A Lisa Selman-Holman blog
Question: If a patient has a disrupted wound post c-section, do we do an OASIS assessment?
Lisa says: No, maternity patients are exempted from OASIS. The ONLY time you’d want to complete OASIS on a maternity patient is if Medicare is the payor. In that case, you’d want an HHRG.
To comply with CMS security regulations, CMS is changing the way agencies login to the OASIS Submission System and CASPER Reporting. The change will require agency users to register for a named individual user account ID.
When the security changes are deployed to your state, you will no longer be able to
access the OASIS State Submission System using your state-assigned shared login ID.
You will be required to register for a named individual user ID.
The HHA Individual User Registration link will be added to the OASIS State Welcome
page. The link will be displayed directly above the OASIS Submission link.
It seems that many agencies believe that the SOC OASIS needs to be done by the same clinician who did the first visit, but that’s not true.
The initial assessment does not have to done by the same person who does the comprehensive assessment. Most times, it is the same person because both assessments are completed during the same visit, but the CoPs allow for the initial assessment being performed at a different visit.
Remember that if nursing is involved in the POC, an RN must conduct both assessments. In some instances, it may be a therapy only case, the therapist may complete the initial assessment and the RN may visit on the same day or within five days after the therapist’s visit to complete the comprehensive assessment.
As we start our new code year, we’re always scrambling for education on codes, but what about other subjects, like PPS fundamentals or OASIS best practices or coding and filling out OASIS information on those pressure ulcers?
It’s time for new education in the new year, and I’m offering these in the month of October, in addition to my live education around the country.
PPS Fundamentals, Monday, October 11
Understand the fundamentals of PPS that are essential to agency operations for administrators, quality personnel and coders. This includes information on:
12pm -1:45pm CST
OASIS C Best Practices, Monday, October 18
What is a “best practice”? And what does it mean to your agency? The first quality reports have been released from OASIS C. How did CMS derive the information and how can your agency do better next time? In this education, we will:
12pm -1:45pm CST
Pressure ulcers, coding and OASIS-C, Monday, October 25
Coding pressure ulcers and responding to OASIS data items regarding pressure ulcers are some of the most difficult areas of home health practice. Lisa will lead your staff through the latest guidance on answering OASIS-C regarding pressure ulcers and contrast that with coding guidance. Lisa will:
12pm -1:45pm CST
Correct documentation, and wording in that documentation, are crucial to correct OASIS and coding. Pressure ulcers have very specific wordings, and using the incorrect phrase with a certain stage ulcer can result in rejection or validation errors as you electronically submit your records.
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Here is subject I field many, many questions on: the coding of stage 3 and 4 pressure ulcers.
Question: I recently read that closed pressure ulcers, regardless of stage, should not be coded. Is this true? I thought all Stage 3 & 4 closed pressure ulcers should still be coded.
Lisa says: Stage 3 and 4 pressure ulcers are never considered healed, but they can close. Because there is a strong risk that they will open again, they should be coded in a patient’s episode. If they are open ulcers, they would require much care, so they probably would be listed higher in your coding sequence, but the sequence will always depend on the seriousness of conditions, not just that these are difficult pressure ulcers. If they are closed pressure ulcers, you would probably code them lower, based on the time of care expended vs. the patient’s other needs.
Remember (and never forget) that closed stage 3s and 4s always require active intervention, including assessment and pressure ulcer risk interventions. The tissues lost are replaced by granulation tissue and they are always at risk. Because they should be addressed in the POC, they should be coded.
As for Stage 1 and 2 pressure ulcers: Code them when they are open. When they are closed and evidence of them is gone, they are considered healed, and they should not be coded.
In any case, watch the OASIS: There are nine items that deal with pressure ulcer assessment; be sure to watch all of them.
Looking for references on pressure ulcers? This is the WOCN’s position statement, which is considered official guidance.
CMS has been answering questions regarding dialysis shunts and surgical wound rules. In short, the dialysis shunt is a surgical wound, but the 30 day rule does not apply. It is considered a surgical wound as long as it is in place. Read below for the official information:
Question: M1342 Surgical Wound –implanted venous device: I am confused by one of the CMS OASIS Q&As. The answer to Q105.3 states that an implanted venous device is considered a surgical wound until it has been epithelialized completed for 30 days at which time it becomes a scar. The next sentence of the answer says that the site is considered a surgical wound as long as the device is in place. Can you clarify this?
Answer from CMS: An implanted venous access device is considered a current surgical wound as long as it is implanted in the patient’s body.
When first implanted, the incision is the surgical wound. The assessing clinician will follow the 12/09 WOCN guidance to determine the healing status of the incision. Once it is fully epithelialized, the site due to the implanted device will remain a current surgical wound with a status of “Newly epithelialized” for as long as it is present in the patient’s body, unless it later develops complications. This guidance clarifies and supersedes CMS OASIS Q&A Category 4b, Q105.3.
Are rehabilitation facilities considered inpatient settings? That is the key to answering M1010, M1012 and M1016 correctly if you patient comes from such a facility.
Let’s say a patient is discharged from a hospital on Sept. 1 and goes to a rehab facility and isn’t discharged from their until Sept 24. SOC is Sept. 25.
How should M1010 (inpatient diagnosis), M1012 (inpatient procedures) and M1016 (regimen change) be answered?
The key is to remember that a rehab facility is an inpatient facility (see M1000), so the diagnoses treated there would pertain to M1010 and M1016. Procedures would not be performed at a rehab facility, so M1012 wouldn’t apply.
I receive many, many questions on M1024, OASIS’s payment question. I recently had this one:
Question: I am trying to get some clarification on when to fill in M1024 if a V code is used in place of a case mix. It was my understanding that you would fill in M1024 if a V code was used in the primary spot for an acute or resolved condition or a DM, Neuro or Skin 1 code. You would not fill in M1024 for a V code in the primary spot if the condition was still active and going to be listed in the secondary spots, other than the DM, Neuro or Skin 1 code.
Also what about V codes in the secondary spots, do we need to fill in M1024?
Lisa says: Remember that M1024 was created as a payment slot for when V codes replace diagnosis codes. This way, the patient’s condition is fully represented. M1020 and M1022 deal with active diagnoses. M1024 is mainly for resolved diagnoses, but CMS has made a few exceptions to this general rule.
The OASIS manual offers a lot of guidance on when to use M1024, and it boils down to these situations:
• When a V code replaces a resolved case mix condition that is the reason the V code is placed in M1020 or M1022.
• When a V code replaces a fracture. Fractures are acute diagnoses, so they are not allowed in M1020 and M1022, per official coding guidelines. We can place them in M1024.
• Use M1024 when a V code in M1020 replaces a diagnosis from the Diabetes, Skin 1 and Neuro 1 case mix categories, regardless of active or resolved status. These three case mix categories are the only ones that receive different case mix points based on whether they are coded primary or secondary. CMS has allowed coding of active conditions in M1024 in these very specific conditions. Still code these three categories in M1022 when active.
If a diagnosis code is active, and therefore eligible for coding in M1022, it cannot be listed in any M1024 slot, with the exception of the three categories listed above.
Yes, you should fill out M1024 in secondary slots, as long as the etiology is for a different underlying, resolved condition than a diagnosis listed in another M1024 slot. For example, if resolved breast cancer is the reason for V codes in M1020 and M1022, don’t put 174.9, the breast cancer code, in both M1024 slots. You have already represented the disease in the M1024 slot across from M1020. Don’t put it across from an M1022 slot, as well. If you code multiple V codes and each has a different etiology, certainly list each across from the appropriate V code. Only case mix codes are eligible for M1024, but there is more than case mix at play: risk adjustment can also be recognized in M1024 slot.
Remember: Only case mix codes are eligible for M1024.
Keep in mind this compliance issue: All M1024 and resolved conditions must be on the plan of care, even though M1024 is not part of the claim. There is no “official” or “right” place to put these conditions, but Locator 21 is an often-used documentation spot.
Question: People were overusing 781.2, and then the criteria changed on how to capture case mix points: You also needed and ulcer and/or IV therapy. Is this still the criteria?
Lisa says: The criteria haven’t changed since January 2008. Abnormality of gait is still case mix, but does not receive points unless the patient also has a pressure ulcer, it’s an early episode and there are less than 14 therapy visits. (See row 19 of CMS’s Table 4 for the official cite.)
Infusion therapy has never been part of the criteria for 781.2. Always remember that you code for medical necessity and services provided, NOT case mix.
