OASIS Alert
Make Changes by The Book
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Always thoroughly document the rationale for changes to the OASIS. Before a coder changes a patient's codes, or makes additions or deletions, she needs to make sure any changes are approved by the assessing clinician, says
Whenever you make a change to an OASIS, you should document the rationale for the change on the correction sheet, Selman-Holman says. "If that chart is called for medical review two years from now, you're not going to remember what transpired," she says.
If the assessing clinician is not available for some reason, a clinical supervisor can approve the change, but be sure to document the rationale behind the change and why the clinician was not available to approve the change (vacation, sick leave, termination), Selman-Holman says. Keep all corrections with the OASIS.
Whenever you make a change, ensure that all related forms receive the same changes, Selman-Holman says. If you have already exported the OASIS, then you'll need to delete that OASIS from the data repository and change it. If you have already sent the request for anticipated payment (RAP), you'll need to cancel that RAP. Remember that the diagnoses on the plan of care, claim form and OASIS must match. If HIPPS codes do not match on the OASIS submitted for data quality purposes and on the bill, Medicare can deny the entire episode.
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