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Home Health Guideto OASIS -C2
Melinda A. Gaboury, COS-C
A Reference For Field Staff
HHPGC2_cover_final.indd 1 1/25/17 12:10 PM
MELINDA A. GABOURY, COS-C
Home Health Guideto OASIS -C2
A Reference For Field Staff
Home Health Guide to OASIS-C2: A Reference for Field Staff is published by HCPro, a division of BLR.
Copyright © 2017 HCPro, a division of BLR
All rights reserved. Printed in the United States of America. 5 4 3 2 1
ISBN: 978-1-68308-188-3
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© 2017 HCPro
Home Health Guide to OASIS-C2
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Contents
Chapter 1: What Is OASIS-C2? ..................................................... 1
Why OASIS? ................................................................................................................4
Who Collects OASIS-C2 Data? ................................................................................4
On Whom Are OASIS-C2 Data Collected? ............................................................4
When Are OASIS-C2 Data Collected? .....................................................................5
How Are OASIS-C2 Data Collected?........................................................................5
Where Are OASIS-C2 Data Collected? ....................................................................6
What’s New in OASIS-C2? .........................................................................................6
Chapter 2: Incorporating OASIS ................................................. 15
Chapter 3: Home Health PPS and OASIS-C2 .............................. 19
Home Health Quality of Care Star Ratings, Value-Based Purchasing, and OASIS-C2...........................................................................................................31
Chapter 4: Patient Tracking Sheet ............................................. 33
Chapter 5: Start-of-Care and Resumption-of-Care Assessments ............................................................................... 37
Chapter 6: Follow-Up and Other Follow-Up Assessments ......... 43
Chapter 7: Transfer and Discharge Assessments ....................... 47
Chapter 8: General Instructions for Completion of the OASIS-C2 M/GG Items ............................................................... 53
M/GG: Item by Item .................................................................................................56
CHAPTER 1
What Is OASIS-C2?
What Is OASIS-C2?C
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The Outcome and Assessment Information Set (OASIS) is a set of data items that
was originally developed to monitor health outcomes. Beginning October 1,
2000, the OASIS data set became a key factor in determining reimbursement for
a home health episode under the Medicare prospective payment system (PPS).
Effective January 1, 2010, the data set was updated to OASIS-C, and effective
January 1, 2015, it was updated yet again to OASIS-C1. Further revisions, to coin-
cide with implementation of ICD-10-CM, were effective October 1, 2015. The
most recent update is OASIS-C2, effective January 1, 2017. This update includes
many changes that will meet the standardization required for other post-acute
care data sets. Although the OASIS-C2 data set is not a complete, comprehen-
sive assessment instrument, it must be fully integrated into every agency’s com-
prehensive assessment forms (see Chapter 2 for more information).
Outcomes derived from OASIS-C2 data are defined as those that measure
changes in a patient’s health status between points in time. For example, an
OASIS-based outcome might compare a patient’s dyspneic state at the point of
admission to home health to the patient’s dyspneic state at the point of dis-
charge from home health. OASIS-based outcomes form the foundation of Out-
come-Based Quality Improvement systems (see Chapter 3 for more information).
They also serve as measures in other programs. For example, on January 1, 2016,
the five-year Value-Based Purchasing (VBP) Pilot went into effect in nine states,
and VBP is measured, in large part, by OASIS-based outcomes (see Chapter 4 for
more information).
Additionally, home health Medicare PPS reimbursement is based on the calcula-
tion of one of 153 Home Health Resource Groups (HHRG), which are assigned
based on responses to 19 key questions from OASIS-C2. Although numerous
types of adjustments can result in a higher or lower reimbursement than the
HHRG calculates, the HHRG always serves as the foundation for the reimburse-
ment (see Chapter 3 for more information): It is converted to a HIPPS (Health
Insurance Prospective Payment System) code that is reflected on the claim for
payment.
What Is OASIS-C2?
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Why OASIS?
OASIS was chosen to be the basis for home health outcomes and reimburse-
ment following a five-year national research program. The OASIS data set was
tested in two demonstration projects, a national project with 50 agencies and a
New York state project with 22 agencies. Nearly 200 agencies across the country
tested and contributed to the refinement of the data, which began with the orig-
inal report from The Research Center at the University of Colorado in 1994 and
has been reviewed, revised, and expanded as a result of recommendations by
the Centers for Medicare & Medicaid Services (CMS) and the outcomes of the
demonstration projects.
Who Collects OASIS-C2 Data?
The clinician who performs the home care visit collects the OASIS data. This per-
son can be an RN, a registered physical therapist, or a speech-language pathol-
ogist, any of whom can complete any type of OASIS assessment. A registered
occupational therapist (OT) may collect the data for any assessment type except
for the start-of-care assessment, which requires performing care in the home
when OT is referred. Note that this OT restriction applies to patients for whom
Medicare is the payer; however, if an agency receives a referral for OT only and
the payer is strictly commercial insurance or private pay, then the OT can com-
plete the start-of-care assessment. Licensed practical/vocational nurses, therapy
assistants, social workers, and home health aides are all prohibited from com-
pleting the OASIS documents.
On Whom Are OASIS-C2 Data Collected?
OASIS-C2 data are collected on any patient who is receiving skilled care from a
Medicare-certified home health agency and whose payer for the services is
Medicare Traditional, a Medicare Advantage Managed Care Plan, or a Skilled
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Medicaid program. Effective December 2003, if the patient’s services payment
will be made by a non-Medicare payer, the OASIS-C2 data collection is not
required. If the patient has a non-Medicare primary payer and the patient is also
covered by Medicare secondary benefits, OASIS-C2 data must be collected. The
OASIS-C2 data are collected only for adult, non-maternity patients who are 18
years of age and older. Patients who are receiving only personal care, home-
maker, or chore services are excluded from the OASIS-C2 data collection
requirements.
When Are OASIS-C2 Data Collected?
OASIS-C2 data collection is required at different intervals throughout the
patient’s care. Depending on the type of assessment, data collection takes place
during different time frames, as shown in Table 1.1.
How Are OASIS-C2 Data Collected?
OASIS-C2 data are to be collected in the patient’s home as a combination of
interactions and interviews with the patients and caregivers, observation, and
measurement.
Observation through sight, sound, smell, and touch will allow for additional data
collection. Measurement of such data is also necessary when warranted. Exam-
ples include the following:
• Height
• Weight
• Joint range of motion
Observing the patient is imperative when addressing certain parts of the assess-
ment, such as functional status. Asking a patient to ambulate to the kitchen to
What Is OASIS-C2?
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measure his or her ability to ambulate independently, and for what distance,
would be an example of combining observation and measurement. Be very clear
that the interview/interaction should supplement, but not replace, observation/
measurement.
Where Are OASIS-C2 Data Collected?
OASIS data are collected wherever the patient is receiving care (including the
home). The OASIS-C2 documents should not be an afterthought. Interaction,
interview, observation, and measurement should all be part of the process. It is
extremely important that the data be collected during the visits and serve as a
true reflection of the patient’s health status.
What’s New in OASIS-C2?
The OASIS-C2 represents one of the most comprehensive revisions to OASIS
since its original release. See Table 1.2 for a summary of the types of revisions
made to OASIS. An “X” in a column indicates that a change has been made to
the OASIS-C2 Data Set and/or the OASIS-C2 Guidance Manual.
What Is OASIS-C2?C
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Table 1.1 Assessment time frames
Type of assessment
When to complete
Time frame to complete
Reason for assessment (RFA)
Start of care (SOC) Admission
of patient
Initiated within 48
hours of referral
and completed
within five days
of the SOC date
(M0030)
1
Resumption
of care
Following inpa-
tient stay of 24
hours or more, for
care other than
diagnostic tests
Within 48 hours
of patient’s return
home from inpa-
tient facility
3
Recertification—
follow-up
Every 60 days—
when patient is
continuing care
Within the past
five days of the
current episode
(days 56–60)
4
Other follow-up Any time a patient
experiences a
change in condi-
tion as defined in
agency policy
Within 48 hours of
the change
in condition
5
Transfer to inpa-
tient facility—
not discharged
from agency
Following a trans-
fer to an inpa-
tient facility and
placing patient
on hold for home
health
Within 48 hours
of transfer date
(M0906)
6
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Type of assessment
When to complete
Time frame to complete
Reason for assessment (RFA)
Transfer to inpa-
tient facility—
discharged
from agency
Following a trans-
fer to inpatient fa-
cility, and patient
is discharged from
home health
Within 48 hours
of transfer date
(M0906)
7
Death at home Following pa-
tient’s death at
home
Within 48 hours
of the death date
(M0906)
8
Discharged
from agency—
not to an
inpatient facility
Following pa-
tient’s discharge
from home health
Within 48 hours of
the discharge date
(M0906)
9
Table 1.1 Assessment time frames (cont.)
What Is OASIS-C2?C
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Table 1.2 OASIS-C2 revisions
OA
SIS
-C2
dat
a se
tO
ASI
S-C
2 G
uid
ance
Man
ual
OA
SIS-
C1
item
nu
mb
er
OA
SIS-
C2
item
nu
mb
er
New
or
del
eted
it
em
New
it
em
num
ber
Item
w
ord
ing
ch
ang
e
Co
nver
ted
re
spo
nse
spac
es t
o b
ox(e
s)
Skip
p
atte
rn
chan
ge
Item
in
tent
Tim
e p
oin
tsR
esp
ons
e-sp
ecifi
c in
stru
ctio
ns
Dat
a so
urce
s/
reso
urce
s
M00
10M
0010
X
M00
14M
0014
X
M00
16M
0016
X
M00
18M
0018
X
M00
20M
0020
X
M00
30M
0030
XX
M00
32M
0032
XX
M00
40M
0040
X
M00
50M
0050
X
M00
60M
0060
X
M00
63M
0063
X
M00
64M
0064
X
M00
65M
0065
X
M00
66M
0066
XX
M00
69M
0069
XX
M00
80M
0080
X
M00
90M
0090
XX
M01
00M
0100
X
M01
02M
0102
XX
M01
04M
0104
XX
What Is OASIS-C2?
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OA
SIS-
C1
item
nu
mb
er
OA
SIS-
C2
item
nu
mb
er
New
or
del
eted
it
em
New
it
em
num
ber
Item
w
ord
ing
ch
ang
e
Co
nver
ted
re
spo
nse
spac
es t
o b
ox(e
s)
Skip
p
atte
rn
chan
ge
Item
in
tent
Tim
e p
oin
tsR
esp
ons
e-sp
ecifi
c in
stru
ctio
ns
Dat
a so
urce
s/
reso
urce
s
M01
10M
0110
X
M01
40M
0140
M01
50M
0150
M09
03M
0903
XX
X
M09
06M
0906
X
M10
00M
1000
X
M10
05M
1005
XX
M10
10M
1010
M10
11M
1011
XX
M10
17M
1017
XX
M10
18M
1018
X
M10
21M
1021
XX
M10
23M
1023
XX
M10
25M
1025
XX
M10
28N
EW
XX
XX
M10
30M
1030
M10
33M
1033
M10
34M
1034
XX
M10
36M
1036
M10
41M
1041
X
M10
46M
1046
XX
Table 1.2 OASIS-C2 revisions (cont.)
What Is OASIS-C2?C
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OA
SIS-
C1
item
nu
mb
er
OA
SIS-
C2
item
nu
mb
er
New
or
del
eted
it
em
New
it
em
num
ber
Item
w
ord
ing
ch
ang
e
Co
nver
ted
re
spo
nse
spac
es t
o b
ox(e
s)
Skip
p
atte
rn
chan
ge
Item
in
tent
Tim
e p
oin
tsR
esp
ons
e-sp
ecifi
c in
stru
ctio
ns
Dat
a so
urce
s/
reso
urce
s
M10
51M
1051
XX
M10
56M
1056
XX
M10
60N
EW
XX
XX
M11
00M
1100
X
M12
00M
1200
XX
M12
10M
1210
X
M12
20M
1220
X
M12
30M
1230
X
M12
40M
1240
XX
M12
42M
1242
X
M13
00M
1300
XX
M13
02M
1302
XX
M13
06M
1306
XX
XX
M13
07M
1307
XX
XX
M13
08M
1311
XX
XX
X
M13
09M
1313
XX
XX
M13
20M
1320
XX
X
M13
22M
1322
XX
XX
M13
24M
1324
XX
M13
30M
1330
X
Table 1.2 OASIS-C2 revisions (cont.)
What Is OASIS-C2?
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OA
SIS-
C1
item
nu
mb
er
OA
SIS-
C2
item
nu
mb
er
New
or
del
eted
it
em
New
it
em
num
ber
Item
w
ord
ing
ch
ang
e
Co
nver
ted
re
spo
nse
spac
es t
o b
ox(e
s)
Skip
p
atte
rn
chan
ge
Item
in
tent
Tim
e p
oin
tsR
esp
ons
e-sp
ecifi
c in
stru
ctio
ns
Dat
a so
urce
s/
reso
urce
s
M13
32M
1332
X
M13
34M
1334
X
M13
40M
1340
XX
M13
42M
1342
XX
M13
50M
1350
XX
M14
00M
1400
X
M14
10M
1410
M15
00M
1501
XX
XX
X
M15
10M
1511
XX
M16
00M
1600
XX
M16
10M
1610
X
M16
15M
1615
X
M16
20M
1620
X
M16
30M
1630
XX
M17
00M
1700
XX
M17
10M
1710
XX
M17
20M
1720
XX
M17
30M
1730
X
M17
40M
1740
X
M17
45M
1745
XX
M17
50M
1750
X
Table 1.2 OASIS-C2 revisions (cont.)
What Is OASIS-C2?C
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OA
SIS-
C1
item
nu
mb
er
OA
SIS-
C2
item
nu
mb
er
New
or
del
eted
it
em
New
it
em
num
ber
Item
w
ord
ing
ch
ang
e
Co
nver
ted
re
spo
nse
spac
es t
o b
ox(e
s)
Skip
p
atte
rn
chan
ge
Item
in
tent
Tim
e p
oin
tsR
esp
ons
e-sp
ecifi
c in
stru
ctio
ns
Dat
a so
urce
s/
reso
urce
s
M18
00M
1800
X
M18
10M
1810
X
M18
20M
1820
XX
M18
30M
1830
X
M18
40M
1840
XX
M18
45M
1845
X
M18
50M
1850
X
GG
0170
CN
EW
XX
XX
M18
60M
1860
X
M18
70M
1870
X
M18
80M
1880
X
M18
90M
1890
X
M19
00M
1900
XX
M19
10M
1910
X
M20
00M
2001
XX
XX
X
M20
02M
2003
XX
X
M20
04M
2005
XX
XX
M20
10M
2010
X
M20
15M
2016
XX
XX
M20
20M
2020
XX
M20
30M
2030
XX
Table 1.2 OASIS-C2 revisions (cont.)
What Is OASIS-C2?
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OA
SIS-
C1
item
nu
mb
er
OA
SIS-
C2
item
nu
mb
er
New
or
del
eted
it
em
New
it
em
num
ber
Item
w
ord
ing
ch
ang
e
Co
nver
ted
re
spo
nse
spac
es t
o b
ox(e
s)
Skip
p
atte
rn
chan
ge
Item
in
tent
Tim
e p
oin
tsR
esp
ons
e-sp
ecifi
c in
stru
ctio
ns
Dat
a so
urce
s/
reso
urce
s
M20
40M
2040
XX
X
M21
02M
2102
XX
X
M21
10M
2110
X
M22
00M
2200
XX
M22
50M
2250
M23
00M
2301
XX
XX
X
M23
10M
2310
X
M24
00M
2401
XX
M24
10M
2410
X
M24
20M
2420
X
M24
30M
2430
Table 1.2 OASIS-C2 revisions (cont.)
Home Health Guideto OASIS -C2
A Reference For Field Staff
Home Health Guide to OASIS-C2: A Reference for Field Staff walks home health providers through OASIS-C2 documentation and the changes made to the OASIS data set by CMS. This book includes step-by-step instructions for filling out each OASIS-C2 item, explanations of how OASIS items fit into various assessments, a breakdown of how the data collection affects reimbursement, and troubleshooting tips to avoid incorrect payments, denials, and fines. This edition also points out items related to quality of patient care star ratings, offers case-mix tips, and provides examples with diagnosis to properly document.
HHPGC2
100 Winners Circle, Suite 300Brentwood, TN 37027www.hcmarketplace.com
Melinda A. Gaboury, COS-C
HHPGC2_cover_final.indd 2 1/25/17 12:10 PM