OASIS Alert

Published on Sat May 01, 2010 PDF

Here's what you should -- and shouldn't -- consider when choosing a diagnosis code.

If you fill out M1024 without taking reimbursement into account, you'll actually be going against another instruction for completing the item.

This catch-22 is the result of the Centers for Medicare & Medicaid Services' confusing guidance in the body of the OASIS User Manual (Appendix D), notes Lisa Selman-Holman of Selman-Holman & Associates in Denton, Texas.

On one hand: CMS advises you not to select a diagnosis code based on case mix points. Further, in the instructions for M1024, CMS doesn't instruct you to avoid the item if no points are available.

On the other hand: Yet, in the case scenario examples, CMS mentions that coders would not use M1024 in certain instances because there are no points available, Selman- Holman points out.

Problem: Asking coders to determine for each episode whether a certain diagnosis should be placed in M1024 makes a somewhat difficult task even more difficult, she says.

Remember, some diagnoses get points under certain circumstances and not in others, and the number of points can change based on the episode number and the patient's level of therapy utilization, Selman-Holman points out.

Suppose your patient has a fracture and you provide aftercare as it heals. The fracture does not qualify for added case mix points because the patient doesn't have a pressureulcer and is not receiving infusion therapy. As a result, you shouldn't report the fracture in M1024, says Selman-Holman.

Later, the patient is recertified with a Stage II pressure ulcer. The fracture now qualifies for case mix points and you should report it in M1024, according to Medicare's comments in the Appendix D case scenarios. But if the next episode is a later episode, the fracture will no longer qualify for case mix points, says Selman-Holman.

Further impact: In the past, Medicare looked at the codes reported in M0246 to calculate risk adjustment, but now they will look to the new expanded items taking the place of M0190 and M0210 (M1010 and M1016) as well as M1012 (Inpatient Procedures) for this information, Selman-Holman says.

However, M1010, M1016, and M1012 aren't answered on recertification. So for the above example, you won't have that opportunity to gather risk adjustment information when the patient is recertified for the Stage II pressure ulcer.

Tip: CMS refers to Table 2a in the updated OASIS documentation, but Table 2a is now Table 4 in OASIS C, Selman-Holman adds. You can find these tables at www.cms.hhs.gov/HomeHealthPPS/05_CaseMixGrouperSoftware.asp.