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n the last issue, we discussed the use of Outcome and Assessment Information Set (OASIS) data in the survey process. In November 2003, the home health industry will see another use of its OASIS data with the publication in newspapers and on a Centers for Medicare and Medicaid Services (CMS) home health website of how home health agencies in each community compare to others in their local market and to the national averages. The purpose of publishing these comparisons is to give the consumer a means to compare the quality of care provided by all the home health agencies in their community and to motivate the agencies to improve the quality of care they provide.
       This process began in October 2002 when CMS convened a technical expert panel to review the OASIS outcomes data and to recommend indicators for comparison and publication. The technical expert panel consisted of 18 representatives and included home health agency representatives, clinicians (nurses and physicians), consumer reporting experts, a consumer group organization, a quality improvement organization, state survey agencies, researchers, and an epidemiologist.
       Taking the panel's recommendations into consideration, CMS announced the chosen indicators earlier this year:
- Improvement in dressing upper body*
- Improvement in bathing*
- Improvement in confusion frequency*
- Improvement in management of oral medications*
- Improvement in ambulation/locomotion*
- Improvement in toileting
- Improvement in transferring*
- Improvement in pain interfering with activity*
- Stabilization in bathing
- Any emergent care provided
- Acute care hospitalization*
* These indicators will also be evaluated during the survey process.
       The community's first exposure to this information came in May when the data was made public for eight pilot states: Florida, South Carolina, Oregon, Wisconsin, Massachusetts, Missouri, New Mexico, and West Virginia. The information was published in local newspapers and was also available on CMS's Home Health Compare website: http://www.medicare.gov/HHCompare/home.asp.
       During this pilot phase, the reference sample for this comparison is the eight pilot states, not a true national average. The CMS website also includes a plain language description of the indicators to assist consumers in understanding the reports and in using the information to help them select a home health agency.
       In these pilot states, consumers (physicians, discharge planners, and potential patients and their families) have the ability to review the outcome data comparing your agency and others in the area. In November 2003, the pilot will be expanded to all states, and all the comparisons will be available on the CMS website. Again, CMS is considering placing newspaper ads in many markets to increase awareness of the information on the website.
       So what should you do now? As with the survey process discussed in the last article, you need to know your agency data. For those indicators impacting the survey process, this evaluation should already be done. On the four additional indicators, evaluate your reports to determine strengths and weaknesses. Remember that not having knowledge is worse than knowing an error was made--if you are able to review the records, identify any problems, and put a corrective action plan into place.
       First and foremost, you should celebrate your strengths and congratulate your caregivers for providing exceptional care.
       Second, evaluate areas where your agency scores lower than others in your market and the national average. Where issues are identified, put a plan in place to prevent the issue from recurring. This may include audits, employee training, or clinical oversight responses. Having the analysis will allow you to respond to questions from potential patients, physicians, discharge planners, and other consumers when asked about the quality of care you provide.

Frequently Asked Questions
       Question: What is the purpose of the new question M0245?
       Answer: One component of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation requires the standardization of coding for billing in the healthcare environment. Because of this change, beginning in October of this year, V-codes will be allowed as a diagnosis in an OASIS assessment. When a V-code is used in the primary (M0230) or secondary (M0240) diagnosis and the ICD-9 code it replaces represents a case mix diagnosis, complete M0245 with that ICD-9 code (see the Federal Register V65, #128, July 3, 2000, for a listing of these diagnoses; examples include diabetes, multiple sclerosis, and abnormality of gait). This change allows you to enter the diagnoses that impact reimbursement in M0245 when a V-code is used for M0230/240 to prevent a reduction in payment.
       The question is as follows: (M0245) Payment Diagnosis (optional): If a V-code was reported in M0230 in place of a case mix diagnosis, list the primary diagnosis and ICD-9-CM code, determined in accordance with OASIS requirements in effect before October 1, 2003--no V-codes, E-codes, or surgical codes allowed. ICD-9-CM sequencing requirements must be followed. Complete both lines a and b if the case mix diagnosis is a manifestation code or in other situations where multiple coding is indicated for the primary diagnosis; otherwise, complete line a only.

(M0245) Primary Diagnosis ICD-9-CM
a. (__ __ __ * __ __)
(M0245) First Secondary Diagnosis ICD-9-CM
b. (__ __ __ * __ __)

       An example from CMS on the use of M0245 is as follows: An 85-year-old independent woman fell in her home, sustaining a left hip fracture. An open reduction with internal fixation was performed seven days ago. The patient was discharged to home where her sister now cares for her. The patient is non-weightbearing on her left lower extremity but can perform supervised pivot transfers with contact guard assist in and out of bed. The physician orders the agency to provide physical therapy for gait training and exercise three times per week for four weeks: ICD-9-CM coding for M0230: V57.1 Physical Therapy and M0240: 781.2 Abnormality of Gait.
       The treatment is directed at rehabilitation following the hip fracture and surgery; therefore, V57.1 is selected as the primary diagnosis. Coding guidelines stipulate that the acute fracture code may only be used for the initial, acute episode of care. The acute fracture code is no longer appropriate once the patient has been discharged from the hospital to home healthcare. Abnormality of gait was selected as the first secondary diagnosis because it accurately describes her current condition and the need for therapy. Since the V code used in M0230 replaces a case mix diagnosis that would have impacted payment, completion of M0245 is indicated. ICD-9-CM coding for M0245 should be 781.2 Abnormality of Gait.
       Question: What is the appropriate response to M0670 if the patent fell getting out of the shower on two previous occasions and is now afraid and unwilling to try again?
       Answer: If the patient's fear is a realistic barrier to her ability to get in and out of the shower safely, then she is unable to bathe in the shower. If she refuses to enter the shower even with another person present, either response 4 or 5 would apply, depending on the patient's ability at the time of the assessment. If she is able to bathe in the shower, however, when another person is present, then response 3 would describe her ability.
       Question: Is a patient incontinent of urine if she or he only has incontinence when coughing (i.e., stress incontinence)?
       Answer: Yes, the patient is incontinent of urine if incontinence occurs under any situation, and M0520 should be answered with option 1 "Patient is incontinent."
       Question: Is a hospitalization considered emergent care for answering M0830?
       Answer: Emergent care includes all unscheduled visits to medical services as noted in the response options, including a hospital emergency room. If a patient is admitted to the hospital via the emergency room, you should mark M0830 with response 1--hospital emergency room.
       Question: Recently, I received transmission errors on the OASIS validation reports for "out of sequence" records in the following situation: Physical therapy is ordered, and upon assessment, a home program is established and teaching performed. It is determined that no further visits are necessary. A Time Point One is completed to allow for billing to Medicare. A month later, the patient has an exacerbation of her disease process and skilled nursing is ordered. Again, a Time Point One is completed, and we receive the error message upon transmission of our OASIS date. Is this an issue?
       Answer: This situation is caused by the elimination of the Time Point Two assessment. For these cases, you need to document on your validation reports the reason for the issue, so that if questioned by a surveyor, you can explain the errors. This should not be counted against your agency.
       Question: Is there any way to get "credit" for a pressure ulcer that is unstageable due to being covered with eschar when we admit the patient and do the OASIS?
       Answer: Probably not--unless you have the patient long enough to perform a recertification OASIS in 60 days. It's important to remember that as a necrotic (unstageable) pressure ulcer is debrided, it would change to a stage 2, 3, or 4 even though the wound is actually improving. This is confusing to many clinicians and points out an inherent problem with the pressure ulcer staging system--it is a poor tool for documenting progress. You might be inclined to perform a significant change in condition (SCIC) OASIS when the necrotic tissue is removed and the ulcer can be staged, but many OASIS experts would say that this improvement (due to debridement of necrotic tissue) is an expected outcome, and therefore, a SCIC OASIS shouldn't be done. And we agree with this interpretation.
If you have a question that you would like addressed in "OASIS: More Than Just an Assessment," call Renee Olszewski, Managing Editor, at (800) 237-7285, extension 209, with your question, or e-mail it to rolszewski@hmpcommunications.com and we will address it in a future issue.