Three Little Questions


Because the OASIS C database has become easier for you, Medicare has taken measures to ensure that 2017 offers some challenges in the way of OASIS C2.  In turn, we have taken measure to ensure that you understand at the very minimum the three new questions.  They come complete with their own conundrums, confusion and lots of reformatting and subtle shifts in definition.  It’s not as simple as it seems but it certainly isn’t out of your range of capabilities.

New Questions

Written by someone who is comforted by redundancy, MO1028 assesses (again) whether a patient has diabetes or peripheral vascular disease.

(M1028) Active Diagnoses– Comorbidities and Co-existing Conditions—Check all that apply

See the OASIS Guidance Manual or click here for a list of relevant ICD-10 codes.

  • Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
  • Diabetes Mellitus (DM)

Additional guidance is not much different from coding conventions.  The diagnoses must be documented in the medical records produced by the physician or NP.

Having the condition is not enough to win a checked box.  The C2 manual states that the diagnosis must be active and the manual infers that ‘active’ means that there are orders written or monitoring of the disease process ongoing.

So, that’s two criteria –

  1. Does the patient have the condition and
  2. Is anyone watching it or writing orders for it.

Worth noting, if only for a laugh, the OASIS Guidance manual for the C2 dataset provides the following rationale for this question.  We are not kidding.

Disease processes can have a significant adverse effect on an individual’s health status and quality of life.

Section GG

Another new question is (GG0170C) Mobility.  The question occupies an entire page in the manual and if you are like me, it may take you a while to understand what they are truly asking.  Look the column in the body of the table to the very most right where it says something about the patient moving from a completely supine position to sitting on the side of the bed, feet flat on the floor with no backrest.   Everything else on the page refers to that single activity.

The answer reflecting the greatest impairment is 01 and a patient who can complete the tasks independently gets a 06 score.  Note that this is a new opportunity to make a careless error as the level of severity for every other question is reversed with 00 being the least impaired and the last possible response being the worst level of severity.

But there’s more.  The dataset asks for a goal.  If your patient is able to do this task at admission, it is not a problem.  Your initial response and your goal will be the same.  However, if some improvement is expected by the grace of your carefully crafted careplan, there will be a second response describing your patient’s expected ability upon discharge.  Take your best shot and don’t fret about not being able to predict the future.  It is true that all kinds of things can happen between admit/resumption of care and discharge but it is not reasonable to downgrade your goal in the event of a zombie attack.  On the other hand, remember that you are not so good that you can take a person who is totally dependent following a cerebral vascular accident and have them independent at discharge.

Getting Personal

Medicare wants to know the patient’s height and weight in M1060.

(M1060) Height and Weight—While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up.

The Coders assume that you know how to round off numbers but Medicare does not and includes explicit instructions within the question.

Guidance for this question includes a helpful tip to measure your patient’s height and weight in accordance with the agency’s policies and procedures, which should reflect current standards of practice.  So, how many of you have a policy addressing how to measure the height and weight of a patient?

Assuming that such a policy exists in your agency, is it based upon sound clinical practice standards?  On your behalf, we have scoured the internet for practice standards for measuring height and weight and like the CDC Antropometry Procedures Manual.  Sadly, the manual refers to the Integrated Survey Information System anthropometry computer application (ISIS).   Do not be alarmed when you see this.

Also, when determining how height will be measured, plan on buying a stadiometer.  This is the apparatus seen in Physician offices that measures height.  Most of the affordable ones are wall mounted and we suggest that wall mounting is not recommended in your patient’s home environment.  Also, note that anything with brightly colored giraffes and ruler-like markings cheering on big boys and girls is not likely to be received well by adult patients or meet the practice standards. Call your medical supply company and plan to spend about $150.00 per portable stadiometer.

The Dash

There’s more – so much more but you have patients to see and notes to write.  We are going to leave you with information about The Dash.  This is not a simple dash as found in other places like a date or a social security number.  According to Medicare,

a dash (–) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged or dies before assessment of the item could be completed. CMS expects dash use to be a rare occurrence.

This definition is consistent throughout the manual.  When a dash value is an available option for questions, OASIS guidance generally indicates if the dash is a valid response.

For your convenience, we have uploaded some of these documents.  Hopefully, you will read them and then fill us in.  As always, we welcome your questions.  Maybe we’ll even answer a couple.

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Weights


The Oxford English Dictionary defines weight as a body’s relative mass or the quantity of matter contained by it, giving rise to a downward force; the heaviness of a person or thing.

What the OED fails to mention is that weights are a critical measurement of overall health.  Symptoms of many diseases cause a person to shed weight.  Other diseases cause people to add body mass or weight.  It is a good thing to know what your patient weighs but more important to know how their weight changes over time.

Nobody gets concerned about weight loss of a pound or two.  Some of us are even thrilled when we notice the needle on the scale drift downwards a bit.  What we occasionally see when I look at episodes in their entirety is significant weight loss over the period of 60 days that is unexplained by diet or increased activity.  Nurses in the field sometimes fail to realize that the pound or two here and there over several weeks could point to an unresolved health issue.

It seems almost pointless to tell nurses to weigh their patients with congestive heart failure and yet over the week, we have reviewed numerous charts from different agencies where no weights were recorded.  This lack of attention to a basic measurement of congestive heart failure can and does lead to unnecessary hospitalizations. 

Sometimes, it seems that orders are written to prevent that burdensome task of notifying a physician of a decline in a patient’s condition.  A frail elderly woman weighing 103 pounds should not have to gain five pounds before the physician is called for orders.

What you may not know is how much this is costing you in terms of denials.  If you are a manager or administrator responsible for ensuring compliance to Medicare coverage rules, pay close attention.  

Observation and assessment is only a skill for three weeks unless there are credible findings that a patient is at risk for exacerbation.  For our purposes, an exacerbation is a worsening of a condition that involves changing the care plan.  In order to change the plan of care, the physician must be involved and new orders received.  Not every order must be for medications so be prepared to ask the physician if he needs lab or if you can make an extra skilled visit to check on the patient.

Each order you receive is like a ticket to ride the episode train a little longer.  Skills are provided and they are reasonable and necessary because there is documented information upon which decisions regarding care are made.

Without a documented information, the same skills may very well be provided without meeting the reasonable and necessary criteria.  Or, the weight gain may not be noticed especially if a different nurse sees a patient. 

None of this is anything that can’t be handled but the first step is to take it seriously.  The easiest way to do this is to begin weighing all patients.  Reserve written orders only for those patients with diagnoses or conditions that require weights to prevent unnecessary tags on survey in the event one is overlooked.  Habits are powerful things.  You will know the habit is real when you just don’t feel comfortable until a weight is documented.

Every patient should have a scale in their home.  No home health agency has ever filed for bankruptcy because scales were purchased for patient care.  It doesn’t even have to be a good scale.  It just needs to be the same scale in the same place at the same time each day. 

If you want to provide telemedicine but don’t have the resources, you can get the patients to call their weights into the voicemail of an unused line at your office by three o’clock every day.  Those patients who have not called can then be contacted by a part time student.  Imagine the delight of a surveyor when they see pretty little spreadsheets with weights on them and orders in the chart corresponding with increases or decreases.  Better yet, imagine the horror of the MAC reviewer who desperately wants to deny your claims because care was not reasonable and necessary and sees the very same thing. 

This low-tech telemedicine program also allows you to be more conservative with visits so you can attack weight changes like a SWAT team.  Go ahead and make daily visits for two to four days and cut out some of those visits where the patient is taught that one side effect of Lasix is frequent urination as if they didn’t know after taking it for a year or more.  The worst that could happen by scheduling conservatively while following weights telephonically is that patients will develop the habit of weighing themselves and become more compliant with meds and diet.  Then you actually save money by making fewer visits.  How cool is that?

Don’t stop with failure patients.  The sad fact is that some people don’t have enough to eat.  Your patients are confined to the home and may be too embarrassed to tell you that they do not have enough money for food.  Other elderly people seem to lose their desire for food and still more have side effects from medications that cause increased or decreased appetite.   Whatever the underlying reason, it can only be addressed if you know about it.  Assuming your patients are not wearing tight yoga pants and a sports bra during nurse visits, the easiest way to determine weight changes before harm comes to the patient is by weighing them.

You are nurses.  You can do this.  I promise. If you are one of those nurses who habitually forgets to weigh your patients, think of us for a change.  It will be so much easier to code charts if there are orders and exacerbations.  We’re not asking you to cause an exacerbation by slipping some salt in their tea or moving the needle of the scale up a few pounds.  We just want you find out about an exacerbation and get some orders while the problem is manageable and get paid well for taking good care of patients.