It’s almost time for PDGM, the payment system that could dampen our holiday spirits if agencies are not ready. As you can see by the chart below, provided by our friends at CMS, the HIPPS code, which determines payment, will be calculated a little differently than the current PPS HIPPS code.
Position 1 will refer to a new 30 day billing cycle and only the first 30 day period of care will be considered ‘Early’. Bring your billers Starbucks or Redbull. They will need it as twice as many claims will be dropped. And yet, OASIS will still be collected on the same 60 day cycle.
Look at next column. There are 12 different groups into which patients will fall according to their diagnosis codes. Most agencies have certified coders (presumably us) and the assessing clinician’s job is to provide accurate assessment information to assist The Coders in finding the correct codes and sequence. Many codes that are currently used will not be accepted as primary in PDGM and The Coders will be searching for clues to refine the diagnosis codes.
The source of the episode is not very flexible but agencies can change marketing strategies to try to increase the number of patients admitted post hospital. Understand that refusing community referrals that meet your admission criteria policy to improve your ‘numbers’ is highly unethical and possibly illegal. But, if you have a very high percentage of community admissions, there is nothing wrong with increasing marketing efforts to surgeons and other physicians who typically admit patients directly after a hospitalization.
The admitting clinician’s largest contribution to payment is the functional domain which has been chronically under assessed and given the least attention of all payment elements. Many agencies will be leaving money on the table and risking denials for homebound status if nurses and therapists don’t know how to respond to the questions make up the functional status. There are eight OASIS questions used to in the PDGM calculations and seven of them are the functional domain questions.
The first place to start is teaching and reteaching the Conventions for completing OASIS. The can be found in Chapter 1 of the manual. They haven’t changed since the advent of OASIS but as new clinicians rotate in and out, they are often overlooked in orientation. The ones that are misunderstood are sandwiched between statements of common sense. Here are two that are frequently misunderstood (without wonder).
These two conventions could mean that some of your patients who had a procedure the day before admission are being underscored. Misunderstanding them could also cause a nurse to underscore a patient if they simply record what is true at the time of the visit. (Read about a real life example from 2009 here.) Sundowning generally occurs after the nurse’s visit. Add a sleeping pill at ten PM and it could be true that the patient wasn’t safe to get to the restroom independently for over 12 hours of any given day. Agencies can improve OASIS scoring and ethically increase payment by understanding these two conventions.
Here are two more.
The definitions of words as used in OASIS often varies from normal everyday use. This is why seemingly intelligent employees sometimes answer OASIS questions incorrectly. Consider OASIS question m2020 that investigates the patient’s ability to take all oral medications but when you read the OASIS manual it instructs us to consider the medication for which the most assistance is needed when selecting a response. (Why the bold, italicized font if the definition of ‘all’ wasn’t ‘all’)
If a family member must constantly remind your patient to use a cane, that is considered assistance. If someone must remind them to eat, they need assistance.
This information is from the official OASIS Guidance manual. It is not an invitation to upcode. Rather, it is a warning to not leave money on the table. Don’t wait until PDGM to teach and reteach these conventions. Start checking admission paperwork now and educating the nurses and therapists doing your admissions when you see contradictions between the chart and the OASIS. Good agencies work hard to provide care to patients and deserve to be paid. We have friends and colleagues working in the field and we see how tired they are at the end of the day.
If you have any questions, do not hesitate to contact us. We are always available to check your OASIS and ICD-10 coding but for now, pull ten charts and see if the functional domain questions are answered in accordance with these conventions.
Don’t worry. We’re making this adventure with you and will post more information next week.
Is it ever acceptable to bill Medicare for health services for a 
patient other than the Medicare Beneficiary?
The surprising answer is Yes! Should you ever decide to be a live donor for an organ transplant to a Medicare Beneficiary, your care is covered under their eligibility. Now you have no reason not to offload a kidney that’s just taking up room that could be used for something else.
OASIS and Coding Review 