Watch this webinar to see homecare coding expert Lisa Selman-Holman talk about home health OASIS software from ABILITY Network. She’ll discuss:
- Why OASIS accuracy is so important
- Why it's such a challenge to get it right
- How ABILITY | OPTIMIZE OASIS can help you:
- Save time by comparing your assessment against 3,600 rules in seconds
- Accurately document the full extent of care provided
- Get faster, more accurate payment by quickly identifying and correcting errors and inconsistencies
- Improve your CMS rating
Lisa: Hello, this is Lisa Selman-Holman. I want to tell you about ABILITY | OPTIMIZE OASIS. Now, we have to worry about OASIS accuracy. Why optimize OASIS accuracy? Well, OASIS reflects the need for care. I'm sure there are some of you out there that have reviewed an entire OASIS and then sat there pondering, "I'm not even sure why we admitted this patient. I'm not sure what the care is going to be for this patient." Usually when we sit down with the assessing clinician and talk to them about it, they have other information in their heads that didn't make it onto that OASIS comprehensive assessment.
One of the reasons why we want to optimize OASIS accuracy is to show the care that this patient needs through our assessment. Second, obviously, related to that is compliance. Compliance is really important with OASIS because of the care and the payment. Some of the compliance issues with OASIS is, number one, we have to transmit that OASIS within 30 days of M0090, the date the assessment is completed.
Sometimes that whole process is slowed down because we haven't gotten through reviewing the OASIS yet. We have to be ready to transmit that OASIS before that request for anticipated payment known as RAP is dropped. If there's correction to OASIS, then we have to have a correct process according to Medicare for correcting that OASIS. Meaning we have to go back to that assessing clinician and get their approval to change what they may have not chosen correctly to begin with. Of course, if we need to correct OASIS later, we have to re-transmit. We need to revise the plan of care in some cases, and sometimes we need to cancel the RAP and re-RAP.
There's a lot of compliance issues with OASIS accuracy. Wouldn't it be so much better if we were accurate to begin with before we submitted everything? That's one other reason for OASIS accuracy because our HIPPS code on the OASIS has to match the HIPPS code on the claim.
Payment is very important so we would know that we have certain OASIS items that go to the payment score known as the HHRG or Home Health Resource Group. Plus we have proposed respective payment system changes. Medicare is proposing reductions in reimbursement of 5 to 8% based on the outcomes. Those outcomes are reported on OASIS. Another reason why OASIS accuracy is so important is those outcomes because we want to get the best outcomes there are.
There are a lot of systems and a lot of reviewers out there that will look at your OASIS and determine the payment items. We want to make sure outcomes are also included in that review because we have the typical outcomes that we have come to know and love, and then we have 22 process outcome measures. We've added five more to Home Health Compare about the patient experience of care. Now, Medicare is taking some of those, nine of those and doing a Home Health Agency Five Star rating. The 9 of the 22 such as timely initiation of care, drug education on medication, influenza immunization. Then outcome measures such as improvement in ambulation, bed transferring, bathing, pain interfering with activity, shortness of breath and, of course, that all important acute care hospitalization. Our Home Health Compare and our Five Star ratings are making OASIS accuracy even more important.
Why is it a problem? Well, people are in a hurry. We've got to get that cash flow so the RAP has to be dropped. The RAP is not supposed to be dropped until the OASIS is ready. Well, sometimes we have a whole pile of OASIS that needs to be reviewed. We're getting pushed to go as fast as we can to get those RAPs dropped, and so the OASIS is not checked as closely for accuracy as really is necessary.
The other thing why OASIS accuracy is the problem because guidance provided by CMS is sometimes subtle, and there is so much of it. It's like even if you had all that in your head, there are so many things to consider and so many variables. If we don't have it in our head, we have to take the time to look it up. Guidance is a problem.
Then the OASIS descriptions on the C1 form are not always saying what they really mean. If you haven't had training in OASIS and you just read what the question says, you may answer based on what it says but that's not really what it means. There's lot of subtle guidance, and there's a lot of manuals that must be referenced in and additional Q&A to make sure your OASIS is correct.
Then your OASIS must be properly supported through your documentation. Again, you may have seen that comprehensive assessment where there's a bunch of check marks. When you get through reading it, you're just scratching your head wondering, "Why are we seeing this patient?"
What is ABILITY | OPTIMIZE OASIS? Essentially we downloaded decades and really decades of Home Health Agency experience along with OASIS experience in audits and education, real life OASIS collection from a team of experts into this ABILITY | OPTIMIZE OASIS product. I put together a team with decades of experience in home health and involved in OASIS education outcomes and analysis since inception. I started teaching OASIS myself back in 1999. OASIS education, and analysis, and certification in OASIS competency are a big part of what I do in my business. I collect the nurses with all that experience plus nurses certified by the Wound Ostomy and Continence Nurses Society to work through the wound questions as well as the continence questions on the OASIS.
Then I also contracted with therapist Cindy Krafft. You probably have heard of Cindy Kraft. She's part of Kornetti & Krafft. She's well-known nationally for her expertise in home care therapy as the current president of the Home Care Section of the American Physical Therapy Association. We got together as a team and divided up that OASIS and wrote the rules. That's what ABILITY | OPTIMIZE OASIS is, and we essentially downloaded our brains into this product.
Let's look at a couple of examples. We took real life OASIS data and, of course, we changed the patient's name. We'll look at Daniella McCulley here and just a simple example to start out with. On M1302, the risk for developing pressure ulcers item, the assessing clinician answered zero. Meaning the patient does not have a risk of developing pressure ulcers.
Now, this report says how this assessing clinician answered the question. Then it gives you these warnings. For example, M1610 equals one, patient is incontinent of urine. Then it tells you why that's important. Skin is exposed to moisture, increasing risk for breakdown and orders for prevention may still be part of plan of care. Reevaluate your response to M1302. Essentially, are you sure that this patient is not at risk for developing pressure ulcers? Of course there's ... Maybe you did a Braden Scale, and it said, "No, the patient was not at risk." However the fact that they are incontinent of urine switches it to a clinical evaluation of this patient at risk for developing pressure ulcers.
The other thing that this tool gives you is this tip down here at the bottom. That if you say the patient is not at risk of developing pressure ulcers, that takes that particular episode of care out of the process measure calculation and the plan of care synopsis for prevention of pressure ulcers.
Let's take a look at a couple of items. First, M1300 is was the patient assessed? This one is one that's very different from other best practice items in that you can use an evaluation of clinical factors as well as using a standardized validated tool. Again, this assessing clinician may have used the standardized validated tool. According to the tool's score, they decided they were not at risk.
However, you can also use clinical factors. Of course, one of the clinical factors is incontinence. Based on the clinical factors, this patient should have been at risk for developing pressure ulcers. This is a logic that's built into the system. Again, this assessing clinician marked, no, the patient is not at risk. When we look at M1610 and this assessing clinician marked the patient incontinent, this is showing you the inconsistency between these two items and telling you the rationale why this may not be right, so you need to re-evaluate your responses.
Now, let's look at another example. M1850 transferring and M1860 ambulation/locomotion. Out of those ADLS and IADLs, these two are the ones that looked a little different. Let's look at the transferring first. This assessing clinician has chosen 01. Now, 01 is they need assistance with the device or minimal human assistance to transfer safely. This action here tells you the patient must be able to access the nearest seating surface safely with a device or minimal human assistance. It tells you what the option actually says, and it reminds you what the guidance is.
The guidance is they have to get from the sleeping surface, up on the side of the sleeping surface and then to the nearest seating surface safely. Then back actually to bed. That seating surface may be down the hall. It may be next to the bed. It may be the wheelchair that's pulled up next to the bed. That's something that you need to evaluate with that specific patient.
What they have marked is that M1910 is the patient is at risk for falls. M1910 at risk for falls is not really in line with someone who is a 01 on transferring. That they can transfer safely with a device or minimal human assistance.
The documentation prompt is really good here because it reminds you ... If this patient is really a 01, then you need to document which of the two issues are present. Do they need minimal human assistance and what would that minimal human assistance mean? Do they need an assistive device, and what assistive device is being used? Include why they have to have an assistive device.
Let's look at the transferring question. Just to remind you, number 1, able to transfer with minimal human assistance or with the use of an assistive device. That is very important because if that patient needs an assistive device and we can choose an assistive device as even the arms of the chair, and they need somebody to help them, and that's minimal human assistance, so maybe that's a hand on their arm, or maybe that's prompting, or maybe that's getting the walker next to them. If they need both of those, then they're not a 1. They're a 2. Considering that M1910 was marked at risk for falls, you need to reconsider your 1 on transferring.
Now, let's take a look at the next one, ambulation/locomotion. We marked a 2 on that one. Two is they need intermittent assistance essentially. Let's look at what the inconsistency was. If the need for assistance is due to issues with cognitive function, M1700, is likely to increase the level of need for assistance to continuous on 1860, response 3, to be safe with ambulation. Update your response to M1860. Now, document the factors contributing to the need for intermittent assistance. Two usually means intermittent assistance. Three means continuous assistance.
Let's look at how that is not lining up with how M1700 was marked. 1860, this one is one that is commonly confused because of the and/or in there. Requires use of a two-handed device, for example, walker or crutches, to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs, or steps, or uneven surfaces. This one compared to number 3, able to walk only with the supervision or assistance of another person at all times ... You need to remember that 2 is intermittent assistance to be safe. Three is they need somebody with them at all times to be safe. We have marked 1700 as requires prompting.
Now, cognitive functioning here is the current day of assessment for the level of alertness, orientation, comprehension, concentration and immediate memory for simple commands. This is what they're looking like on the day of assessment which is the time of assessment and 24 hours back.
You said or the assessing clinicians said that they require prompting only under stressful or unfamiliar situations. Well, they've just gotten out of the hospital. This is your start of care. Maybe that's exactly where they are. This one is asking you to reevaluate whether they need intermittent assistance ambulation or continuous assistance ambulation. That just may be for short period of time as they get used to being back home. Reevaluate how you answered M1860.
The next one is M2020, management of oral medications. This assessing clinician marked response 0 for current management of oral medications. They answered M1710 that the patient was confused. The note is telling you reconsider if the patient is independent with medications when confused. Reevaluate that response to M2020 because it does not look right.
M1710 when confused, reported or observed within the last 14 days. They're confused on awakening or at night only. They're a two. One wonders if they're confused upon awakening or at night only, how they're independent with their medication? Since most medications are taken first thing in the morning or at nighttime or both. That one is telling you reevaluate this 0 on the medication because 0 medication means they're able to take all the oral medications reliably and safely including remembering to take them, remembering how much you're supposed to take because it's proper dosages, which one you're supposed to take, and it also includes accessing those medications safely. Where are those medications kept? Are they kept in the kitchen and they're spending all their time in the bedroom because they're confused in the morning? How are they accessing those medications? M2020 is not in line with what you said on the confusion question.
Now let's look at shortness of breath M1400. M1400 is one of those that really contributes to the outcome measures. It's one of those that's kind of confusing also because shortness of breath has some guidance that's completely different than some of the other ones.
The assessing clinician marked a 2 on shortness of breath. Now, that is with moderate exertion, for example, while dressing, using commode or bed pan, walking distances less than 20 feet. Now the guidance on this one is kind of strange because if the patient doesn't walk, you can still mark it 2. If that patient gets short of breath with demanding mobility activities, transfer activities, for example, or turning back and forth in bed even if they're bedfast, they can still be a 2. You kind of have to reevaluate what level of mobility this patient have when you're marking a 2 as well.
Now, what the guidance said on this one that I said was different from others, this one, the patient can avoid activity to be not short of breath. If the patient doesn't do anything and so they're not short of breath, they could be a 0. This one is a really strange one to look at that one's relationship with others as well.
Look at the first one. Patient must be able to safely complete toilet transfer to be a zero M1840. Now, the toilet transfer is another one that has sort of strange guidance, or the wording of the question is different from some of the others. If the patient was short of breath at this level, they could be a zero at toilet transferring.
Now, this one did not show up anything else as far as the ADLs is different. Toilet transferring, you can be 0 if you get to the toilet with a wheelchair. Maybe you have a power wheelchair and you take the power wheelchair into the bathroom. You transfer onto the toilet. You transfer back to the power wheelchair and you leave. You could be a 0. The question is document how patient will safely complete this toileting transfer considering the level of the shortness of breath. Then also document teaching on energy saving techniques.
Now, let's look at M2102. This assessing clinician marked a 0 on M2102 medical procedures and treatments. Now this patient, we don't know this for sure, but they're probably on oxygen. If they have medical procedures or treatments at all, we wonder, even if they're not on oxygen, how are they doing that themselves? No assistance needed. Patient is independent or does not have needs in this area. Now, if they have no needs in this area, they don't even have oxygen that they have to know how many liters, when should they wear it, what's a safe way to do it, all those kinds of things, that's a medical procedure treatment. If they don't need any help at all, they could be a 0 but it's not likely with this level of dyspnea.
Then let's look at M2102. If they have oxygen, this assessing clinician marked it 0. They can manage their equipment. They can clean out the reservoirs. They can do all these things by themselves is what this assessing clinician is marking when they marked it 0. Patient is independent.
Now, there's a possibility they don't have any needs in this area, but with a dyspnea level of 2, they wouldn't likely have oxygen. Zero does not look like the right answer. If anything, if they have a caregiver but they need training, supportive services to provide assistance, that person would be a 2. If they don't have a caregiver, they're actually doing it by themselves ... This is where we have a little problem. The assessing clinician will mark it 0 because the patient live by themselves, and they are taking care of it. Are they safe? Do they really have the ability to do this independently? We may have to switch that to a 3 if they don't have a caregiver for that particular aspect.
M1710 when confused, reported or observed within the last 14 days. This patient was marked a 1 on M1710. Let's look because there's a lot of things that didn't look right based on a confusion of 1. One is in new or complex situations only. Now, we have some guidance from Medicare about that one. If they're on new medications and they're confused about that, then obviously, that's going to impact several other items. If there's new treatments and they don't understand what they're supposed to do, then that's confusion in new or complex situations. New caregivers, they don't know who that care person is and they're not sure what they're trying to tell them, then that's new or complex situation.
At what point are those not new? Medicare says if that continues more than a couple of days, then they're no longer 1. Then you move them down the scale. If that patient was confused in new or complex situations that occurred more often, a couple of days later they still don't know who that caregiver is or why they're in their house, and they're confused upon awakening, then this 1 actually moves to 3. There's a lot of things here as far as folks answering these questions wrong. This is what the assessing clinician said in new or complex situations only.
Now, when we looked at risk for hospitalization, what we think is you should evaluate whether there is a decline in mental, emotional, behavioral status in the past three months. Is this new? Has this been going on for a while, but it's gotten worse in the last three months? Number 5 should be chosen.
Risk for hospitalization is a big item for risk adjustment for this patient's acute care hospitalization. So many people just lackadaisical just check, check, check or put a number 10 or maybe they put a number nine, but they don't say anything about what the other risk may be. These are very important. If you checked that they're confused in new or complex situations, is that new or is that older but it has gotten worse in the last three months? Then number 5 should be checked.
Then reported or observed history of difficulty complying with any medical instruction, for example, medications, diet, exercise, in the past three months. This patient with confusion in a new or complex situation, again, how long have they had a problem with this? Maybe they're confused at first but then they're okay. Have they had difficulty complying with any medical instructions? Number 6 needs to be reevaluated.
Now, M1033 has been marked that they have had two plus falls or injury in the past year. Looking at what we have on the report, we assessed whether falls are possibly the result of impaired decision-making such as forgetting to use assistive device. In that case, M1740 should be a 2.
We look at the next one. Evaluate whether the patient needs therapy and update response to M2200. Well, if they're at risk for hospitalization because of fall, they probably do need therapy. This assessing clinician said 0 for therapy. The patient has to access medication safely for M2020 to be a 0 or 1, so we need to look at that question. You see all the things that are listed here because you marked hospital risked two plus falls or injury falls in the past year, should line up with some of these other ones.
Now, the one on the last, the last one there with the exclamation point, if the patient is having falls or is at risk for falls, M2102 option F should reflect their need for supervision. Let's take a look at some of these. First, whether falls are possibly the result of impaired decision-making and M1740. This one, we're just trying to look is the risk for falls, which is what you marked here, related to this one, M1740? This nurse marked 7, none of the above behaviors demonstrated. What we're just trying to do is reevaluate whether number 2 should be marked because if they have impaired decision-making, they're forgetting to use their walker, for example, and jeopardizes safety through actions, then number 2 should be marked. That's just kind of a, hey, check this out. Make sure this is right.
Now, the next one we want to talk about is the patient has to access medication safely for M2020 to be a 0 or 1. Now, if they really are a 0 or a 1, then someone must have moved their medications close by is what I'm thinking because if they're at risk for falls, they have to be able to access their medications safely. Zero again if the patient's falling and ability to access medications is included in this question, then there must be documentation what adaptation has been made. For example, someone may have moved their medications and the water that they need to take their medications next to their chair in the morning. Then they can take all of their medications safely and at the right time reliably, all those kinds of things. Then they can be a 0. If they still have to get up from that chair and go to the kitchen and get their medications, and they are at falls risk, then they can't be a 0.
Let's look at the next one. If the patient is having falls or is at risk for falls, M2102 option F should reflect the need for supervision. When we look at M2102 F supervision and safety, for example, due to cognitive impairment, that's also due to falls. They need someone to check on them, make sure they're not laying on the floor or make sure that they're not doing things they shouldn't be doing because they're at risk for falls, then that patient cannot be a 0 because they do need assistance, and they're not independent. We know that they have needs since they're at the falls risk. Again, 0 is not going to be the right answer. You need to know whether they have a caregiver or they don't. If they have a caregiver, they're going to be a 1 or 2. If they don't have a caregiver, they're going to be a 3.
There are warnings that if you checked a 4 on one of these particular lines in M2102 and you try to check something else besides the 4 on another line, it's going to warn you that that's not possible because the only time you check 4 is if they have no assistance whatsoever for any one of those particular items in M2102.
M1018 conditions prior to medical or treatment regimen change or inpatient stay within the past 14 days. This is one of those questions that I've seen people not really making an effort to answer correctly because there'll be documentation, for example, that the patient has urinary catheter and they've had the urinary catheter for months. Then M1018 does not show that they have a prior urinary catheter. I think M1018, because it's not a payment question perhaps or because it's prior conditions, it kind of gets ignored or just skimmed over. Again, this is another one that's very important to your risk adjustment for acute care hospitalization.
In this case, the assessing clinician marked prior condition, impaired decision-making. That's good. They actually took the time to mark number 4, impaired decision-making. In this case, I want to say that response 1 means that the box is marked. Box four is marked. We have an exclamation mark. The first thing we see is the patient has impaired decision-making. This likely is increasing hospitalization risk. Reevaluate response to M1033 option five. We have impaired decision-making as a prior condition and then M1018 but we don't have the response to M1033 consistent with that.
Impaired decision-making just so that you can see M1018, remind yourself what that one looks like. If this patient experienced an inpatient facility discharged or change of medical treatment regimen within the past 14 days, indicate any conditions that existed prior to the inpatient stay or change in medical treatment regimen, and then to mark all that apply. We marked impaired decision-making on this one.
When we come to risk for hospitalization though, we don't have number 5 marked which seems like it probably should, decline in mental, emotional, behavioral status in the past three months. Is that impaired decision-making brand new? Then obviously there's a decline in the past three months. How long has it been there? Has it gotten worse in the last three months? Those are the things that you should be evaluating. Number 5 most likely should be checked.
The next one is impaired decision-making may be the result of patient having increased confusion. We said prior condition is impaired decision-making but when we looked at M1710, we have in new or complex situations only. Impaired decision-making usually goes with confusion; not always. We're asking you to reevaluate your response to M1710 considering this impaired decision-making.
Then the last one here M1740 should also reflect impaired decision-making if the problem continues. Prior condition was impaired decision-making. Now maybe they had some wonderful procedure and they're not impaired anymore but, of course, that's not likely. M1740, again, the nurse said, "None of the above behaviors." They have past behavior of impaired decision-making, but number 2 is not marked. Now, this one is cognitive, behavioral and psychiatric symptoms that are demonstrated at least once a week reported or observed. That just needs to be looked at more closely as far as the frequency of those particular behaviors. Maybe it's not once a week but number 2 probably should be checked based on this particular patient's condition. Instead of a 7, number 2 should be marked.
Louie: Great. Now, I'll pass control over to Karen and she'll take you through ABILITY | OPTIMIZE demonstration. Karen, I'll pass control over to you.
Karen: Good morning, everyone. As Lisa just shared, optimizing your OASIS is incredibly important to ensure your agency receives proper credit for the services delivered by your agency. As you know, the responses completed on the OASIS feed directly into the quality measures tracked by Medicare and reported back out to the public through the Home Health Compare website and Five Star rating.
To do a thorough review as Lisa just walked us through for a portion of a single assessment is very time-consuming and actually requires referencing multiple sources of documentation. ABILITY | OPTIMIZE was designed specifically to streamline that OASIS review to call out not only errors that will result in Medicare rejecting the OASIS but also, as Lisa was just speaking about, she identified inconsistencies across multiple M items that will impact your process and outcome quality measures.
Let's just take a look at how easy it is to have OPTIMIZE OASIS analyze your OASIS. ABILITY | OPTIMIZE is accessed through the myABILITY portal. What I'd like to take you through is actually uploading a file which ... The way the process works is the file that you would normally submit to Medicare that contains one or more assessments in it, prior to submitting it to Medicare, you would select it and upload it here to ABILITY | OPTIMIZE. It is really as simple as making an attachment to your email.
We again have focused on trying to really minimize the number of steps required to get that additional analysis going to focus your efforts. As I just demonstrated, clicking the upload file button, selecting your file, will get the whole process going.
Here we have a couple of assessments that we've already uploaded. Again, these were actual assessments. We've changed the patient identifying information. We felt that it would be most helpful for everyone to see the actual analysis results. What I'm going to do is actually click on Daniella McCulley which is the same patient that Lisa had just walked you through. Let's go ahead and do that. This actually takes you to the actual analysis output. As you can see we've intuitively designed the screen to focus your efforts. At the top, we have just some basic information such as the patient's name, the type of assessments, HIPPS code and so forth.
We also include a summary that allows you to take a look at particular areas that were identified to have errors or inconsistencies. Normally, top of mind for most folks are any errors or inconsistencies that might result in Medicare rejecting your OASIS file when you attempt to upload it through the ASAP system. You're able to actually click on that filter and it will bring you down into the actual M item or portions of the record that have that particular error so that you're able to read through that and make a required change.
Additionally, we realized that folks actually doing the review of the assessment have varying levels of experience and knowledge. The default view that we provide has a lot of information. Again, as Lisa described her and the team that she compiled, spend a lot of time pulling together all those various sources of documentation into ABILITY | OPTIMIZE so that you really have pretty much everything that you need at your fingertips to determine whether or not some sort of adjustment is required to the assessment prior to you submitting to Medicare.
The initial view is really all errors and guidance. You'll see that there is a lot of information here including plan of care inclusions, documentation prompts and ICD review suggestions. For folks who are maybe much more familiar with the guidance and manuals and really is looking to just see what the errors and potential inconsistencies are, we do have other views available. For example, if you just want to see the CMS required and best practice issues, you're able to filter that.
Additionally, we know lots of folks need to have the ability to print out the analysis information, attach it to a chart or the actual assessment to help facilitate reviews. We also provide the ability to do that through clicking the save PDF button.
As Lisa also shared with you, we really are trying to focus your eye on items that are of the most importance, and so everything is color coded. Red, as we saw with this CMS required, are items that are either are going to result in an error when you attempt to upload the assessment to CMS or items that are really considered a best practice that you should definitely look at prior to sending the assessment on. Orange just reflects best practices and other things that are maybe slightly lower priority but will still potentially impact your process or outcome measures. Definitely want to take a look and determine whether for the patient that you're assessing, the particular message applies. Then finally we have yellow, which is just those suggestions, and additional guidance, and feedback to help provide additional color to your review.
If I go back to the main screen, again, just keeping in mind making the application as easy to use to help facilitate and streamline your analysis review effort, we provide various filters to allow you to sort through your assessment and prioritize. As folks on the phone are probably fully aware, start of care and resumption of care assessment have the tendency to have ... They really have the opportunity to have the most inconsistencies and errors along with discharge. You have the ability to filter and prioritize those for review first.
Additionally, if we come down here to the grid that lists all of the assessments that have been uploaded and analyzed, you have some additional information again to help focus your efforts. Here we can see the number of CMS violations or process- or outcome-related measure issues and then finally the number of issues that were identified on M items that actually feed into your HIPPS code calculation.
At this point, we would love to open the floor up to questions.