Category 1 - Applicability

The Conditions of Participation do not require OASIS data collection on pediatric patients. However, if Medicare is the payer, at least the payment OASIS items would have to be collected in order to generate the payer requirement of a HHRG/HIPPS code. jHAVEN or other software may be used to generate the HIPPS/HHRG code. This code would be submitted to the Medicare Administrative Contractor (MAC) for billing purposes only. The data should not be submitted to the OASIS system. The OASIS system will reject any incomplete assessments, or any data submitted for patients younger than 18 years of age. For further information regarding data submission, contact your OASIS Automation Coordinator (OAC). Contact information is available at https://www.cms.gov/Medicare/Provider-Enrollmentand-Certification/SurveyCertificationGenInfo/OASIS-Coordinators. For further information about coverage or billing, contact your MAC.

The Conditions of Participation do not require OASIS data collection for patients receiving only maternity-related services. Post-partum complications and a wound infection in the C-section incision are only possible in maternity patients. Maternity patients are patients who are currently or were recently pregnant and are receiving treatment as a direct result of the pregnancy.

Medicare Conditions of Participation (CoP) for home health are separate from the rules governing the Medicare hospice program. Care delivered to a patient under the Medicare home health benefit needs to meet the Federal requirements put forth for home health agencies, which include OASIS data collection and submission. Care delivered to a patient under the Medicare hospice benefit needs to meet the Federal requirements put forth for hospice care, which do not include OASIS data collection or reporting. However, if a patient is receiving skilled terminal care services through the home health benefit, OASIS applies.

If an HHA is required to meet the Medicare Conditions of Participation (CoP), then all of the CoP apply to all branches of that agency including the comprehensive assessment and OASIS data collection. Whether the agency has different branches operating under a single provider agreement/number serving different patient populations does not matter. Some States, as a part of State licensure or certification, allow HHAs to establish completely separate entities for serving other than Medicare/Medicaid patients. If the separate entity does not have to comply with the Medicare CoP for any reason (e.g., they do not have to meet the Medicare CoP to compete for managed care contracts, etc.) and the individual State does not require Medicare compliance, then none of the CoP applies. To be considered a separate entity, several requirements must be met, including separate incorporation for tax and business purposes, separate employer IDs, separate staff, separate billing and cost reporting systems, etc. If this separate entity is not meeting the Medicare CoP, then it cannot be using Medicare certification for any reason, including payment or competing for contracts.

If a Medicare patient receives therapy services at a SNF, hospital, or rehab center as part of the home health benefit simply because the required equipment cannot be made available at the patient's home, the Medicare Conditions of Participation apply, including the comprehensive assessment and collection and reporting of OASIS data. However, if the services are provided to a patient RESIDING in an inpatient facility, then these are not considered home care services, and the comprehensive assessment would not need to be conducted.

If the individual was determined to not be eligible for services, the patient would not be admitted for care by the agency, and no comprehensive assessment or OASIS data collection would be required. No data would be transmitted to the OASIS system.