnoses, should only be entered when a definitive diagnosis cannot be established by the physician. Clinicians should focus on diagnoses that cause these symptoms, unless the cause is unknown. Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise specified by guidance. Most signs and symptoms codes are located between codes R00.0 - R99. If a symptom is present that doesn’t fall under another diagnosis, then symptom codes are appropriate.

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Code the Patient’s Injury and Not an Aftercare Code When Possible

The code for the type of injury the patient suffered (e.g., fracture, burn, laceration) and the seventh character that is required to accompany it should be entered when possible instead of an aftercare code (Z48). This is the case even if the injury was surgically treated and the agency is providing surgical aftercare, such as after joint replacement surgery. Assigning the seventh character “D” indicates that aftercare is being provided instead of the initial treatment obtained in the acute care setting, which would be captured with a seventh character of “A.”

The 7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. The Excludes 1 note in the Tabular list indicates that only one code (injury code) should be documented. The Z aftercare code should not be entered. The injury code with the appropriate 7th character of “D” supports all aftercare for the injury.

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Initial versus Subsequent Encounter Codes

The 7th character in an ICD-10-CM code applies greater specificity to a diagnosis. An initial encounter has a 7th character of “A” and describes the entire period in which a patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. The 7th character “D” is used for encounters after the patient has received active treatment for the condition and is receiving routine care for the condition during the healing or recovery phase.

In home care, most conditions are coded as subsequent encounters, “D”; however, there may be situations when the 7th character of “A” would be appropriate, indicating active treatment. The key to assignment of the 7th character for an

initial encounter is whether the patient is still receiving active treatment for that condition.

For OASIS purposes, injuries (e.g., burns, lacerations, etc.) that are treated surgically may be considered surgical wounds, depending on the extent of the surgical procedure. However, when coding the lesion in M1021-M1023, the injury code should be entered with the appropriate 7th digit of “D.”

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An example when an initial encounter would be coded in home care would be a patient admitted to home care with an infected internal fixation device of the right femur. The patient was receiving I.V. antibiotics in the hospital and will continue receiving them at home. Because the antibiotic administration is the continuation of active treatment, the 7th character of “A” would be appropriate.

Symptom Control Ratings

Within the OASIS assessment, diagnoses are documented with a symptom control rating in column 2 of M1021 and M1023 that reflects how well symptoms of the diagnosis are controlled with the current treatment. The symptom control rating of each diagnosis should not be used to determine the sequencing of the diagnoses. These are separate items and sequencing may not coincide.

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Symptom control ratings should not be assigned for V, W, X, Y or Z-codes.

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OASIS Surgical Wounds

This job aid provides an overview of wounds that are and are not considered as surgical wounds within the OASIS assessment (M1340) Does this patient have a Surgical Wound? and (M1342) Status of Most Problematic Surgical Wound that is Observable.

OASIS Surgical Wounds Not OASIS Surgical Wounds

l Stapled, sutured or chemically bonded incisions until incision heals (30-days)

l Incisions with drains, even after drain is removed; except drains associated with an ostomy

l Central line sites (centrally-inserted venous catheters)

l Mediport sites and other implanted infusion devices or venous access devices (functional or non-functional)

l AV fistulas

l Peritoneal catheter sites

l Left-ventricular assist device exit sites

l Orthopedic pin sites

l Shave, punch, and excisional biopsy sites

l Implanted pacemakers until placement incision heals (30-days)

l Old surgical wound with scar or keloid formation (> 30 days without complications)

l Intravenous catheters (peripheral)

l Peripherally-inserted venous catheter (PICC), either tunneled or non-tunneled

l External infusion devices that infuse medications subcutaneously

l Implanted pacemakers after placement incision heals (>30-days)

l Internal defibrillators after placement incision heals (>30-days)

l VP shunts after placement incision heals (>30-days)

l Debridement of a pre-existing wound or ulcer

l Non-integumentary surgeries

l Surgery to the mucosal membranes

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OASIS Surgical Wounds Not OASIS Surgical Wounds

l Internal defibrillators until placement incision heals (30-days)

l VP shunts until placement incision heals (30-days)

l Skin graft donor site

l Placement of a skin graft to a pre-existing wound or ulcer

l Muscle flap, skin advancement flap

l "Take-down" procedure of a previous bowel ostomy

l Ostomy reversal incision

l Surgical procedure performed via arthroscopy

l Surgical incision used to insert “Mammosite” balloon catheter

l Incision or “cut-down” created for a procedure via a femoral sheath

l Gynecological surgical procedure via a vaginal approach

l All ostomies, including the insertion incisions (Examples: gastrostomy, colostomy, cystostomy, jejunostomy, ileostomy, thoracostomy, urostomy, tracheostomy, etc.)

l Chest tubes

l Puncture sites unless a drain is in place (Examples: cardiac catheterization, thoracentesis, paracentesis, kyphoplasty, arthrocentesis, etc.)

l Simple incision and drainage (I&D), unless the procedure becomes more invasive (e.g., removal of necrotic mass)

l Traumatic wounds that are sutured, unless more extensive surgery is associated with the closure

l Enterocutaneous fistula

l Simple excision of a toenail

l Callus removal

l Pressure ulcer closed with sutures

l Piercing or tattoo removal

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Best Practices for Coding GG Items

The following best practices should be used when assessing the activities within GG0130 – Self-Care and GG0170 – Mobility.

Direct observation of demonstration of ability produces the most accurate results.

If you can’t observe a demonstration of ability, attempt to obtain reports from others (i.e., patient, caregiver, other clinicians, physician, etc.)

Determine the patient’s safe ability. If the patient can perform the activity independently but is unsafe doing it, the activity should be coded as if the patient is unable to perform the activity or requires assistance.

Determine the amount of helper assistance required and code according to the amount of assistance needed for safe performance of the activity.

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If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual ability” or what is true greater than 50% of the assessment time frame, unless the item specifies differently.

Activities may be completed with or without assistive device(s). Use of assistive device(s) to complete an activity should not affect coding of the activity.

In situations where the patient’s ability varies between the listed GG activities, group all activities together and code based on patient’s ability considering all activities together.

Consider the patient’s ability during the assessment timeframe. The assessment timeframe for the GG items is the maximum number of days within which to complete the specific comprehensive assessment.

l SOC: 5 days after the first billable visit or start of care date. l ROC: within 2 calendar days of the facility discharge, knowledge

of the discharge, or the resumption of care date requested by the physician.

l Recertification: the last 5 days of every 60-day episode. l Discharge: the last five days the agency provided visits.

Although the assessment of each activity may take place during the assessment timeframe, a functional assessment should occur at or soon after the patient’s SOC/ROC, before therapy services have been started.

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Observe the patient in different locations and circumstances within the home to obtain the most accurate comprehensive understanding of the patient’s functional status.

At SOC/ROC, the discharge goal may be coded the same as SOC/ROC performance, higher than SOC/ROC performance or lower than SOC/ROC performance. An activity not attempted code may also be entered.

A dash is a valid response for the performance score, as well as the discharge goal score. If a performance item is skipped based on skip instructions, a score may be entered for the associated discharge goal.

If the patient is independent in performing an activity but requires assistance to obtain an assistive device or to set up supplies or other items to perform the activity, code the patient as 05. Setup or clean-up assistance.

The patient should be assessed for the ability to put on whatever clothing is routinely worn (defined as what the patient usually wears and will continue to wear or what is expected to become the patient's new routine clothing). If the patient modifies the clothing that is worn due to a physical impairment, the modified clothing should be considered routine only if there is no reasonable expectation that the patient could return to the previous style of dressing. There is no specified timeframe at which the modified clothing style will become routine. Clinical judgment should be used.

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When determining the best code between 09. Not applicable versus 88. Not attempted due to medical conditions or safety concerns or 10. Not attempted due to environmental limitations in a patient who is unable to perform an activity, consider whether the patient could perform the activity prior to the current illness, exacerbation or injury. If the patient was not able to perform the activity (with or without assistance) and is still unable to perform the activity, code 09. Not applicable. If the patient could perform the activity prior to the current illness, exacerbation or injury and is now not able to perform the activity, code 88. Not attempted due to medical conditions or safety concerns or 10. Not attempted due to environmental limitations depending on the reason the activity cannot be performed.

In any situation that two helpers are needed for a patient to perform an activity safely, the patient should be coded as 01. Dependent, regardless the patient’s ability.

When assessing activities for GG0130 – Self-Care and GG0170 - Mobility, if the activity cannot be assessed because the patient does not have the necessary environment (e.g., car or flight of stairs), clinicians should first attempt to identify the patient's ability based on assessment of similar activities or from patient or caregiver report. If the assessment is still unable to be made, a code of 10 – Not attempted due to environmental limitations should be entered.

Item-Specific Guidance

For GG0130 Self-Care A. Eating, assistance with tube feedings and TPN are not considered when coding the activity. If the patient eats and drinks by mouth and relies partially on obtaining nutrition and liquids via tube feedings or TPN, code eating based on the amount of assistance the patient requires to eat and drink by mouth.

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For GG0130 Self-Care B. Oral Hygiene, if the patient does not perform oral hygiene during home visit, determine the patient’s abilities based on the patient’s performance of similar activities during the assessment, or on patient and/or caregiver report.

When assessing GG0130 Self-Care E. Shower/bathe self, the patient should be assessed performing the activity at whatever location that the task can be performed by the patient, including in the shower, tub, sitting in a chair or standing in front of the sink.

Items that cover the foot and the lower leg (like socks) should only be coded for H. Putting on/taking off footwear and not for G. Lower body dressing.

For GG0170 Mobility A. Roll Left and Right, B. Sit to lying, and C. Lying to sitting on side of bed, while it is acceptable for the head to be raised slightly, the patient must be able to lie in a mostly flat position to be coded as able to perform the activity.

GG0170 C. Lying to Sitting on Side of Bed assesses the patient’s ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor without back support. While a stool or prop can be used if the patient’s feet do not touch the floor, if the patient can independently and safely sit on the side of the bed with no back support, and the feet do not touch the floor, the patient can be scored as a 06. Independent.

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For GG0170 D. Sit to stand, a reclining lift-chair would be considered an assistive device. If a patient can move from a sitting position to a standing position independently with the user of the lift-chair, the patient would be coded at 06. Independent.

When assessing GG0170 Mobility F. Toilet transfer and GG0170 G. Car transfer, the patient is assessed for the ability to transfer on and off the toilet or in and out of the passenger side of the care. Getting to and from the place where the activity is performed is not included.

For the activity of ambulating 50 feet with two turns in GG0170 J. Walk 50 feet with two turns, the turns can occur at any time during the 50-foot walk.

For GG0170 M. 1 step (curb), N. 4 steps, and O. 12 steps, clinicians should assess the patient's ability to go up and down the stairs, by any safe means, with or without portable assistive devices and/or with or without some level of assistance. Portable assistive devices are those that are moveable. Examples include canes and walkers or a wheelchair used to go up and down a curb. Patients may also propel themselves by scooting up and down the stairs on their bottom, as long as the activity is performed safely. Nonportable assistive devices, such as a stair lift with a track attached to the wall or an elevator, would not be considered "completing the stair activity."

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When is a Fall a Fall for J1800 and J1900?

(J1800) Any Falls Since SOC/ROC and (J1900) Number of Falls Since SOC/ROC ask about the presence of any falls since the most recent SOC/ROC and the number and level of injuries resulting from any sustained falls. It is completed at Transfer (RFA 6 and 7), Death at Home (RFA 8), and Discharge (RFA 9). This job aid defines falls as captured in these items and reviews how to determine the level of injury resulting from one or more falls.

What is a Fall

A fall is defined as any unintentional change in position coming to rest on the ground, floor, or onto the next lower surface, such as a bed or chair.

The fall may be witnessed or unwitnessed, reported by the patient or an observer, identified when a patient is found on the floor or ground, or from a review of the home health clinical record, incident reports, fall logs, and other relevant clinical documentation. The fall can occur in the home or at any other location.

Two Types of Falls Counted for J1800 and J1900

Actual Fall

The person falls to the floor, ground, or a lower surface, such as a bed or chair.

Intercepted Fall

The person would have fallen if he or she had not caught him or herself or had not been intercepted by another person.

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Two Types of Falls NOT Counted for J1800 and J1900

Reporting the Level of Injury from One or More Falls

Once it’s determined in J1800 that the patient had one or more “qualifying” falls since SOC/ROC, clinicians then report the level of injury for each fall. The levels of injury are:

No Injury:

Not a Major Injury:

Person Falls from External Force

The person falls as the result of an overwhelming external force, such as a person being pushed by another person or pushed by an external force like a door.

Challenged Intercepted Fall

The person has an intercepted fall while his or her balance is being challenged as the result of an intentional therapeutic intervention (i.e., therapy balance exercise).

l No evidence of any injury noted on physical assessment by the nurse or primary care clinician

l No complaints of pain or injury by the patient

l No changes in the patient’s behavior as noted after the fall

Examples include:

l Skin tears

l Abrasions

l Lacerations

l Superficial bruises

l Hematomas and sprains

l Reports of pain (without major injury)

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Major Injury:

For J1900:

l Each row should receive a number of 0, 1 or 2. Two is coded for 2 or more falls.

l Each fall should be coded only once, even if the patient sustained both less than major and major injuries.

l If the patient has multiple injuries in a single fall, the clinician should code the fall for the highest level of injury.

Examples include:

l Bone fractures

l Joint dislocations

l Closed head injuries with altered consciousness

l Subdural hematoma

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