1. Clinical Record Issues
OASIS-C
Clinical Record Issues
Contact: Cindy Skogen, RN (OEC)
, or
for questions.
Source: Center for Medicare and Medicaid Services
Clinical Record Issues

2. M0080 Discipline of Person Completing Assessment
1-RN 2-PT 3-SLP/ST OT
Only one individual completes the comprehensive assessment:
- If more than one discipline involved in case
Care consultation/coordination is needed
But only one actually completes &records assessment
Clinical Record Issues

3. M0080 discipline of Person Completing Assessment (cont.)
RN & PT/SLP ordered at initial referral, the RN must complete SOC comprehensive assessment
LPN’s, PTAs, COTAs, MSWs, & HHAs not authorized to complete comp assessments
Last qualified clinician to see patient at DC completes the DC assessment
Clinical Record Issues

4. M0090 Date Assessment Completed
_ _/_ _/ _ _ _ _
Month/date/year
Actual date the assessment is completed
M0090 cannot be before the SOC date
If agency policy allows assessments to be completed over more than one visit date – M0090 =the last date-when the final assessment data is collected
Clinical Record Issues

5. M0090 Date Assessment Completed (cont.)
Record date data collection completed after learning of event:
-Transfer to Inpatient Facility; no agency DC
-Transfer to Inpatient Facility: patient DC from agency
-Death at home
A visit is not necessarily associated with these events
Clinical Record Issues

6. Clinical Record Issues
M0100
(M0100) This assessment is Currently Being Completed for the Following Reason:
Start/resumption of Care
1-/start of care-further visits planned
3-Resumption of Care (after inpatient stay)
Follow up
4-Recertification (follow up) reassessment {Go to M0110}
5-Other follow-up {Go to M0110}
Transfer to an Inpatient Facility
6-Transferred to an inpatient facility-pt not DC from agency {Go to M1040}
7-Transferred to an inpatient facility-pt DC from agency {Go to M1040}
Discharged from Agency-Not to an Inpatient facility
8-Death at home {Go to M0903}
9-DC from agency {Go to M1040}
Clinical Record Issues

7. Clinical Record Issues
M0100 (cont.)
Start/resumption of care
1-Start of Care-further visits planned
3-Resumption of care (after inpatient stay)
Follow-Up
4-Recertification (follow-up) reassessment [Go to M0110]
5-Other follow-up [Go to M0110]
Clinical Record Issues

8. Clinical Record Issues
M0100 (cont.)
Transfer to Inpatient Facility
6-Transferred to an inpatient facility-pt not discharged from agency [Go to M1040]
7-Transferred to an inpatient facility-pt d/c from agency [Go to M1040]
Discharge from Agency-Not to an Inpatient Facility
8-Death at home [Go to M0903]
9-Discharged from agency [Go to M1040]
Clinical Record Issues

9. Clinical Record Issues
M0100 (cont.)
Assessment/data collection time points
Reason why the assessment data are being collected and reported
-reason for assessment (RFA)
Data reporting software accepts or rejects certain data based pm the M0100 response
-Accuracy critical
Clinical Record Issues

10. Clinical Record Issues
RFA 1: Start of Care
Must be conducted during a home visit
Comprehensive assessment completed when the POC established
-Whether or not further visit will be provided after the SOC visit
-Appropriate response anytime a HHRG is required
Clinical Record Issues

11. Clinical Record Issues
RFA 3: ROC
Must be conducted during a home visit
Resumption of care (ROC) comprehensive assessment
Performed when resuming care of patient
-following inpatient stay of 24 hrs. or longer
-for reasons other than diagnostic testing
Clinical Record Issues

12. Clinical Record Issues
RFA 3: ROC (cont.)
If resuming care during last 5 days of the episode following inpatient discharge
-Perform ROC not a Recertification (RFA 4)
Answer payment questions as if Recert
-This assessment establishes payment code for next 60-day episode
Clinical Record Issues

13. Clinical Record Issues
RFA 4: Recertification
Must be conducted during a home visit
Comprehensive assessment during last 5 days of the 60-day cert period
-Need to continue services for additional 60-day episode of care
If HHA misses recert window
-Make a visit as soon as possible
-Explain in clinical documentation
Clinical Record Issues

14. Clinical Record Issues
RFA 5: Other Follow-up
Must be conducted during a home visit
Comprehensive assessment due to a major decline or improvement in health status
-At any time other than during the last 5 days
-HHA should have policy
Reevaluation of patient’s condition
-Allowing revision of POC, as appropriate
Clinical Record Issues

15. Clinical Record Issues
RFA 6: Transfer; No DC
Data collection completed when:
-Admitted to inpatient facility bed for 24 hrs or more
-For reasons other than diagnostic test
Exception that home care will be resumed following discharge from facility
Clinical Record Issues

16. RFA 6: Transfer; No DC (cont.)
Short stay observation periods in a hospital do not count as a transfer
-regardless of duration
Not a comprehensive assessment-does not require a home visit
-May gather information via telephone
If hospitalization discovered during home visit, need transfer (RFA 6) and ROC
Clinical Record Issues

17. Clinical Record Issues
RFA 7: Transfer & DC
Data collection completed when:
-Admitted to inpatient facility bed for 24 hrs or more
-For reasons other than diagnostic test
No plan to resume care of patient
No additional OASIS DC data required
Short stay observation periods in a hospital do not count as a Transfer
-Regardless of duration
Clinical Record Issues

18. RFA 7: Transfer & DC (cont.)
Also completed when patient dies:
-In ER
-In inpatient bed before stay of 24 hours
(M0906 guidance)
Clinical Record Issues

19. Clinical Record Issues
RFA 8: Death at Home
Data collection-not assessment
Patient dies before being treated in an ER or before being admitted to an inpatient facility
Clinical Record Issues

20. Clinical Record Issues
RFA 9: Discharge
Comprehensive assessment when patient discharged from agency
-For reasons other than death or transfer to inpatient facility
-An actual patient interaction, a visit, is required
Complete when you transfer and discharge to another HHA or an in-home hospice
Clinical Record Issues

21. Unplanned or Unexpected Discharge
If discharge is unplanned, requirement must still be met
Discharge assessment must report patient status at an actual visit
Assessment data should be based on the last visit conducted by a qualified clinician
Clinical Record Issues

22. Clinical Record Issues
M0102
(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified.
_ _/_ _/ _ _ _ _
Month/date/year
{Go to M0110, if date entered}
NA – No specific SOC date ordered by physician
Clinical Record Issues

23. Clinical Record Issues
M0102 (cont.)
Date of physician-ordered SOC/ROC
-If MD indicated a specific date on referral
-If date entered, skip M0104 Date of referral and go to M0110 Episode Timing
-Mark NA: If initial orders do not specify a SOC date
If the originally ordered SOC is delayed for any reason
-Report the date on the updated or revised order
Clinical Record Issues

24. Clinical Record Issues
M102 (cont.)
Referral from a facility is made on behalf of the physician and is considered for M0102
Date must be specific, not ranges (i.e., 1-2 days following hospitalization)
Clinical Record Issues

25. Clinical Record Issues
M0104
(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.
_ _/_ _/_ _ _ _
Month/day/year
Clinical Record Issues

26. Clinical Record Issues
M0104: Date of Referral
Most recent date verbal, written or electronic authorization to begin care was received by HHA
If SOC is delayed for any reason, driven by patient’s condition of MD request
-Report the date HHA received updated/revised referral information
Does not refer to calls from ALF or family preparing HHA for possible admission
Clinical Record Issues

27. Clinical Record Issues
M0110
(M0110) Episode Timing: Is the Medicare home health payment episode fro which this assessment will define a case mix group an “early” episode of a “later” episode in the patient’s current sequence of adjacent Medicare home health payment episodes?
early
later
UK -unknown
NA -Not applicable: No Medicare case mix group to be defined by this assessment
Clinical Record Issues

28. Clinical Record Issues
M0110: Episode Timing
PPS payment item
-Also used by non-PPS payers using a PPS-like payment model
Identifies placement of the current MC payment episode in the patient’s current sequence of adjacent MC PPS payment episodes
Clinical Record Issues

29. M0110: Episode Timing (cont.)
Sequence of adjacent MC PPS payment episodes = a continuous series of MC PPS payment episodes
-Regardless of whether the same HHA provided care for the entire series
-Low utilization payment adjustment (LUPA) episodes (less than 5 total visits) and Partial Episode Payments (PEP) included
-Denied episodes are not included
Clinical Record Issues

30. M0110: Episode Timing (cont.)
Adjacent means there was no gap between MC-covered episodes of more than 60 days
-care under HMO, MA or private payer = gap days when counting the sequence of MC episodes
Clinical Record Issues

31. M0110: Episode timing (cont.)
“1-Early” selected if this is:
-The only PPS episode in a single episode case Or
-The first or second PPS episode in a sequence of adjacent MC home health PPS payment episodes
Clinical Record Issues

32. M0110: Episode Timing (cont.)
“2-Later” selected if this is:
-The third or later PPS episode in a current sequence of adjacent Medicare home health PPS payment episodes
“UK – Unknown” selected if:
-The placement of this PPA payment episode in the sequence of adjacent episodes is unknown
-For payment, this will have the same effect as selecting the “Early” response
Clinical Record Issues

33. M0110: Episode Timing (cont.)
Enter “NA” if no Medicare case mix group is to be defined for this episode
If you select “NA” you cannot generate the PPS payment code (HIPPS/HHRG)
Some non-MC payers will use this information in setting an episode payment rate
Clinical Record Issues

34. Counting Days Manually
An MC payment episode ordinarily comprises 60 days beginning with SOC date, or 60 days beginning with recertification date
There can be a gap of up to 60 days between episodes in the same sequence
To determine if adjacent count from the last day of one payment episode (Day 0) until the first day of the next
If you count 60 or less = adjacent episode
Clinical Record Issues

35. Counting Days Manually (cont.)
A sequence of adjacent MC payment episodes continues as long as there is no 60-day gap, even if MC episodes are provided by different home health agencies
Episodes with HMO’s, Medicaid, or private payers do not count as part of a sequence-they are part of the gap between PPS episodes
If the period of service with those payers is 60 days or more, the next MC home health payment episode would begin a new sequence
Clinical Record Issues

36. Clinical Record Issues
Questions???
Cindy Skogen, RN;
Oasis Education Coordinator
Clinical Record Issues