heavily on clinical characteristics to place home health periods of care into meaningful payment categories. Within the typical 60 day episode of care, PDGM dictates two 30-day periods of payment, which are placed into different subgroups for each of the following broad categories: ● Admission source ( two subgroups ): community or institutional admission source. ● Timing of the 30-day period ( two subgroups ): early or late. ● Clinical grouping ( twelve subgroups ): from primary diagnosis on the claim. ● Comorbidity adjustment ( three subgroups ): none, low, or high based on all 24 secondary diagnoses. ● Functional impairment level ( three subgroups ): low, medium, or high, based on certain items in the OASIS.
OASIS data need to be accurate for a number of reasons – for instance, the data are used in care planning, in measuring outcomes, and as a legal record of how carefully the therapist has assessed the patient and selected appropriate interventions. However, use of the data to determine how much CMS pays the agency for the patient’s care elevates the need for accuracy to a new level. If OASIS inaccuracies result in the agency being paid less than the agency should have been paid for caring for the patient, this has an adverse impact on the agency’s financial health. If OASIS inaccuracies result in the agency receiving overpayments from the CMS, this can have even more serious repercussions on the agency, as the overpayment could be regarded as Medicare abuse or fraud.
RULES FOR COMPLETING AN OASIS ASSESSMENT
This section discusses the rules established by the CMS for completing an OASIS assessment. These rules include guidelines about which patients must be assessed using OASIS and when these assessments need to be performed. Other rules cover which home health agency personnel can administer and complete an OASIS assessment and when they need to perform the various tasks related to each OASIS assessment. The rules also include instructions for correctly interpreting and Who needs an OASIS assessment? According to CMS regulations, all adult Medicare and Medicaid patients receiving skilled home care services must have OASIS assessments, with the exception of perinatal patients receiving care related to their pregnancies (see Table 2). The Outcome and Assessment Information Set was designed only for adult patients – patients who are age 18 or older – who have illnesses, injuries, or disabilities. It is not an appropriate instrument for measuring the status or needs of maternity or pediatric patients. In addition, the CMS excludes patients with unskilled or hospice needs from OASIS assessments. Thus, patients receiving only personal care services, such as bathing and homemaking, do not need OASIS assessments. For measuring the status and needs of hospice patients, the CMS requires a different standardized assessment data set, the Hospice Item Set (CMS, 2020b). When do patients need an OASIS assessment? The CMS requires an OASIS assessment at certain time points during a patient’s stay in home care. In general, these assessments must be performed by a qualified clinician: either a registered nurse (RN) or a rehabilitation therapist (physical therapist [PT], occupational therapist [OT], or speech-language pathologist [SLP]) during the course of a visit (see Table 3). Start of care The OASIS assessment performed at the patient’s admission is sometimes called the Admission OASIS , Start of Care OASIS, or SOC OASIS. It is part of the patient’s comprehensive assessment initiated at admission to services. The SOC OASIS is started (and frequently completed) on the day the patient is first admitted to home care services. This OASIS assessment must be performed by a nurse unless the patient is a “therapy only” case – that is, no nursing services have been ordered for the patient, only therapy services. In this case, a therapist can perform the SOC assessment. Transfer to an inpatient facility A Transfer OASIS must be completed when the patient is admitted to an inpatient facility for 24 hours or more. Admissions for diagnostic purposes or for “observation only” are not considered “admissions to an inpatient facility.” Under PDGM, an inpatient facility is considered a hospital. The inpatient stay must be 24 hours or longer. If the patient is hospitalized for only
completing each of the OASIS questions. This section highlights some of these instructions and indicates the importance of referring to the OASIS-D Guidance Manual (even though we are using OASIS-D1, CMS has not revised the title for the Guidance Manual, so it remains at OASIS-D) for correctly interpreting OASIS questions. Selecting the most accurate response to each OASIS question is also discussed. Table 2: Who Needs an OASIS Assessment? Included Excluded • Medicare or Medicaid adult (18 years or older) needing skilled care. • Medicare Advantage patients. • Managed Medicaid patients. • Some other payers MAY require OASIS, such as TRICARE. • Patients with private insurance. • Pediatric patients less than 18 years old. • Maternity patients receiving care related to their pregnancy. • Patients requiring only unskilled service. Note . Adapted from Centers for Medicare and Medicaid Services. (2019). Outcome and assessment information set OASIS-D guidance manual . Effective January 1, 2019. https://www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ HomeHealthQualityInits/Downloads/OASIS-D-Guidance-Manual-final. pdf 23 hours, for instance, a Transfer OASIS is not completed. If the patient is directly transferred to a skilled nursing or rehabilitation facility, this should generate a discharge OASIS. If the patient does not return to the agency within the certification period, a Discharge OASIS should not be completed. This is because, in the CMS tracking system, the transfer to an inpatient facility serves as a “discharge.” Resumption of care The Resumption of Care OASIS , better known as the ROC OASIS, is performed when a patient returns to a home health agency after a period of hospitalization while still within the patient’s 60-day certification period. The ROC OASIS is very similar to the SOC OASIS, as a return to home care after a hospitalization requires a comprehensive assessment of the patient similar to the assessment performed at admission. Recertification A Recertification OASIS , frequently called a Recert OASIS , is performed whenever the patient continues to need home care services beyond the previous certification’s 60-day period. The purpose of the Recert OASIS is to determine the CMS payment for the next 60 days of care, as well as to support the comprehensive assessment that is required at the patient’s recertification for continuing services.
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