A Lisa Selman-Holman blog
Dear Lisa: We are receiving many referral from hospitals that the patient was listed as “observation only.” How do we mark M1000?
Lisa says: Your answer depends on whether the observation was inpatient or outpatient observation. If the patient was inpatient observation then the patient was discharged from a facility. If the patient was billed as outpatient, then it does not count as an inpatient facility discharge.
CMS addresses valid risk of falls tools and M1910 …
Question: We see that a validation study has been published for the Missouri Alliance for Home Care’s Fall Risk Assessment Tool (MAHC-10). Does this mean that we can now use that tool as the single standardized, validated, multifactor tool to meet the “Yes” response for M1910? And if so, should the threshold of “4” or “6” be used to indicate fall risk?
Answer from CMS: Per existing guidance, if you want to report M1910 as “Yes” (that Fall Risk Assessment was conducted), you must use a multifactor standardized tool that has been scientifically tested and validated, and the tool must be appropriately administered based on established instructions. CMS does not approve or disapprove individual tools.
It is the agency’s responsibility to determine if the tool you are using includes these elements. If an agency has evidence (from published literature, the tool developer, or another authoritative source) that the tool they are using assesses multiple factors that contribute to the risk of falling, has been scientifically tested and validated on a population with characteristics similar to that of the patient being assessed, and shown to be effective in identifying people at risk for falls, and includes a standardized response scale, then the agency can consider the tool to meet the requirements for the OASIS-C best practice assessment.
In determining if a patient is at risk for falls, the standardized tool should have a standardized response scale, and/or established and validated threshold at which fall risk exists. A tool may have multiple thresholds identifying various levels of risk (i.e, “no risk”, “low risk”, “high risk”). Select Response 1 if the standardized response scale rates the patient as no-risk, low-risk, or minimal risk. Select Response 2 if the standardized response scale rates the patient as anything above low/minimal risk. If the tool does not provide various levels, but simply has a single threshold separating those “at risk” from those “not at risk”, then patients scoring “at risk” should be reported as Response 2.
There’s a lot of hype about the world ending in 2012. I don’t believe that, but it reminds me of an REM song & M1024—“It’s The End of the World as We Know It.”
Why? M1024 and its predecessors, M0245 and M0246 have been a part of our home health coding world since 2003 when we started using V codes in our coding. Medicare’s final rule for PPS 2013 limits the use of M1024 to only one particular instance for payment diagnoses beginning Jan. 1, and the plan is to decimate it all together once ICD-10-CM is ushered in Oct. 1, 2014. I applaud deleting M1024 from the OASIS, but I desire a different outcome with the remnants of M1024.
M1024 will be used for fractures only beginning in January. Medicare, in a surprise move, stated that resolved conditions do not belong in M1024 and we shouldn’t have been earning points there. CMS reports that the change will be minimal to our case mix scoring, however other sources report that as many as 60% of our assessments include resolved case mix diagnoses in M1024—that will mean a drop in our payment.
We can still get primary points for diabetes, Neuro 1 and Skin 1 case mix diagnoses if we sequence correctly without using M1024 according to Medicare’s grouper change. But, there is one frequently used method for coding that can mean the end of those points if coders are not careful (less points = less money for those who need it spelled out).
I have a short recording on the change to M1024 that will be posted on my website soon and do not miss the opportunity for more in-depth instruction on the change and its impact in upcoming classes in Dallas and Corpus Christi in December. Check my website for details.
So, it’s the end of the world as we know it. It remains to be seen if we’ll “feel fine.”
A clarification from CMS on M1018 and nephrostomy tubes …
Question: When answering M1018, if client has a nephrostomy tube do you mark indwelling/suprapubic catheter?
Answer from CMS: If the nephrostomy tube is utilized for urinary drainage, it is an indwelling
catheter, therefore Response 2 – Indwelling/suprapubic catheter would be selected.
See more Q&As.
CMS has clarified some new Q&As. This one deals with hospitalization at the end of an episode.
What OASIS is required when a patient returns home on day 61, in a situation where the patient was admitted to the hospital before or during day 56-60 recert window, is in an inpatient bed longer than 24 hours, but only for diagnostic testing; No Transfer OASIS had been completed?
Answer from CMS: Treat this situation as a missed recertificatior and complete the
recertification as soon as possible after the patient’s return home.
See more Q&As
Question: If a M2250 question is answered N/A on the SOC or ROC, would M2400 on the transfer or DCO automatically be N/A as well?
For example: M2250 (E) pain was answered N/A on the SOC because no pain was identified. Then sometime during the episode the patient fell and now has pain in the Rt knee r/t the fall. The patient is placed on a pain medication for the acute pain. The nurse identifies the need for pain interventions to monitor and mitigate the pain. The nurse uses a standardized pain assessment tool to rate the pain, writes a verbal order to add pain interventions to the POC, and implements the interventions. At the discharge OASIS, would M2400 (D) be answered N/A because no other OASIS was performed since the SOC and on the SOC the POC synopsis (E) was N/A OR since the nurse addressed the pain by assessing the patient’s pain with the standardized tool, wrote the VO to include the interventions in the POC and implemented them, could she answer #1 on M2400 ?
Lisa says: Intermittent verbal orders count as well, so if you get an order for assessment and intervention sometime in the episode and the interventions are completed as you described in your scenario, then the answer is ‘yes’ on the discharge.
Formal assessment does mean the standardized and/or validated tools contained in those specific M items you mentioned. The trick is that if the last assessment done was the recert, those M items are not part of the recert. However, N/A cannot apply if no formal assessments were done, so when discharging and the last OASIS was a recert the answer has to be either yes or no.
Question: We have a patient that did not get a face-to-face until after the 30-day mark after SOC. I know I can go 30 days prior to when the face-to-face took place. When I count back, the patient was seen by a therapist that day but was not seen by a skilled nurse until several days later. Do I have to have the clinician do an OASIS/485 for the date she saw? The specifics:
HH original SOC 6/29
Face to Face encounter 8/9
Possible new SOC 7/11 (30 days prior to 8/9)
SN saw 7/9, therapy saw 7/11, SN saw 7/20
Do all consent forms need to be redated to new SOC date as well? New 485, new OASIS?
Lisa says: Your new SOC should be generated based on a date of 7/11 (30 days back from F2F was 7/11). 7/11 is chosen because it is the first eligible date and the first billable visit was made. Medicare doesn’t care who made the visit as long as it was billable.
To generate a new SOC assessment, any qualified clinician can sit down with the old SOC and complete the new one based on the same answers with updates to M0110 and M2200. A new 485 will need to completed with updated orders to reflect the 60 days beginning with 7/11 as the “from” date. M0090 will be the actual date that the new SOC is generated so you will receive late warnings.
Medicare does not speak to new consents, but I suggest you at least have some kind of communication with the patient in the interest of patient rights. This could get signed at the next visit. For example:
Dear {Patient},
A visit with your physician within a certain time frame when beginning care with a home health agency is a condition of payment for the home health agency. Because you did not see your physician until {date}, we have a new start of care date for you and the care previous to the date is non-covered by Medicare. (You are not responsible for payment.)
We will continue to provide you care under the previous consent forms signed by you or your representative. Please sign this letter to indicate your receipt of this information.
Regards.
Administrator Signature Patient Signature
CMS has clarified some behaviors that should make you mark a ’1′ on M2020. This is from the recent April Q&As.
Question: I have a patient who has macular degeneration with partial vision loss. Her son writes big letters on her medication bottles so the patient is able to correctly identify the medications. How should M2020 be correctly marked?
Answer: If the patient requires the assistance of someone, other than the pharmacy, to set-up the medications in order to take the correct dose, at all the prescribed times, the patient would be scored a “1″ on M2020, Management of Oral Medications. Set-up could include placing the medications in a medi-planner or other container or device or modifying the original medication container to enable the patient to access their medications correctly, e.g. removing childproof lids, marking the label for the visually impaired or illiterate, or pouring into individual cups.
CMS’s April answers document includes 10 questions on late F2F issues that have been brewing.
Some highlights include:
p.s. No new guidance on M1020, M1022, M1024
I don’t know why I’ve had people ask me lately if you can reverse pressure ulcer stages for Stage I and II ulcers, but you can’t, and CMS has clarified M1324 in a recent Q&A.
CMS also clarified an M1307 question dealing with a pressure ulcer that progressed from Stage I to Stage II during the episode:
Question: If the patient had a Stage I pressure ulcer at SOC that progressed to a Stage II, how do we answer M1307 at discharge?
CMS Answer: If a patient had a Stage I pressure ulcer at SOC/ROC and it advanced to a Stage II by discharge, Response “1-Was present at the most recent SOC/ROC assessment” would be appropriate due to the fact that the ulcer, caused by pressure, was present at the most recent SOC/ROC assessment, even though it was a Stage I at that time.
