The home health conditions of participation (CoPs) require that agencies update and revise the current OASIS assessment under the following conditions:
(1) The last 5 days of every 60 days if the patient is to be 're-certified', unless there is a beneficiary-elected transfer,
(2) a significant change in condition,
(3) patient discharge and return to the same HHA during the 60-day episode;
(4) within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests; and
(5) at discharge.
If, during a 30-day billing episode, a patient experiences a significant deterioration which changes the primary diagnosis, the claim for the FOLLOWING 30-day billing period (assuming the patient will receive another 30-day period of care) will reflect the change in diagnosis, the change in HIPPS code, and ultimately a change in payment.
If the patient has a significant change after admission, providers would not change the claim for the first 30-day period. A follow-up assessment would be completed and submitted before the start of the second 30-day period to reflect the change in the functional level and the second 30-day claim would be grouped into its appropriate case-mix group. Accordingly, two 30-day periods would have two different case-mix groups to reflect any changes in patient condition. The case mix group cannot be adjusted within each 30-day period.
Agencies must be sure to update the assessment completion date on the second 30-day claim if a follow-up assessment changes the case-mix group to ensure the claim can be matched to the follow-up assessment. HHAs can submit a claims adjustment if the assessment is received after the claim has been submitted, if the assessment items would change the payment grouping. Click here to learn how to get a Prior Authorization.
How to Manage a Patient's Significant Change in Condition
Complete a Followup OASIS (Type 5) Before the Start of 2nd 30-Day Billing Period
Before the start of the second 30-day billing period, a follow-up assessment (type 5) would be completed and submitted before the start of the second 30-day period to reflect the change in the diagnosis and functional level. The second 30-day claim would be grouped into its appropriate case-mix group accordingly.