You can’t assess what you can’t see!

Guest Blogger-Brandi Whitemyer, RN, HCS-D, HCS-O, COS-C, AHIMA Approved ICD-10-CM Trainer/Ambassador, Senior Associate

 

You can’t assess what you can’t see!

When assessing your patients, its important to remember that you can’t assess what isn’t there! For example, how often is it that you arrive to perform a start of care or resumption of care assessment and your patient has yet to pick up their medications from the pharmacy? Every home health clinician knows the line, “I have the scripts, I just don’t have all of them yet”, or, “I can’t afford those until Tuesday.” But how do you assess a patient’s ability to take all of their medications safely and reliably all of the time, when they only have some of their medications?

 

Well, CMS says you can’t! M2020, Management of Oral Medications, is an OASIS item frequently missed by clinicians due to a simple misunderstanding of OASIS-C guidance. Here is what CMS has to say (Q& A- January, 2011):

 

Question: If the patient does not have her prescribed medications in the home because she cannot afford them and she does not plan on getting them, what is the most appropriate response for M2020?

Answer: When completing M2020, Management of Oral Medications, you are reporting the patient’s ability to take all oral medications reliably and safely at all times on the day of the assessment. If the patient did not take her medications on the day of the assessment because they were not present in the home, you cannot make assumptions about a patient’s ability to take medications she doesn’t have. If the medications were not in the home, you would not be able to determine if she could take each medication at the correct time and dose. The patient’s status would be reported as “3-Unable to take medications unless administered by another person”.

So, if your patient does not have the ordered medications in the home, you as the assessing clinician, obviously cannot make any judgment as to how the patient is able to take his or her medications safely and reliably at all times and must respond “3.” Just keep in mind that patient compliance and willingness does not get taken into consideration. If your patient does not have his or her medications because he or she has no intention of taking them or refuses to pick them up because he or she does not ever take them, then you would not consider this in your response.

Similarly, when responding to OASIS items such as M1860 (Ambulation/Locomotion), if the patient is determined to only ambulate safely with the assistance of a device, but does not have any assistive device in the home (note: holding onto walls and furniture does not count as “assistive device” when assessing!), then you will need to respond “3” (“able to walk only with the supervision or assistance of another person at all times”) to M1860, Ambulation/Locomotion, (CMS Q& As Cat. 4b-Q155.1) Again, you cannot determine the patient’s safe ability to use a device that he or she does not have!

Selman-Holman & Associates, LLC and CoDR—Coding Done Right provides customized education for your agency on OASIS issues, as well as OASIS review. Call us at 214-550-1477 or send an email to QandA@selmanholman.com

Guest Blogger: Brandi Whitemyer, RN, HCS-D, HCS-O, COS-C, AHIMA Approved ICD-10-CM Trainer/Ambassador, Senior Associate

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