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ver the past year, we have presented many aspects of Outcome and Assessment Information Set (OASIS) development, utilization, and external use. In this article, we will discuss how to get the most from your assessment and explain why it will become increasingly important to patients, clinicians, and society.
       In the Medicare home healthcare environment today, the reality is assessing nurses and therapists determine your reimbursement. Since your agency's viability rests with these caregivers, special training should be conducted to ensure they understand the intricacies of the OASIS assessment and how to respond accurately to each question. Most responses progress from the least severe to the most severe acuity or dependence. Sometimes, however, responses are independent of each other. Some questions can only have one response, while others are "mark all that apply." For example, M0610 (Behaviors Demonstrated) has independent behaviors the patient can display with option 7 being none. Additionally, some of the activities of daily living (ADL) questions specify if the patient can safely perform the task, while others simply require that the patient be able to perform them. Knowing the differences can impact reimbursement.
       While all OASIS questions are important, special focus should be given to two groups of questions. First are the 24 questions used to determine reimbursement. Second are those that are analyzed and compared to other providers to support the Outcomes Based Quality Improvement (OBQI) efforts from the Centers for Medicare and Medicaid Services (CMS). Part of the effort will report this data to the public. When reviewing records identified on the adverse event reports for possible quality-of-care issues, many agencies are discovering the negative outcome is due to a data-entry error or the clinical professional merely answering the question incorrectly. The patient in fact did not have an adverse event.
       Assessment strategies will vary for the questions, but some questions can be grouped together. For example, when answering the ADL questions, the assessing professional should observe the patient performing the task and not rely on his or her verbal response to his or her skills. It is not unusual for a person to exaggerate his or her abilities to care for himself or herself when being interviewed. Why? Remember that most elderly patients want to stay in their homes, and they know that if they cannot take care of themselves there is a greater chance of being placed in a long-term care facility. Actually seeing the patient perform these tasks removes this subjectivity. That does not mean that you need to see all tasks individually performed. You can make some correlations from one question to another. For example, if you observe a patient utilizing the toilet facilities, you have a good idea of his or her transferring capabilities. One area frequently missed with the ADL component is the use of non-durable medical equipment assistive devices. For example, if the patient has to hold on to the furniture or walls to ambulate, he or she does require assistance, and he or she is not freely ambulating. Another form of assistance missed is when the patient requires a "spotter" to transfer, ambulate, or bathe. This is assistance even though it may not always be hands on.
       Some questions are better answered at the end of the assessment. The behavior question (M0610) is a great example. If you can observe throughout the assessment, you will have a better idea of alterations in behavior. You may even see some demonstrated. Pain is another example of this type of question. If you observe for pain throughout the assessment, you have the opportunity to watch for nonverbal cues to pain. Does the patient grimace when he or she gets up from the chair? Does he or she not get up, as moving is the source of the pain?
       There are several excellent resources to assist you with your training and support caregivers on an ongoing basis. CMS has recently completed an interactive training program that covers all aspects of OASIS completion. This can be accessed via the internet at http://www.oasistraining.org/oasis11/upfront/U1.asp.
       Also, CMS recently updated chapter 8 of the implementation guide with the addition of the V code. It is located on its website at http://www.cms.hhs.gov/oasis/usermanu.asp.
       CMS also has published many of the frequently asked questions for everyone to reference on its website at http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php.

Frequently Asked Questions
       Question: I recently had a claim down coded because the intermediary stated the patient was in a hospital prior to our admission; however, we received the patient directly from a skilled nursing facility (SNF). Is this correct?
       Answer: While I do not know the specifics of your patient, this is definitely possible. M0175 is one of those questions requiring you to answer with all that apply. You must count back 14 days and mark all facilities that apply to your patient. It is very possible your patient was sent to the SNF from an acute hospital. How long was he in the SNF? If less than 14 days, that is most likely your answer. This situation is the easier of the two related to M0175. Using questioning of the family and physician, you can typically determine the admission history of the patient. However, some acute hospitals have rehabilitation or SNF beds within their institution. This makes the research a little more difficult in that the patient did not leave the facility. Contact the hospital records department and ask generically if they have any of these types of beds. They may be all grouped on one floor or unit, which will make the responses to this question easier to answer.
       Question: We recently hired a caregiver experienced in home care, and when completing a resumption of care assessment (time point 3) post hospitalization, she answered M0825 yes, even though the physical therapist was only going to provide six more therapy visits (8 visits were performed prior to the admission). Is she correct?
       Answer: Yes, she is. If you look in the OASIS implementation guide for completion of M0825, it indicates that this question should be answered based on the Medicare payment period or episode. Chapter 8 of the guide states, "If the (resumption of care or other follow-up) assessment is being completed to document a significant change in condition, report whether the threshold will be met taking into account therapy visits already made since the start of the current payment period as well as those for the remaining portion of the planned payment period." Not answering this correctly can have a negative impact on reimbursement.
       Question: We recently started using V codes; however, I am having difficulty trying to find a V code for every patient. Do you have any suggestions?
       Answer: While the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulation mandated that CMS allow V codes on an OASIS assessment, it is not required that all patients have a V code as one of the listed diagnoses. Think of the V codes as more codes that you can now choose from. Pick the ones for your patient that most appropriately fit the care you are providing.
       Question: Do the answers to M0903 (date of most recent home visit) and M0906 (date of discharge) have to be the same?
       Answer: No, they do not. The first--date of most recent home visit--is asking for the last visit performed in the admission. The date of discharge is determined by agency policy or physician order.
       Question: When a pressure ulcer is closed per a surgical procedure, e.g., a flap, is it still a pressure ulcer or do we now call it a surgical wound?
       Answer: After a pressure ulcer is closed by a surgical procedure, e.g., a myocutaneous flap, it would then be considered a surgical wound when answering OASIS questions. A pressure ulcer that has been surgically debrided, however, would still be a pressure ulcer.
       If you have a question that you would like addressed in "OASIS: More Than Just an Assessment," e-mail it to Renee Olszewski, Managing Editor, at rolszewski@hmpcommunications.com and we will address it in a future issue.