Home Health ICD-9/ICD-10 Alert

Reader Question:

Locate These Resources for OASIS Coding Practices

Question: Can you point me to any resources that provide information on properly correcting OASIS coding errors on SOCs, and re-certs done by clinicians? I have read that only the clinician performing the OASIS assessment can make changes, but I could use some documentation that describes proper OASIS error correction.

Ohio Subscriber

Answer: There are several resources that you may use, plus you can implement operational processes to decrease the number of corrections. The first line of defense, of course, is educating the assessing clinicians on properly completing the OASIS data items. If the OASIS is completed correctly the first time, then there won't need to be corrections. The problem is that coding is technical, and most assessing clinicians don't have the time, energy, or motivation to become expert coders.

Resources that describe proper OASIS coding practices include the OASIS Q&As from the Centers for Medicare & Medicaid Services found here: https://www.qtso.com/hhadownload.html. Answers included here state that the assessing clinician must determine the primary and secondary diagnoses and their severity. Another Q&A states that the coders cannot change the coding, even for technical errors, unless the clinician agrees. There are exceptions in the absence of the clinician, but certain criteria must be met. Those criteria can also be found in the OASIS Q&A's dated October, 2011.

Another resource is the Interpretive Guidelines at 42 CFR 484.48, which state that home health agencies may create policies for OASIS correction. Any corrections made must have the clinician's agreement, but the guidelines also state that the policy should be flexible for supervisors to be able to make a change without the clinician's approval in case of staff turnover. See https://www.cms.gov/manuals/Downloads/som107ap_b_hha.pdf for more.