Therapy Need and Plan of Care

Therapy Need and Plan of Care
OASIS-C Therapy Need and Plan of Care Contact: Cindy Skogen, RN (OEC) , or for questions. Source: Center for Medicare and Medicaid Services Therapy Need and Plan of Care

M2200 Therapy Need (M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech- language pathology visits combined)? (Enter zero [ “000” ] if no therapy visits indicated.) (__ __ __) Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined). ⃞ NA - Not Applicable: No case mix group defined by this assessment. This item is used in the Medicare PPS payment calculation. Instructions to Class Therapy Need and Plan of Care

M2200 Therapy Need (cont.) Identifies the total number of therapy visits (PT, OT, SLP combined). Planned for the Medicare payment episode for which this assessment will determine the case mix group. Only applies to payers utilizing a payment model based on case mix group assignment. Report a number that is “zero filled and right justified.” For example, 11 visits should be reported as “011.” Therapy Need and Plan of Care

M2200 Therapy Need (cont.) Answer "000" if no therapy services are needed. If the number of visits that will be needed is uncertain, provide your best estimate. For multidisciplinary cases - Nursing and Therapy may collaborate to answer this item correctly PT, OT, and/or SLP are responsible to communicate the number of visits ordered by the physician to the RN completing this item Therapy Need and Plan of Care

M2200 Therapy Need (cont.) When the ROC will act as the Recert because the patient was discharged from the inpatient setting between days 56-60 Total number of therapy visits planned for the upcoming 60-day episode should be reported in M2200 Select “NA” when this assessment will not be used to determine a case mix group for Medicare, or other payers Emphasize that if you select NA, you cannot generate a HHRG. Therapy Need and Plan of Care

M2250 Plan of Care Synopsis Collected at SOC/ROC
(M2250) Plan of Care Synopsis: (Check only one box in each row.) Does the physician-ordered plan of care include the following: This item is used in the calculation of quality measures. Instructions to Class Collected at SOC/ROC Therapy Need and Plan of Care

M2250 Plan of Care Synopsis (cont.)
Identifies if the physician-ordered home health POC incorporates specific best practices “Physician ordered plan of care” means that the patient condition has been discussed and there is agreement as to the POC between HHA staff and the physician Process measure item Best practices included are not necessarily required in the CoPs OAI note – The guidance below is too important to not include on slides…. CMS Q & A – October 2009 M1510, M2002, M2004, M2250, Process Measure Items requiring physician and/or physician designee communication Question 32: Some process measure items refer to providing and/or receiving communication to/from the physician or physician-designee (M2002 & M2004), another refers to the physician or other primary care practitioner (M1510) while another (M2250) includes only the physician. Please define physician-designee and primary care practitioner. Do they include physician extenders, like physician assistants and nurse practitioners? When an item refers to “physician-ordered”, would that include DOs? Answer 32: For process measure items reporting communication to/from the physician or physician-designee, (such as reporting heart failure symptoms for M1510, or communication to report/resolve medication issues for M2002) communication can be directly to/from the physician, or indirectly through physician’s office staff on behalf of the physician, in accordance with the legal scope of practice. For process measure items requiring physician orders, (e.g., M2250 Plan of Care Synopsis), the plan of care/orders must be “physician-ordered” including orders from MDs, Doctors of Osteopathic Medicine (DOs), and Doctors of Podiatric Medicine (DPMs) practicing within their legal scope of practice. M2250 includes only physicians as defined here. Therapy Need and Plan of Care

Specified best practices for the process measures must be physician-ordered and come from: Medical Doctors (MDs) Doctors of Osteopathic Medicine (DOs) Doctors of Podiatric Medicine (DPMs) practicing within their legal scope of practice Therapy Need and Plan of Care

Can answer “Yes” prior to the receipt of signed orders if: Clinical record reflects evidence of communication with the physician to include specified best practice interventions in the POC Assuming all other OASIS information is completed M0090 date becomes the date of the communication with the physician to establish the POC CMS Q & A – January 2010 Question 24: Many of the areas related to M Plan of Care Synopsis follow evidence based practice. Use of fall prevention interventions, instruction in proper foot care for diabetic patients, pressure ulcer prevention education, and ongoing pain assessment/monitoring are all good clinical practices that routinely implement without specific physician’s orders. Are we now required to obtain physician’s orders for these general care practices? Answer 24: It is understood that some of the best practices captured in M2250 includes care that might be routinely provided to a patient without a specific order. For instance, you may be admitting a patient for wound care, and in the process of your assessment, encounter a fall risk, like clutter on the floor. You might resolve the issue through intervention or education, all without obtaining a physician’s order. However, if your agency wants to “get credit” for conducting this fall prevention intervention (by marking “yes” on M2250 (c)), you must have an order for fall prevention interventions. Therapy Need and Plan of Care

What makes the best practice “Not Applicable” Row a – Agency standardized guidance will be used Row b – No diagnosis of diabetes or patient is bilateral amputee Row c – Assessment (informal or formal) reveals no, low, or minimal risk for falls Row d – No diagnosis of depression and Assessment (informal or formal) reveals no symptom of depression Row e – Assessment (informal or formal) reveals no pain of any kind Row f – Assessment (informal or formal) reveals no risk for pressure ulcers Row g – Patient has no pressure ulcers with need for moist wound healing Therapy Need and Plan of Care

Select “No” if the best practice interventions specified in this item are not included in the POC Select "No" when orders for interventions have been requested but not authorized by the end of the comprehensive assessment time period, unless otherwise indicated in row g In this case, the care provider should document rationale in the clinical record Reminder: These POC orders must be in place within the 5-day SOC window and the 2-day ROC window in order to meet the measure definition Therapy Need and Plan of Care

Assessing clinician may choose to wait until after other disciplines have completed their assessments and developed their care plans This does not violate the requirement that the comprehensive assessment be completed by one clinician Must complete within required timeframes Five days for SOC, two days for ROC CMS Q & A from October 2009 M1240 Pain Assessment, M2250 Plan of Care Synopsis, and M2400 Intervention Synopsis Question 12: If I complete my comprehensive assessment late (my M0090 date is 6 days post SOC) and I do a standardized pain assessment on that 6th day, would I report the pain assessment when completing M2250 (and when completing M2400 at Transfer/Discharge) because I did conduct the pain assessment? Answer 12: M2250 and M2400 don’t directly report if the pain assessment was conducted. M2250 reports if the physician-ordered plan of care includes specific interventions (in this case, to monitor and mitigate pain) and should be marked “No” or “Yes”, depending on the presence of the orders, whether or not a formal pain assessment for the related issue was conducted within the assessment timeframe, or conducted at all. M2400 reports if specific interventions (in this case, to monitor and mitigate pain) were BOTH included in the physician-ordered plan of care AND implemented. M2400 should also be marked “No” or “Yes” based on the presence of the orders and documentation of their implementation, whether or not a formal pain assessment for the related issue was conducted within the assessment timeframe, or conducted at all. “NA - Formal assessment did not indicate pain since the last OASIS assessment” may not be selected in this case, since item guidance states that the formal assessment referred to for column d is M1240, Pain Assessment, and that since the pain assessment was conducted after completion of the comprehensive assessment (and outside the assessment timeframe), M1240 should be reported as “0 – No standardized assessment conducted”, and therefore “NA” could not be reported for row d on M2400. Therapy Need and Plan of Care

Example: If the RN identifies fall risk during the SOC comprehensive assessment RN can wait until the PT conducts his/her evaluation and develops the PT care plan to determine if POC includes interventions to prevent fall risk M0090 date should reflect the last date that information was gathered that was necessary for completion of the assessment CMS Q & A – April 2010 Question 38: Please clarify the use of the “NA” response option in M2250 rows c-f, and M2400 rows b-e, specifically when the previous/most recent assessment was a Recert assessment, where items related to pain, pressure ulcers, depression and fall risk assessment are not collected. The Chapter 3 guidance states this: 'For rows b-e, a formal assessment (as defined in the relevant OASIS item M1240, M1300, M1730, and M1910) must have been performed to select "Not Applicable." My question is then if the recert assessment did not contain these fields, am I correct to assume that the answers for each row would be “No”, and not “NA”. Answer 38: When collecting OASIS data at transfer or discharge where the most recent assessment was a recertification, M2400 rows b-e do not necessarily need to be reported at “No” because the formal assessments for pain, pressure ulcers, depression and fall risk are not collected on the Recert assessment. The clinician may have conducted a formal assessment either at the recert time point, or since that time, indicating that the patient was not at risk for falls (or did not have pain, etc.), in which case “NA” might be the appropriate response, depending on all other available information. The following two flowcharts guide M2250 and M2400 decision making: CMS OCCB Q&As – April 2010 ( Page 16 of 20 Therapy Need and Plan of Care

Plan / Intervention Yes Not Applicable No a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings ⃞ 1 ⃞ na Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference ⃞ 0 Instructions to Class Therapy Need and Plan of Care

Row a: Select “Yes” if the physician-ordered POC contains specific clinical parameters relevant to patient's condition that, when exceeded, would indicate that the physician should be contacted The parameters may be ranges and may include temp, pulse, respirations, BP, weight, wound measurements, pain intensity ratings, intake and output measurements, blood sugar levels, or other relevant clinical assessment findings CMS Q & A – January 2010 Question 28: A clinician assesses the patient at SOC and calls the physician with a report and to discuss the POC. The clinician asks if the physician would like a report of abnormal vital signs during the episode and recites the parameters found in the agency’s standardized guidelines. The physician says “Yes” and the order with the parameters are printed on the POC for his signature. Is this considered “patient specific parameters” resulting in a YES response for row a? Answer 28: If the physician agrees that the agency's standardized parameters would meet the needs of this specific patient, they would become patient specific parameters. CMS Q & A – July 2010 Question 22: If we are using standardized agency parameters, do they have to be listed specifically in the plan of care or can the order read “Notify MD of VS as per agency's patient clinical parameter guidelines”? Answer 22: The specific parameters must be included. The physician has to be aware of what he/she is agreeing to and cannot possibly be aware of every home health agencies standardized parameters. Question 23: If we add our agency's standardized parameters to every plan of care for every patient we admit, without first communicating with the physician, we can always answer “Yes” to M2250a - Plan of Care Synopsis, Patient Specific Parameters? Answer 23: No. In order to answer "Yes" to the responses, the plan of care must include patient specific parameters provided/approved by the physician, or inclusion of your agency specific parameters, which the physician has agreed meet the individual needs of this specific patient. As with any physician orders, these must be approved either through verbal or written approval by the physician prior to providing care. If the agency utilizes agency standardized guidelines without specific physician approval and orders, then "NA" should be reported for M2250a. Therapy Need and Plan of Care

Row a: Select “NA” if the physician chooses not to identify patient-specific parameters Agency can mark NA if they choose to use agency guidelines without contacting doctor And The agency will use standardized guidelines that are made accessible to all care team members OAI note – Not completely accurate. Based on 7/10 Q 23. Agency can mark NA if they chose to use agency guidelines without contacting doc. Add when you would say No as last bullet. CMS Q & A – October 2009 Question 40: For row a of M2250, Plan of Care Synopsis, If “NA-Physician has chosen not to establish patient-specific parameters for this patient” is selected, should there be additional documentation in the record specifically stating the physician chose not to establish patient specific parameters for the patient? Answer 40: Selecting response “NA” on M2250a indicates that the physician has chosen not to establish patient-specific parameters for this patient. This implies that the physician was contacted by the agency with a request for patient-specific parameters, and none were given. It would be expected that such communication would be present in the clinical record in the form of a communication note, or otherwise documented in the clinical record. Therapy Need and Plan of Care

Plan / Intervention Yes Not Applicable No b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care ⃞ 1 ⃞ na Patient is not diabetic or is bilateral amputee ⃞ 0 Instructional Guidance Instructions to Class Therapy Need and Plan of Care

Row b: Select “Yes” if the physician-ordered POC contains both orders for a) Monitoring the skin of the patient's lower extremities for evidence of skin lesions AND b) Patient education on proper foot care Select “NA” if the patient does not have a diagnosis of diabetes or is a bilateral amputee Select “No” if the physician-ordered POC contains orders for only one (or none) of the interventions CMS Q & A – July 2010 Question 24: If a patient has Diabetes Insipidus, would the appropriate response be “NA” for M2250b - Plan of Care Synopsis, Diabetic foot care? Answer 24: Yes, “NA” is the appropriate response for a patient that has Diabetes Insipidus, not Diabetes Mellitus. M2250b best practice interventions are intended for patients with Diabetes Mellitus. Therapy Need and Plan of Care

Plan / Intervention Yes Not Applicable No c. Falls prevention interventions ⃞ 1 ⃞ na Patient is not assessed to be at risk for falls ⃞ 0 Instructional Guidance Instructions to Class Therapy Need and Plan of Care

Row c: Select “Yes” if the physician-ordered POC contains specific interventions to reduce the risk of falls Environmental changes and strengthening exercises are examples of possible fall prevention interventions Select “NA” if not at risk for falls, per assessment If best practice is applicable, mark “No” if there are no fall prevention interventions Need to explain that if patient is assessed to be at no, low or minimal risk for falls, you may select NA. Under NA, need to add (formal or informal assessment) Therapy Need and Plan of Care

Plan / Intervention Yes Not Applicable No d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment ⃞ 1 ⃞ na Patient has no diagnosis or symptoms of depression ⃞ 0 Instructional Guidance Instructions to Class Therapy Need and Plan of Care

Row d: Select “Yes” if the physician-ordered POC contains orders for treating depression Interventions for depression may include: New medications Adjustments to already prescribed medications Existing antidepressant medication Referrals to agency resources (e.g., social worker) M2250/M2400 Question 26: Does the inclusion of existing ordered antidepressant medications on the medication profile equate to a "Yes" response to Depression Interventions on M2250 and/or M2400? Answer 26: M2250, Plan of Care Synopsis and M2400, Intervention Synopsis, report whether the physician-ordered plan of care includes depression interventions. The presence of an existing antidepressant medication in the medication profile/plan of care is considered a depression intervention. Therapy Need and Plan of Care

Row d: If the patient is already under physician care for a diagnosis of depression, interventions may include: Monitoring medication effectiveness Teaching regarding the need to take prescribed medications, etc. Select “NA” if the patient has no diagnosis and symptoms of depression Assessment for symptoms could be formal or informal CMS Q & A – January 2010 Question 23: M If the patient has a diagnosis of depression but no symptoms per the standardized tool, can the clinician choose "NA". Answer 23: No. NA is only appropriate if the patient has NO diagnosis of depression AND the clinician completed an assessment that indicated the patient has no symptoms of depression (or does not meet criteria for further evaluation or treatment if a standardized depression screening tool was used). CMS Q & A – October 2010 Question 14: A patient has depressive symptoms as identified by a PHQ-2 score of “4”, but the patient has no diagnosis or current treatment for depression. If the clinician notifies the physician of the depressive symptoms and is instructed to continue to monitor the patient, with no orders for specific treatment, what response would be selected for M2250d? Answer 14: After reporting the patient's status, a physician order to continue to assess for signs of depression could be considered an intervention for depression, and be reported as “Yes” for M2250d. Therapy Need and Plan of Care

Plan / Intervention Yes Not Applicable No e. Intervention(s) to monitor and mitigate pain ⃞ 1 ⃞ na No pain identified ⃞ 0 Instructional Guidance Instructions to Class Therapy Need and Plan of Care

Row e: Select “Yes” if the physician-ordered POC contains interventions to monitor and mitigate pain Medication, massage, visualization, biofeedback, and other intervention approaches have successfully been used to monitor or mitigate pain severity Select “No” if the physician-ordered POC contains orders for only one of the interventions E.g., pain medications but no monitoring plan Select “NA” if no pain was identified after conducting the comprehensive assessment (formal or informal assessment) CMS Q & A October 2010 Question 15: A patient is documented to have chronic arthritic joint pain that interferes with activity at least daily and is taking a pain medication daily as previously ordered. If the clinician only has orders to assess the effectiveness of the current pain medication treatment, is this CMS OCCB Q&As – October 2010 ( Page 5 of 6 CMS OCCB Q&As – October 2010 ( Page 6 of 6 order only an order to MONITOR pain (M2250e “no”), or would this be enough to answer “yes”, that we have an order to both monitor and mitigate pain? Answer 15: An ordered pain medication is considered an intervention to mitigate pain. Assessing for the effectiveness of the pain medication is considered an intervention to monitor pain. If both the pain medication and an order related to pain assessment are included in the physician-ordered plan of care, M2250e would be “Yes”. Therapy Need and Plan of Care

Plan / Intervention Yes Not Applicable No f. Intervention(s) to prevent pressure ulcers ⃞ 1 ⃞ na Patient is not assessed to be at risk for pressure ulcers ⃞ 0 Instructional Guidance Instructions to Class Therapy Need and Plan of Care

Row f: Select “Yes” if the physician-ordered POC includes planned clinical interventions to reduce pressure on bony prominences or other areas of skin at risk for breakdown Planned interventions can include: Teaching on frequent position changes, proper positioning to relieve pressure, careful skin assessment and hygiene, use of pressure-relieving devices such as enhanced mattresses, etc. Select “NA“ if the patient was assessed and found to have no risk for pressure ulcers (formal or informal assessment) OAI note: Need to explain when you would select No. Therapy Need and Plan of Care

M2250 c – f at SOC/ROC Therapy Need and Plan of Care
OAI note – Need to replace this with the new flowchart that Deb Dietz created, then you won’t need the Q&A below. CMS Q & A – July 2010 Question 25: I need clarification about the flowchart included in the April CMS OCCB Q&As Question 38. Can I answer “Yes” to M2250, Plan of Care Synopsis, and M2400, Intervention Synopsis, if the physician-ordered plan of care includes the specified intervention and they were implemented by Transfer/Discharge, even though the assessment revealed no risk? Answer 25: You may answer M2250, Plan of Care Synopsis, "Yes" if the physician-ordered plan of care includes the specified best practice intervention by the end of the allowed assessment time frame. This is true even if the formal or informal assessment revealed no risk. You may answer M Intervention Synopsis, “Yes” at Transfer/Discharge if the physician ordered plan of care includes the specified best practice intervention and there is evidence in the clinical documentation that they were implemented. This is true even if the formal assessments were negative. Therapy Need and Plan of Care

Plan / Intervention Yes Not Applicable No g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician ⃞ 1 ⃞ na Patient has no pressure ulcers with need for moist wound healing ⃞ 0 OAI note: Guidance should be on a slide. Instructions to Class CMS Q & A – April 2010 M2250g; M2400f Question 35: For M2250g - Plan of Care Synopsis and 2400f – Intervention Synopsis, Is a protective skin barrier considered a moist wound treatment for a pressure ulcer? Can you provide specific examples of moist wound healing treatments for pressure ulcers? Answer 35: Moist wound healing treatment is basically any primary dressing that hydrates or delivers moisture to a wound thus promoting an optimal wound environment and includes films, alginates, hydrocolloids, hydrogels, collagen, negative pressure wound therapy, unna boots, medicated creams/ointments. CMS cannot provide you with specific products. Therapy Need and Plan of Care

Row g: Select “Yes” if the physician-ordered POC contains orders for pressure ulcer treatments based on principles of moist wound healing (e.g., moisture retentive dressings) or Such orders have been requested from the physician Select “NA” if the patient has no pressure ulcers needing moist wound healing treatments The physician makes the ultimate decision if moist wound healing is appropriate Therapy Need and Plan of Care

Moist wound healing is basically any primary dressing that hydrates or delivers moisture to a wound thus promoting an optimal wound environment and includes films, alginates, hydrocolloids, hydrogels, collagen, negative pressure wound therapy, unna boots, medicated creams/ointments Therapy Need and Plan of Care

Questions??? E-mail: health.oasis@state.mn.us
Cindy Skogen, RN; Oasis Education Coordinator Therapy Need and Plan of Care

Therapy Need and Plan of Care

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