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n the last issue, we presented an overview of the Outcome and Assessment Information Set (OASIS) used in the home health industry when patients are admitted to a Medicare-certified agency. As we mentioned, this assessment is the basis for the home health agency's total payment for the care provided to a patient over 60 days. Though the OASIS assessment contains 65 to 85 questions, only 23 affect reimbursement. In this issue, we will review these questions and share a few tips on answering them correctly.
       First, the questions are grouped into three areas called domains: clinical, functional, and service utilization. Points are accumulated based on how the OASIS questions are answered, and an overall score, called a Home Health Resource Group (HHRG), is determined. The more points you accumulate, the higher the patient's reimbursement will be for the 60-day episode. Each question is marked with "MO" before the number assigned to the question and stands for measure outcome.
       Table 1 displays a list of the MO questions in the clinical domain that impact reimbursement. Based on Table 1, the reader can see that wounds often impact reimbursement. It is important to note that only three types of wounds have specific questions associated with them: pressure ulcers (MO460), stasis ulcers (MO476), and surgical wounds (MO488). Other wounds may have an impact through MO230.
       For example, if MO230 is coded as a trauma diagnosis (ICD-9s from 870.0 to 897.9) in a patient with an open wound, the HHRG would be much higher, and reimbursement would increase accordingly. These specific diagnosis codes are mentioned because, before the OASIS implementation in 2000, many home care clinicians used these trauma codes (erroneously) as the primary diagnosis for other types of wounds. But now, home care clinicians should only use these diagnoses if the wound is actually the result of trauma and if it is supported by documentation in the patient record.
       CMS guidelines have also directed home care to code MO230 for a patient with diabetic foot ulcers using 250.8 as the primary diagnosis and 707.1-707.9 as secondary. Because 250.8 is a diabetic ICD-9 code, the HHRG would be much higher than if the underlying diabetic condition were not selected as the primary diagnosis.
       Answer the therapy question (MO250) based on the infusions the patient is receiving. It does not have to be administered by the home health agency to receive credit.
       To help determine alterations in vision (MO390), have the patient read a prescription bottle or the return address on an envelope.
       For assessing pain (MO420) in a patient who does not ambulate much, evaluate if the reason the patient cannot walk is due to pain.
       Pressure ulcers impact reimbursement via two questions, MO450 and MO460, both of which relate to the stage. Remember that the stage of a pressure ulcer is never downgraded. Looking at MO460, for example, if the nurse admitting a patient with a resolving stage 4 pressure ulcer erroneously categorizes it as a stage 2, the HHRG would be significantly lower.
       Also, closely assess for any stage 1 pressure ulcers, as they are frequently overlooked. It is worth noting that if a muscle flap was performed for a pressure ulcer, it is now considered a surgical wound (and not a pressure ulcer). Debridement, however, does not convert a pressure ulcer to a surgical wound when answering OASIS questions.
       Venous stasis ulcers (MO476) and surgical wounds (MO488) impact reimbursement through questions about wound status. Shortly after OASIS implementation, wound, ostomy, and continence nurses became concerned that the terms used for answering these two questions (fully granulating, early/partial granulation, and nonhealing) lacked universal definition. They felt this could lead to the questions being answered incorrectly.
       Based on these concerns, the Wound, Ostomy, and Continence Nurses Society (WOCN) developed consensus definitions using a panel of experts and submitted them to CMS. After reviewing the document, CMS accepted these guidelines as valid and directed home healthcare providers to use them to clarify MO questions on wounds. The WOCN Society OASIS Guidance Document is available at no charge from the WOCN Society website, www.wocn.org, to help clinicians answer these MO questions more consistently.
       In order to adequately answer the behavior problems question (MO610) accurately, clinicians may need to ask questions about these behaviors as well as observing for them during the entire assessment process. Also, consult with family members and the physician.
       Table 2 lists the MO questions in the functional domain that affect reimbursement.
       Note that dressing the upper and lower body is considered one combined question. Many clinicians have found that the best way to answer the functional domain MO questions is by asking the patient to demonstrate the associated activity. Frequently, the patient will say he or she is much better in these functional areas, as he or she does not want to be perceived as dependent. For example, asking a patient to button a shirt or to put on or remove a light jacket or sweater will provide more objective information than a patient's statements about these activities. Clinicians can ask to see the bathroom setup to help assess ability to bathe and can observe ambulation on the way as well.
       Table 3 lists the MO questions in the service utilization domain that affect reimbursement. There are only two questions in this domain.
       MO175 relates to where the patient was residing prior to admission to the home health agency. If the patient was not in the hospital in the past 14 days or was in a nursing home, additional reimbursement is received. Caution should be taken when answering this question, as the Office of Inspector General (OIG) has begun audits to determine the validity of these responses. Be sure to not only ask the patient where they have resided recently but also verify the information with the physician and family.
       MO825 is related to the need for physical, occupational, and speech therapy. If the patient needs 10 or more therapy visits (any combination of the skills listed), the home care agency receives significantly more reimbursement. MO825 has a greater impact on reimbursement than any other single OASIS question. Caution should also be taken when answering this question about the number of therapy visits to ensure valid responses are recorded.
       We hope this overview will help clinicians improve the accuracy of OASIS assessments thus ensuring home healthcare agencies receive the correct reimbursement from CMS for the care they provide. We also hope that this overview will stimulate challenging questions from our readers--we're ready! Call Renee Olszewski, Managing Editor, at (800) 237-7285, extension 209, with your question, or e-mail it to rolszewski@hmpcommunications.com and we will address it in a future issue.