With OASIS C2 being implemented on January 1st 2017, it’s extremely important that your agency or facility is educated with the upcoming changes. Because of this, we’d like to do our part in helping all agencies familiarize themselves with the new additions and modifications to OASIS.
We will be dedicating several upcoming blog posts to OASIS C2 in order to reduce the chances of you and your staff getting caught off guard by the new changes. Additionally, we will be providing best practice-based steps to answer these questions as accurately and thoroughly as possible. Since these new items are quite longer than the OASIS items we generally cover in the blog, each item will be broken into pieces in order to reduce confusion and allow you to take your time in getting familiar with them.
The first item we will cover is M1028: Active Diagnoses - Comorbidities and Co-existing Conditions
Part 1:
(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions—Check all that apply
See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.
⃞ 1 –Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
⃞ 2 –Diabetes Mellitus (DM)
ITEM INTENT
- This item identifies whether two specific diagnoses are present, and active. These diagnoses influence a patient's functional outcomes or increase a patient's risk for development or worsening of pressure ulcer(s).
Item Rationale
- Disease processes can have a significant adverse effect on an individual’s health status and quality of life.
- This section identifies active diagnoses that are associated with a patient’s home health episode of care.
TIME POINTS ITEM(S) COMPLETED
- Start of Care.
- Resumption of Care.
Steps for Assessment
- Identify diagnoses: The diseases and conditions in this item require a physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) documented diagnosis at the time of assessment.
- Medical record sources for physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) diagnoses include, but are not limited to, transfer documents, physician progress notes, recent history and physical, discharge summary, medication sheets, physician orders, consults and official diagnostic reports, diagnosis./problem list(s), and other resources as available.
- Available documentation may be limited at admission/start of care. Admission/start of care assessment may indicate symptoms associated with one of this item’s listed conditions while a documented diagnosis is not present in available records. The clinician should contact the physician (or other, as listed above) to ask if the patient has the diagnosis. Once a diagnosis has been identified, determine if the diagnosis is active.
- Although open communication regarding diagnostic information between the physician and other clinical staff is important, it is also essential that diagnoses communicated verbally be documented in the medical record by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other licensed staff if allowable under state licensure laws) to ensure follow-up and coordination of care.
- Diagnostic information, including past medical and surgical history obtained from family members and close contacts, must also be documented in the medical record by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) to ensure validity, follow-up and coordination of care.
- Only diagnoses confirmed and documented by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) should be considered when coding this item.
- Determine whether diagnoses are active: Once a diagnosis has been identified, determine if the diagnosis is active.
- Active diagnoses are diagnoses that have a direct relationship to the patient’s current functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of assessment. Do not include diseases or conditions that have been resolved or do not affect the patient’s current functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of assessment.
- Medical record sources to identify active diagnoses at the time of assessment include, but are not limited to, transfer documents, physician progress notes, recent history and physical, discharge summary, medication sheets, physician orders, consults and other official diagnostic reports, diagnosis/problem list(s), and other resources as available.
- Only diagnoses confirmed by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) that are active should be coded on the OASIS Data Set.
- If information regarding active diagnoses is learned after the Assessment Completed Date, the OASIS Data Set should not be revised to reflect this new information. The OASIS Data Set should reflect what was known and documented at the time of the assessment. If, however, it comes to light that a documented active diagnosis was not indicated on the OASIS Data Set, the Home Health Agency should modify the OASIS Data Set in accordance with the instructions in the Survey and Certification Memo #15-18-HHA, Outcome and Assessment Information Set (OASIS) transition to the Automated Submission and Processing System (ASAP) and OASIS Correction policy (available at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-18.html?DLPage=1&DLFilter=15-18&DLSort=3&DLSortDir=descending) and the OASIS Submission User’s guide (available at https://www.qtso.com/hhatrain.html)
In the next blog post we will cover how to accurately and thoroughly respond to this question using best practices so check back again this week for more useful information!
