OASIS Alert

Published on Sun Nov 27, 2011 PDF

Avoid these common upcoding and downcoding mistakes.

OASIS item M1200 asks you to assess your patient's vision (with corrective lenses if he usually wears them).

Your response options for M1200 are:

• 0 -- Normal vision: sees adequately in most situations; can see medication labels, newsprint;
• 1 -- Partially impaired: cannot see medication labels or newsprint, but can see obstacles in path and the surrounding layout; can count fingers at arm's length; and
• 2 -- Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive.

You complete M1200 at start of care, resumption of care, and follow-up.

When answering M1200, you're assessing the patient's functional vision. "This question refers to functional vision and not visual acuity despite its wording," says Dee McCarraher, RN, HCS-D, COS-C, with Family Care Home Health in Richmond, Va.

That means you should look at the effect your patient's vision has on his ability to safely perform activities of daily living and instrumental activities of daily living as well as navigating his environment, rather than the acuteness or clearness of his vision.

Get your glasses: To select an accurate answer for this item you should assess the patient wearing corrective lenses if he usually wears them. But remember that the glasses don't need to have prescription lenses. Reading glasses (including "grocery store" reading glasses) are considered to be corrective lenses, according to the response-specific guidance on this item. But a magnifying glass (such as might be used to read newsprint) is not an example of corrective lenses.

Tip: Don't focus on your patient's literacy or ability to read when answering M1200.

Because M1200 receives case mix points in equations "1" and "4", you may be upcoding your OASIS without knowing it, warns Kristi R. Wheeler, RN, HCS-D, COS-C, owner of ACCS (Agency Compliance & Consulting Service) in Terrell, Texas.

Why? Many clinicians assume incorrectly that all elderly patients have "impaired vision" when it comes to answering this OASIS item, Wheeler says.

Be careful not to make assumptions when answering this question, experts advise. Don't be tempted to automatically give credit for eye diseases such as glaucoma, McCarraher warns. "Glaucoma doesn't always equal loss of vision," she says.

You also can't assume that because your patient has a diagnosis of legal blindness that it's appropriate to select response "2." "This response indicates that a patient is completely blind, and you can't jump to that conclusion when the patient is legally blind," Wheeler says.

Documentation discrepancy: When selecting response "1" or "2" for this item, make certain the patient's visual deficit is addressed in the plan of care. "I see a lot of '1' responses, but nothing in the plan of care about addressing the vision problem," Wheeler says.

A response of "1" to M1200 indicates the patient can't see medication labels, Wheeler says. If there is no documentation such as "providing instructions in larger font," other interventions for assisting the patient to manage medications, or notes indicating that the patient already has a strategy in place to ensure safe and accurate medication administration, you risk being accused of upcoding this item, she says.

Mistake: The most common mistake clinicians make when answering M1200 is assuming that if the patient wears glasses, you should choose response "1," Wheeler says. This is another incorrect assumption. Remember, you should assess your patient's vision with the glasses on if he normally wears them.

While some clinicians may be inadvertently upcoding M1200, still others make the mistake of downcoding this item because they are fearful of upcoding.

"I am now seeing a trend where clinicians are selecting response '0' for M1200 when, in fact, a response of '1' is appropriate," Wheeler says.

For example: "I recently reviewed a record that had substantial documentation about a patient's visual deficits and the plan of care contained interventions to accommodate for the deficit, yet M1200 was scored as '0,'" Wheeler reports. "In this particular case, the patient had a medical diagnosis of legal blindness as well as cataracts and glaucoma which, as stated, impacted the plan of care," she says.

The missing case mix points from the diagnosis code for the legal blindness combined with the loss of points in equation 1 for the improper response to M1200 resulted in a loss of four points in the clinical domain for this agency, Wheeler says. The number of lost case mix points was enough to change the patient's HHRG from a C2 to a C3, and if not corrected, would have resulted in a loss of $335 for the episode. If the same scenario were true in equation 4, this could have resulted in a loss of $639 for the episode, she says.