Category 2 - Comprehensive Assessment

In most cases, a hospitalization of 24 hours or more, which occurs for reasons other than diagnostic testing, is an event that can trigger changes in the patient and may alter the plan of care. When you learn of a hospitalization, you need to determine if the hospital stay was 24 hours or longer and occurred for reasons other than diagnostic testing. If the hospitalization was for less than 24 hours (or was 24 hours or more but for diagnostic purposes only), no special action is required. If the hospitalization did meet the criteria for an assessment update, complete an assessment that includes the Transfer to Inpatient Facility OASIS data items using Response 6 in M0100 - Reason for Assessment is Being Completed. Enter March 20, 2021, as the response to M0090 - Date Assessment Completed (if that was the date you completed the data collection after learning of the hospitalization) and March 2, 2021, in M0906 Discharge/Transfer/Death Date (the actual date of the transfer). You have 2 days from the point you have knowledge of a patient's return home from an inpatient stay, or on the physicianordered Resumption of Care date to complete the Resumption of Care visit, selecting Response 3 for M0100. M0090 will be the last date that information used to complete the comprehensive assessment and determine the OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed. The Resumption of Care Date (M0032) would be the first visit after return from the hospital, i.e., March 20, 2021 in this example. When completing the Resumption of Care (ROC) assessment, follow all instructions for specific OASIS items. For example, in responding to M1000 - Inpatient Facilities, when the inpatient facility discharge date was more than 14 days prior to the M0032 - ROC date, NA is the appropriate response.

CMS defines a qualified clinician for the purpose of collecting and documenting accurate OASIS data as a Registered Nurse, Physical Therapist, Speech-Language Pathologist, or Occupational Therapist. The qualifications of individuals doing a quality review of the comprehensive assessment, including OASIS items, and/or providing education and instruction related to OASIS data collection should be defined by agency policy.

Each patient must receive a patient-specific comprehensive assessment that accurately reflects that patient’s status, and must include, at a minimum: the patient’s current health, psychological, functional, and cognitive status, as well as their strengths, goals, and care preferences, continuing need for home care, medical, nursing rehabilitative, social and discharge planning needs, a review of all medications the patient is currently taking and the patient’s primary caregiver(s), if any as described in the Conditions of Participation. The OASIS items alone are not a complete comprehensive assessment.

Since an order for nursing existed at the time of the initial referral, the RN must complete the initial assessment visit. If it is determined during the initial assessment visit, that the patient either did not have a need for nursing services and/or the patient declined all nursing services, the Start of Care (SOC) will not be established by that visit. A comprehensive assessment performed on a date BEFORE the SOC date does not meet the Medicare HH CoPs. The RN can notify the physician that nursing will not be involved in the patient’s care, and either continue on to complete the SOC comprehensive assessment including OASIS (if the PT will be establishing the SOC that day), return for a non-billable visit to complete the SOC comprehensive assessment including OASIS on or within 5 days after PT establishes the start of care, OR have the PT complete the SOC comprehensive assessment including OASIS.

If nursing is ordered in the initial referral, then the case is NOT therapy-only, and the RN should conduct the Start of Care (SOC) comprehensive assessment including OASIS. If there is no order for nursing in the initial referral then the case is therapy-only at SOC, and the therapist can perform the SOC comprehensive assessment including OASIS. Either discipline may perform subsequent assessments.

You describe a situation where the physical therapist (PT) provides the start of care (SOC) visit and completes the comprehensive assessment including OASIS and identifies a need for nursing to address medication management and wound care. The type of document that the RN would complete is dependent upon the patient situation and agency policies. The following are some options that an agency may use in the situation described to document the nurse’s first visit:

• •Since the SOC comprehensive assessment including OASIS had already been completed by the PT, the RN could document the nursing visit with a non-OASIS nursing evaluation form or other agency documentation form.
• •If the RN visit is within the 5-day SOC assessment timeframe, the RN may complete another SOC comprehensive assessment including OASIS form. Only one SOC OASIS can be submitted.
• •If the circumstances surrounding the patient’s need for nursing met the agency’s policy/criteria for a major decline or improvement in health status, then an RFA 5 - Other follow-up assessment would be required, and the RN could complete that assessment form to document the nursing visit.

Because no nursing orders exist, the PT (or ST) could perform the comprehensive assessment including OASIS at the SOC and all subsequent assessments.

A comprehensive assessment performed on a date BEFORE the SOC date does not meet the requirements of the regulations. If the agency chooses to have an RN conduct the comprehensive assessment, the RN should perform an assessment on or within 5 days of the therapist's SOC date.

The Start of Care is established when a service is provided that is considered reimbursable by the payer. If an agency sends a clinician to the patient’s home to provide a nonbillable service, it does not establish the Start of Care. The 60-day certification period and the 30-day PDGM payment period (From Date) begin on the date the first billable service is provided. In your scenario, the episode (certification period and payment period) begins on Monday when the PT provides a billable service.

The Discharge comprehensive assessment requires a patient encounter and assessment from a qualified clinician. The RN may complete the discharge comprehensive assessment including OASIS document based on information from their last visit. The assessing clinician may supplement the discharge assessment with information documented from patient visits by other agency staff that occurred in the last 5 days that the patient received visits from the agency. The “last 5 days that the patient received visits” are defined as the date of the last patient visit, plus the four preceding days.

When the agency does not have knowledge that a patient has experienced a qualifying inpatient transfer and discharge home, and they become aware of this during a visit by an agency staff member who is not qualified to conduct an assessment, then the agency must send a qualified clinician (RN, PT, OT, or SLP) to conduct a visit and complete both the transfer (RFA 6) and the ROC (RFA 3). Both the transfer and ROC assessment should be completed within 2 calendar days of the agency’s knowledge of the qualifying inpatient admission. The ROC date (M0032) will be the date of the first visit following an inpatient stay, conducted by any person providing a service under your home health plan of care, which, in your example would be the aide, therapist assistant, or LPN.

When an agency is notified that a patient has had a qualifying inpatient facility admission, a missed Transfer and Resumption of Care assessment would be completed as soon as the agency becomes aware of the missed assessment(s), recognizing that in some situations (as with a patient discharge, death, relocation, etc.) a home visit to conduct the Resumption of Care assessment visit may not be possible. In the scenario cited, even if the Resumption of Care assessment is not able to be completed because necessary data to complete the assessment is not available, the Transfer OASIS (RFA 6 – Transferred to an inpatient facility – patient not discharged from agency) would be completed to end the patient’s quality episode with the M0906 – Discharge/Transfer/Death Date being the date the patient transferred to the hospital, and the M0090 - Date Assessment Completed would be the last day that information used determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed.

The comprehensive assessment including OASIS is the responsibility of one clinician. The assessing clinician responsible for completing the comprehensive assessment may work collaboratively and elicit feedback from other agency staff, to complete any or all OASIS items integrated within the Comprehensive Assessment. This may include collaborating with others in the office to allow completion of items. All staff, including professional assistants or non-clinical staff functioning within the scope of their practice and state licensure as applicable, may perform a record review and communicate the findings to the assessing clinician, who would be responsible for confirming and validating the information used to complete the assessment. In these collaborative situations, it is the single assessing clinician who will complete the comprehensive assessment after any appropriate collaboration has occurred.

Yes, the statement “other agency staff” in the context of the collaboration refers to staff within the assessing clinician’s home health agency, including staff contracted by the agency.

When collaboration is used, other agency staff may provide information to the assessing clinician on what they assessed during a visit conducted during the assessment timeframe. Each person collaborating may provide information that was collected utilizing the existing conventions, including the “day of assessment.” For example, if desired, the PT who visited on Wednesday may provide information that was relevant to the PT’s “day of assessment” (the 24 hours that proceeded the PT’s visit, and the time the PT was in the home) to the RN for consideration when coding the SOC/ROC assessment items.

At Resumption of Care (ROC), the assessing clinician may supplement their assessment with information from visits conducted by other agency staff within the assessment timeframe. A ROC comprehensive assessment including OASIS, if applicable, must be completed within 2 calendar days of facility discharge, or knowledge of the patient’s return home, or the physician’s ordered ROC date. In this scenario, the M0032 - ROC date is Monday (the date of the first visit following a qualifying inpatient stay) and the assessment must be completed by Wednesday (2 calendar days of agency knowledge of the patient’s return home). If desired, the nurse may use the information from the three visits that occur within the assessment timeframe (i.e., the HHA visit on Monday, the RN assessment on Tuesday, and the PT visit on Wednesday) to complete the ROC assessment. The OT visit on Thursday is outside the assessment timeframe and information from that visit may not be considered when determining OASIS responses.

For a planned or unplanned discharge, the assessment must be completed within 2 days of the discharge date, and information from the last five days the agency provided visits may be considered by the assessing clinician when selecting OASIS responses. The “last 5 days that the patient received visits” are defined as the date of the last patient visit, plus the four preceding calendar days. For a Resumption of Care (ROC), the current data collection guidance states that the assessment timeframe (the maximum number of days in which the assessment must be completed) is within two days of the inpatient facility discharge, or knowledge of the discharge, or the physician-ordered ROC date; and the time period under consideration (the period of time in which the patient’s status can be considered when selecting a response) for most items is the “day of assessment”, which is defined as “24 hours immediately preceding the visit and the time spent in the home.” For a Recertification, the assessment timeframe is the last five days of the certification period, and the time period under consideration for most items is the “day of assessment,” which is defined as “24 hours immediately preceding the visit and the time spent in the home.”

In the case of an unplanned discharge (an end of home care where no in-home visit can be made), the last qualified clinician who saw the patient may complete the discharge comprehensive assessment document based on information from their last visit. The assessing clinician may supplement the OASIS items on the discharge assessment with information documented from patient visits by other agency staff that occurred in the last 5 days that the patient received visits from the agency prior to the unplanned discharge. The “last 5 days that the patient received visits” are defined as the date of the last patient visit, plus the four preceding calendar days. In your situation, the last qualified clinician who saw the patient is not available. Follow these steps: 1. If possible, send another clinician out to visit the patient and perform the Discharge comprehensive assessment visit. 2. If not possible to visit the patient, look back in the notes to find another qualified clinician who saw the patient (preferably as close to the time of discharge as possible), and who could complete the discharge comprehensive assessment based on their last visit. The assessing clinician may supplement the discharge assessment with information documented from patient visits by other agency staff that occurred in the last 5 days that the patient received visits from the agency prior to the unplanned discharge. 3. If the clinician on leave was the only qualified clinician to see the patient and it is impossible to make an additional visit to the patient, it may not be possible to complete a Discharge comprehensive assessment. The Discharge comprehensive assessment requires an in-person patient encounter and assessment from a qualified clinician. A supervisor or other agency clinician who has not visited the patient cannot complete a discharge comprehensive assessment compliantly using only information documented from patient visits by other agency staff that occurred in the last 5 days that the patient received visits from the agency prior to the unplanned discharge.

A Discharge comprehensive assessment including OASIS is required within two days of the patient’s discharge date. The Discharge comprehensive assessment requires an inperson patient encounter and assessment from a qualified clinician. If a Discharge comprehensive assessment including OASIS is missed, the agency should complete the discharge assessment as soon as the oversight is identified. There may be situations in which this is not possible (i.e., the discharging clinician does not have sufficient assessment information to complete the discharge assessment and an additional home visit is not possible within two days of the discharge date, or the missed OASIS is not identified until greater than two days after the discharge date). After the discharge assessment timeframe, a missed discharge OASIS may not be created based on previous visits/visit notes. Failing to complete a discharge assessment should be avoided, as not completing a timely discharge assessment represents non-compliance with the comprehensive assessment update standard (of the CoP). For the Medicare PPS (PDGM) patient, payment implications may also arise from a missed assessment based on the QAO threshold calculation. Any questions about payment implications may be directed to your agency's Medicare Administrative Coordinator (MAC).

Yes, whether the discharge is planned or unplanned, all events that have occurred during the quality episode (at the time of or any time since the most recent SOC/ROC assessment) should be reported. This is true regardless of when the last qualifying clinician conducted a visit.

There is no OASIS guidance that allows for a “non-visit” discharge comprehensive assessment with OASIS. The OASIS Guidance Manual coding instructions for M0100 Reason for Assessment, Response 9 - Discharge state: “This comprehensive assessment is conducted when a patient is discharged from the agency for any reason other than transfer to an inpatient facility or death at home". The discharge comprehensive assessment with OASIS requires an in-person patient encounter and assessment from a qualified clinician. For details on how to complete a discharge assessment in the case of an unplanned discharge, see additional guidance in Category 2 Q15.3.6.

Each patient must receive a patient-specific comprehensive assessment that accurately reflects that patient’s status, and must include, at a minimum: the patient’s current health, psychological, functional, and cognitive status, as well as their strengths, goals, and care preferences, continuing need for home care, medical, nursing rehabilitative, social and discharge planning needs, a review of all medications the patient is currently taking and the patient’s primary caregiver(s), if any as described in the Conditions of Participation. In addition to any required OASIS items, an agency may determine what other assessment items will be included in the agency’s comprehensive assessment(s) to meet regulatory, coverage and clinical needs.

In the scenario presented, you describe a case in which an initial assessment was conducted, it was determined the patient met the payer’s eligibility and your agency’s admission criteria and a comprehensive assessment was begun, if not completed. If a reimbursable service was provided, it would have established the start of care (SOC). If the OASIS assessment was not completely finished and the criteria for a Transfer was not met, the assessing clinician would have up to 5 days after the SOC date to complete the RFA 1, SOC comprehensive assessment. The SOC date was established when the first reimbursable service was provided. If no billable service was provided before the patient was transported to the ER, the SOC date was not established and a new SOC would be completed upon return home from the inpatient facility. OASIS data collection and submission is not required when only one visit is made in a quality episode. However, to bill Medicare PPS (PDGM) for a single visit in a quality episode, OASIS data must be collected and submitted If you choose NOT TO BILL Medicare for the single visit provided, there is no requirement to collect and transmit OASIS data for single visit quality episodes. Questions related to coverage and billing for Medicare patients are addressed in the Medicare Policy Benefit Manual and the Claims Processing Manual.

In your case, the initial assessment visit was made, a billable service was provided establishing the Start of Care (SOC) date and the SOC comprehensive assessment was begun but not completed before the qualifying stay in the inpatient facility. When the patient returned to your care on 1/26 which was within the allowed 5-day SOC assessment timeframe, the assessing clinician could complete the SOC comprehensive assessment that was begun on the first visit. M0030 - Start of Care Date, remains the date of the first billable visit. M0090 - Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine the OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed. Unless it had already been completed by someone else, the clinician who completes the SOC assessment on 1/26 may also complete the RFA 6 - Transfer. The agency would then complete the Resumption of Care (ROC) assessment within 2 calendar days of the patient’s inpatient facility discharge date. This ROC assessment may also be completed on the 1/26 visit, by the same clinician who completes the SOC assessment and the OASIS Transfer data collection.

If you need to discharge a patient from Medicare home health when they elect the Medicare Hospice benefit, you are required to complete the discharge comprehensive assessment including the OASIS. M2420 - Discharge Disposition, will be Response 3 - Patient transferred to a non-institutional hospice.

The initial assessment visit at SOC (or the Resumption of Care visit) must be completed within 48 hours of the referral, within 48 hours of the patient’s return home OR on the physicianordered SOC/ROC date. In the absence of a physician-ordered SOC/ROC date, if the patient refuses a visit within this 48-hour period, the agency may contact the physician to determine whether a delay in visiting would be detrimental to the plan of care and request a change in the SOC/ROC date.

Any partial OASIS assessment that was completed can be filed in the patient record, but a partial OASIS assessment cannot be submitted.

• •If, after the 911 call, the patient is admitted to an inpatient facility and then later returns home again after a qualifying inpatient stay, a Resumption of Care visit would be indicated within 48 hours of the hospital discharge or on a Physician-ordered Resumption of Care date, if applicable.
• •If the 911 call results in the ED treating the patient and sending the patient back home, the Resumption of care assessment would be completed within 2 calendar days of the patient’s March 2nd discharge from the inpatient facility.

The initial assessment visit is conducted to determine the immediate care and support needs of the patient and, in the case of Medicare patients, to determine eligibility for the home health benefit including homebound status. If no reimbursable service is delivered, this visit is not considered the start of care (SOC) and does not establish the SOC date. The SOC comprehensive assessment must be completed on or within 5 calendar days after the SOC date and in compliance with agency policies. In the interest of cost-effectiveness, many agencies have combined the initial assessment with the delivery of skilled service(s), assuming the patient is eligible for home care. This would make the initial assessment and the SOC the same date. If the admitting clinician was able to complete the SOC comprehensive assessment including OASIS on this initial visit as well, the SOC date (M0030) is the same as the date the assessment is completed (M0090). These protocols and procedures are a matter of agency choice and agency policy, as long as the regulatory time requirements are met.

The Comprehensive Assessment of Patients Condition of Participation (CoP) §484.55 requires that the initial assessment visit must be completed by an RN, if nursing orders exist at the SOC and by an appropriate, qualified therapist if no nursing orders exist. It would not meet the requirements of the Condition for an individual who is not qualified to perform assessments to enter the home before the skilled clinician who will be performing the initial assessment. This requirement is designed to ensure that the patient's immediate needs can be assessed and met. If an agency allowed a non-clinical person to enter the home to collect demographic information and explain rights and responsibilities, etc., it is possible that a potentially lifethreatening condition may not be assessed and treated. LPNs are not qualified to complete assessments so therefore it would not be compliant with the Condition to allow an LPN to conduct the initial assessment. The agency may have a non-clinical person (or LPN, etc.) communicate with the patient by phone prior to the initial assessment visit to gather or impart some of the information related to patient rights and services as part of the intake process, but the actual first visit to the home constitutes the initial assessment visit and must follow conditions outlined in the CoPs.

To fulfill the comprehensive assessment requirement, agencies should remember that the OASIS data set does not, by itself, constitute a comprehensive assessment. Home Health agencies should refer to the Conditions of Participation to determine the expected scope of the comprehensive patient assessment.

Yes, The OASIS RFA 8 - Death at home is completed when the patient dies at home or anywhere other than after being admitted for a qualifying inpatient stay. A patient who dies en route to the hospital would be considered a death at home. A patient who dies after being admitted to the hospital's emergency department (ED), regardless of how long they have been in the ED, is considered to have died at home. A patient who dies less than 24 hours after being admitted to an inpatient facility is considered to have died at home. A patient who dies while being held for observation is considered to have died at home.

An RFA 8 - Death at home is completed when the patient dies at home or anywhere other than after being admitted for a qualifying inpatient stay. This includes a patient who expires during outpatient surgery or in the care of the recovery room after outpatient surgery.

When a patient dies anywhere other than after being admitted for a qualifying inpatient stay complete an RFA 8 - Death at home OASIS. A qualifying inpatient stay is defined as a patient being admitted to an inpatient facility for 24 hours or more for reasons other than diagnostic testing. Only use RFA 7 - Transferred to an inpatient facility - patient discharged from agency when a patient is transferred from your agency for a qualifying inpatient stay and return to your agency is not expected.

The Transfer completed the OASIS requirements, and no further OASIS data collection is expected. The patient did not resume care with the HHA. The agency's discharge summary should be completed to close out the clinical record.

The reason you are getting the sequencing error is because you completed a Transfer OASIS and then submitted a Discharge OASIS. When a Transfer OASIS is submitted, the next expected submission would be a Resumption of Care (ROC) - RFA 3. If the patient did not resume services at your agency, then an internal agency discharge (with no OASIS collection) would be expected. It is not clear whether or not you made a visit when the patient returned home from the hospital. If the patient returned home from the hospital and refused further visits, the Transfer OASIS would be the last OASIS data collection required. You would not need to complete an OASIS Discharge, just your agency's internal agency discharge paperwork. If the patient returned home from the hospital and you made one visit (the ROC visit) and then the patient refused further visits, you are not required to collect and submit the ROC OASIS data for one visit episodes (quality episodes). You are required by the Conditions of Participation (§484.55) to perform a comprehensive assessment when resuming care of a patient following an inpatient stay of 24 hours or longer for reasons other than diagnostic tests, but OASIS is not required when only one visit is made at the ROC.

In situations where only one visit was performed in a quality episode, such as the situation described, the OASIS does not have to be submitted to the OASIS system. Therefore, it is acceptable to not submit the ROC/Recert assessment to the OASIS system, but rather to maintain the completed ROC/Recert assessment in the patient's clinical record, with documentation explaining the situation. It would also be acceptable to submit the ROC/Recert and Death at Home assessments to the OASIS system. The Death at home OASIS is never mandated in situations of single visits in a quality episode (SOC/ROC date to DAH).

The OASIS items should be answered based on the clinician's total assessment, not administered as an interview. A patient assessment includes (but is not limited to) interaction and observation.

For OASIS items intended to reflect a patient's current status on the day of assessment, like M1830 - Bathing or M2020 - Management of Oral Medications, clinicians should select a response based on the patient's ability on the day of assessment without referring back to prior assessments or documentation of status from a prior care setting. For OASIS items that require a look back to the time of or at any time since the most recent SOC/ROC assessment, like M2401 - Intervention Synopsis, the "look back" is required to determine if specific assessments were completed, what the results of such assessments were, and/or what actions (e.g., orders, interventions implemented) resulted.

Each OASIS item should be considered individually and coded based on the guidance provided for that item. Unless otherwise specified in item guidance, information collected by the assessing clinician during the timeframe for the specified assessment type may be used to inform OASIS coding. Note item guidance does specify special rules for coding pressure ulcer/injury and GG Function items at Start of care/Resumption of care (SOC/ROC). To support consistency of data collection related to pressure ulcers/injuries and GG function data across all post-acute care (PAC) providers, cross-setting guidance directs coding for pressure ulcers/injuries to be based on the “first skin assessment” and coding for GG0130 - Self-Care and GG0170 - Mobility items should be based on a functional assessment that occurs at or soon after the patient’s SOC/ROC, and reflect the patient’s baseline ability to complete the activity, prior to the benefit of services provided by your agency staff.

The Condition of Participation standard for the drug regimen review states the comprehensive assessment must include a review of all medications the patient is using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Each agency must determine the capabilities of current staff members to perform comprehensive assessments, taking into account professional standards or practice acts specific to your State. Only RNs, PTs, OTs, and SLPs are qualified to perform comprehensive assessments.

It is acceptable for an RN in the office to collaborate on the drug regimen review in a situation where a therapist completes the comprehensive assessment. If areas of concern are identified, the agency must notify the physician and as appropriate obtain orders for any nursing intervention to further assess and resolve issues and educate the patient regarding medication changes and management.

Regardless of payer, patients who do not meet an OASIS exemption, and who begin receiving “skilled services” from a Medicare certified home health agency (HHA) with an OASIS Start of Care (SOC) M0090 - Date Assessment Completed on or after July 1, 2025, require OASIS data collection and submission to the Internet Quality Improvement and Evaluation System (iQIES). The OASIS exemptions include patients under the age of 18, patients receiving only maternity services, and patients receiving only chore, housekeeping or personal care services. OASIS is not required when there is only one visit in a quality episode. In your scenario, it does not appear that the patient described met any of the OASIS exemptions and more than one visit was made so it does not meet the definition of a single visit quality episode. Therefore, the comprehensive assessment including OASIS is required for both the SOC (RFA 1) and DC (RFA 9). This is true even if one or more of the visits were non-billable.

Different States, different payers, and different agencies have varying responses to payer change situations, so we usually find it most effective to ask, “Does the new payer require a new SOC?" HHAs usually can work their way through what they need to do if they answer this question. If the new payer source requires a new SOC (Medicare is one that DOES require a new SOC), then it is recommended that the patient be discharged from the previous pay source and reassessed under the new pay source, i.e., a new SOC comprehensive assessment. The agency does not have to re-admit the patient in the sense that it would normally admit a new patient (and all the paperwork that entails). When transitioning from a skilled Medicare or Medicaid patient to a situation not requiring OASIS (e.g., moving from skilled Medicare to personal care only), CMS encourages HHAs to complete a discharge OASIS assessment at the last visit under the Medicare or Medicaid pay source. While this is not a requirement, conducting a discharge OASIS assessment at the point where the patient’s skilled need has ended provides a clear endpoint to the patient’s quality episode for purposes of the agency’s quality initiatives.

When there is a pay source change to Medicare FFS mid-episode a new Start of Care (SOC) is required. The SOC and Discharge comprehensive assessments are based on an inperson patient encounter and assessment from a qualified clinician (which may include collaboration). If the qualified clinician that no longer works for the agency was the only qualified clinician to see the patient since the patient qualified for Medicare, it may not be possible to complete a SOC or Discharge comprehensive assessment. In addition to OASIS completion, other regulatory and payer requirements may be affected by a payer source change.

• •Questions related to home health regulations and compliance may be sent to the Home Health Survey Mailbox at hhasurveyprotocols@cms.hhs.gov
• •Questions regarding general information about the Home Health Prospective Payment System (HH PPS) may be sent to: HomeHealthPolicy@cms.hhs.gov

The Start of Care (SOC) is established on the day the first billable service is provided. The SOC comprehensive assessment must be completed on or within 5 days after the Start of Care date. An initial assessment may be performed prior to the SOC date, (e.g., RN admitting for a therapy only case). If agency policy is for the RN to perform the initial assessment during a non-billable visit to meet the Condition of Participation (§484.55) time requirement of 48 hours for the completion of the initial assessment, and the RN does not provide a billable service, the SOC is not yet established. If the PT does not visit that same day, the date of the RN's initial assessment visit is not the SOC date. If the PT visits the next day, the SOC date is the day the PT visits and provides a billable service. While the RN likely conducted at least part of a comprehensive assessment to meet the requirements of an initial assessment visit and determine immediate care and support needs of the patient, any information collected on that date may not contribute to the SOC comprehensive assessment, as it was collected prior to the SOC date. The SOC comprehensive assessment that will include the OASIS data that will be transmitted to the OASIS system as the SOC assessment must be collected on or within 5 days after the SOC date, not before.

A) If the comprehensive assessment for a patient requiring OASIS data collection was not completed and the assessing clinician is no longer available to finish the comprehensive assessment, the agency may send another qualified clinician out during the allowed assessment timeframe (e.g., within 5 days after the Start of Care (SOC) date), to complete the comprehensive assessment including OASIS. This comprehensive assessment can be completed with or without allowed collaboration, including review of the departed clinician’s documentation. B & C) The comprehensive assessment, including OASIS, is a legal document and when signed by a clinician, the signature is an attestation that all information contained in the document is truthful and accurate. If an error is discovered upon review by a supervisor or other auditing staff and it can be validated that it is a true error and not just a discrepancy (a difference between two data items without knowledge of which data item is correct), that error should be corrected following the agency's correction policy and established professional medical record documentation standards. When a potential inconsistency is identified within the assessment timeframe and the assessing clinician is not available to approve the suggested edits then the original OASIS responses selected by the assessing clinician on the completed OASIS would be submitted. For additional guidance related to the CMS OASIS Correction Policy refer to the State Operations Manual, Chapter 2.

You have described a situation where an OASIS error was discovered during the audit process. The assessment was complete. Documentation reported that the patient had an ostomy and no surgical wounds. HHAs should have a policy and procedure for correcting OASIS errors that involves the assessing clinician. The policy should follow established clinical record professional practice standards and guidance found in relevant CMS regulations and guidance. A correction policy may allow the auditor who found the error to contact the assessing clinician, discuss the discrepancy in the medical record and make the correction. Correction of an error will not impact the M0090 - Date Assessment Completed. When the original assessing clinician is not available, the clinical supervisor or quality staff may make the correction to the documentation following the correction policy. The supervisor may document why the original assessing clinician is not available to make the correction and how the error was identified and validated as an error. When corrections are made to assessments submitted to the OASIS system, consider the impact of the correction on the POC and HHRG. CMS urges HHAs to make corrections and/or submit inactivations as quickly as possible after errors are identified so the OASIS system will be as current and accurate as possible, as the data may be used for quality measurement or payment purposes.

When a potential inconsistency is identified within the assessment timeframe and the assessing clinician is not available to approve the suggested edits then the original OASIS responses selected by the assessing clinician on the completed OASIS would be submitted. If an error is discovered upon review by a supervisor or other auditing staff and it can be validated that it is a true error and not just a discrepancy (a difference between two data items without knowledge of which data item is correct), that error should be corrected following the agency's correction policy and established professional medical record documentation standards. When the original assessing clinician is not available to correct the true error, the clinical supervisor or quality staff may make the correction of the validated error following the agency’s correction policy. The supervisor may document why the original assessing clinician is not available to make the correction and how the error was identified and validated as an error. Please note that the comprehensive assessment, including OASIS, is a legal document and when signed by a clinician, the signature is an attestation that all information contained in the document is truthful and accurate.

While a home health agency may use third party external auditors to review OASIS coding and make recommendations, the assessing clinician is responsible for determining OASIS coding based on their assessment. Each OASIS item should be considered individually and coded based on the guidance provided for that item. When a potential inconsistency is identified within the assessment timeframe (including inconsistencies identified by a vendor/consultant/third-party reviewer), the assessing clinician may consider available input from these other sources and determine if any revisions to OASIS item responses is warranted, within the assessment timeframe and consistent with OASIS guidance.

We encourage HHAs to complete a discharge OASIS assessment for a patient who no longer requires skilled care but continues to receive personal care only. While this is not a requirement, conducting a discharge OASIS assessment at the point where the patient's skilled need has ended provides a clear endpoint to the patient's quality episode for purposes of the agency's quality initiatives. In this case, OASIS item M0100 - Reason for Assessment should be marked with Response 9 (Discharge from agency). While the patient may continue to receive personal care services from a Medicare-certified home health agency, since the services are not skilled, OASIS item M2420 - Discharge Disposition should be marked with Response 1 - Patient remained in the community (without formal assistive services).

No assessment is required at that point. The agency’s last contact with the patient was at the point of transfer to the inpatient facility, so the Transfer OASIS data conclude the quality episode from the point of OASIS data collection. If the agency had not already discharged the patient, there presumably would need to be some documentation placed in the clinical record to close the case for administrative purposes.

Completion of a comprehensive patient assessment is required, even when the patient only receives a single visit in a quality episode. Based on CMS policy, OASIS data collection and submission is not required when only one visit is made in a quality episode (SOC/ROC date to TRF/DC/DAH). However, to bill Medicare PPS (PDGM) for a single visit quality episode, OASIS data must be collected and submitted to the OASIS system and used to calculate a HIPPS code for inclusion on the Medicare claim. If you choose NOT TO BILL Medicare for the single visit provided, there is no requirement to collect and transmit OASIS data for single visit quality episodes. If collected, RFA 1 is the appropriate response on M0100 - Reason for Assessment for a onevisit Medicare PPS (PDGM) patient. For a single visit episode if OASIS data is required for payment by a non-Medicare/nonMedicaid payer (M0150 – Current Payment Sources does not include Response(s) 1, 2, 3, or 4), the resulting OASIS data, which may just include the OASIS items required by the payer, may be provided to the payer, but should not be submitted to the OASIS system. Regardless of pay source, the Discharge comprehensive assessment including OASIS should NOT be collected or submitted, as the patient received only one visit. Agency clinical documentation should note that no further visits occurred. If initial SOC data is submitted and then no discharge data is submitted, you should be aware that the patient’s name will appear on the data management system (DMS) agency roster report for six months, after which time the patient’s name is dropped from the DMS report. If the patient were admitted again to the agency and a subsequent SOC OASIS assessment submitted, the agency would receive a warning that the new OASIS assessment was out of sequence. This would not prevent the agency from transmitting that OASIS assessment, however.

You have described a situation where more than one visit was made - RN or therapist performs SOC comprehensive visit and then an MSW (or aide) visits. Two visits were made. In this situation a Discharge comprehensive assessment including OASIS is required.

OASIS data collection is required if more than one visit was made in a quality episode. In your scenario, the nurse made one visit and the PT made one visit. Therefore, the comprehensive assessment including OASIS is required for both the SOC (RFA 1) and DC (RFA 9). This is true even if one of the visits was non-billable.

The quality episode begins on the SOC/ROC (M0030/M0032) date which is defined as the date of the first billable service. In the case where the PT makes only one visit and the visit is billable this is the SOC date. The nurse provides a second visit (nonbillable) within the 5 days after the SOC to complete the SOC comprehensive assessment including the OASIS. Both the OASIS SOC and a Discharge comprehensive assessment including OASIS would be required, as two visits were made in the quality episode.

All pediatric, maternity, and patients requiring only personal care, housekeeping, or chore services are exempt from the OASIS data collection requirements. For pediatric, maternity, or personal care patients, the HHA will need to complete an agency-developed comprehensive assessment at the required time points. The agency may develop its own comprehensive assessment and tailor it to the needs of the patients of their case-mix. An HHA is not required to conduct a comprehensive assessment including OASIS for individuals where HHA services are entirely limited to housekeeping or chore services.

The OASIS data set was not developed for use with children. If a payer requires OASIS data collection on children, the assessing clinician must use clinical judgment and select the best possible response for each OASIS item, with an understanding that the response may not accurately represent the true status of the child. Clinical documentation will detail the true status of the child and why the OASIS was completed, e.g., payer required a data collection instrument designed for adults to be completed on a child.

Yes, this is acceptable. This scenario appears to fit the criteria for single visit quality episodes for Start of Care or Resumption of Care that became effective December 16, 2002. The Conditions of Participation require that each patient receive a comprehensive assessment. Based on CMS policy, OASIS data collection and submission is not required when only one visit is made in a quality episode (SOC/ROC date to TRF/DC). However, to bill Medicare PPS (PDGM) for a single visit payment period, OASIS data must be collected and submitted to the OASIS system and used to calculate a HIPPS code for inclusion on the Medicare claim. If you choose NOT TO BILL Medicare for the single visit provided, there is no requirement to collect and transmit OASIS data for single visit quality episodes. When a patient is discharged after only one visit (a single visit quality episode), a Discharge OASIS should NOT be collected or submitted.

You are correct that in situations where only one visit was performed in a quality episode, the OASIS does not have to be submitted to the OASIS system. The OASIS data collection instrument was originally developed so that home health agencies could calculate patient outcomes as part of their quality improvement initiatives. In order to produce end result outcomes, patient level data collected at SOC/ROC are compared to the data collected at discharge. When only one visit is made, it is impossible to calculate end result outcomes. Therefore, since the December 2002 OASIS burden reduction initiatives, home health agencies have not been required to collect and/or submit OASIS data for one-visit episodes. If you admit a patient to your home health agency and then become aware that for whatever reason no additional visits will be made after the first visit, by CMS policy you are not required to collect, or submit any already-collected, OASIS data to the OASIS system for that patient episode. However, to bill Medicare PPS (PDGM) for a single visit payment period, OASIS data must be collected and submitted to the OASIS system and used to calculate a HIPPS code for inclusion on the Medicare claim. If you choose NOT TO BILL Medicare for the single visit provided, there is no requirement to collect and transmit OASIS data for single visit quality episodes. When a patient is discharged after only one visit (a single visit quality episode), a Discharge OASIS should NOT be collected or submitted. If the agency elected not to submit the OASIS data collected during the SOC assessment when the patient was admitted to the inpatient facility, an internal agency discharge (not OASIS) would be appropriate. No Transfer OASIS would be required as there was only one visit in the quality episode. The agency would file the pre-hospitalization SOC assessment in the patient’s record and may bill for the visit if the eligibility, coverage and billing requirements of the payer were met. (Note: For a Medicare PPS (PDGM) patient, if OASIS data were not collected and submitted for this single visit patient, billing requirements would not have been met.) When the patient returns home and to the agency's service, a SOC comprehensive assessment including OASIS would be completed. If, after completing the initial assessment visit and the SOC comprehensive assessment including OASIS (in conjunction with a reimbursable visit), the patient was admitted to an inpatient facility before a 2nd visit was provided, but you expected a return of the patient, or the return status wasn't known, the agency would complete the RFA 6 Transfer, and then complete a Resumption of Care (ROC - RFA 3) upon the patient's return home, assuming the ROC assessment is completed within the current certification period.

CMS regulations allow the therapist to conduct the discharge comprehensive assessment including OASIS (if applicable) at the discharge visit in either a therapy-only case or when the therapist is the last skilled care provider. If the agency policy is to have the RN complete the discharge comprehensive assessment including OASIS in a therapy-only case, the RN can perform this assessment after the last visit by the therapist. The RN visit to conduct the discharge assessment is a non-billable visit. The date of the actual discharge is determined by agency policy. The Discharge comprehensive assessment including OASIS should be completed within 2 days of the discharge date. The M0090 - Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed.

The case as described is a therapy-only case, thus the RN or the therapist can conduct the initial assessment to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. Once patient eligibility has been confirmed, and the plan of care contains physician orders for the qualifying service as well as other Medicare covered home health services, the qualifying service does not have to be rendered prior to the other covered home health services ordered in the plan of care. If a covered service is provided, the SOC date is established and the visit is Medicare billable. A Start of Care comprehensive assessment including OASIS cannot be performed prior to the SOC date. Thus, in the situation described, the RN can make the initial assessment visit to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit. However, this is not a billable visit. The home health aide who provides a covered service can be the first billable (SOC) visit. If it is the HHA’s policy for the RN to conduct the SOC comprehensive assessment, including OASIS, this would be completed on or within five days after the SOC date (or according to agency policy, if more restrictive). The timing of the PT evaluation visit is not specifically defined by the Conditions of Participation, except to say that the practice must comply with accepted professional standards and principles.

No. When initial orders exist for nursing and PT, the Conditions of Participation require that the RN conduct the initial assessment visit to determine the immediate care needs of the patient, and for Medicare patients, to determine program eligibility including homebound status. The RN is allowed up to five days after the SOC date to complete the SOC comprehensive assessment. The PT may conduct the PT evaluation visit after the initial visit by the RN, even if the RN has not yet completed the SOC comprehensive assessment including OASIS.

Assuming there is not a specific physician-ordered Resumption of care (ROC) date, the ROC comprehensive assessment including OASIS must be completed within 2 calendar days after the facility discharge date, or knowledge of the patient's return home. Any clinician qualified to perform comprehensive assessments including OASIS (RN, PT, OT, SLP) may complete the ROC comprehensive assessment including OASIS, following the agency's policy. In a PT only ROC, there is no requirement that the PT complete the comprehensive assessment and ROC OASIS on the first visit. It would be compliant with the Condition of Participation, §484.55, for the PT to perform a discipline-specific re-evaluation and then an RN complete the ROC comprehensive assessment including OASIS on a non-billable subsequent visit as long as the comprehensive assessment including the OASIS is completed within 2 calendar days of the facility discharge, or knowledge of the patient's return home. In this case, the ROC date M0032, will be the date of the PT's visit (the first visit after the patient's return home) and the ROC comprehensive assessment's M0090 - Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed. The dates would not be the same if the RN visited and completed the ROC comprehensive assessment including ROC OASIS the day after the PT visited and performed the evaluation. This still represents compliance with the regulations.

“Referral” means the referral from a physician/allowed practitioner (or designee) for home care evaluation and/or services. The referral may come in the form of initial contact by the physician’s office, a hospital discharge planner, or even the patient or family member, who may be in possession of the written physician’s orders for home care. If a patient or family member makes initial contact with the agency and has not discussed and/or received home care orders from the physician for a referral for home care, then this is not considered a “referral” for the purposes of determining compliance with conducting the initial assessment visit. In this case, the agency should contact the physician to obtain necessary orders, and then conduct the initial assessment visit within 48 hours of that referral date, within 48 hours of the patient’s discharge from an inpatient facility, or on the physician’s ordered start of care date.

The Condition of Participation, §484.55, stipulates that a registered nurse must conduct the initial assessment unless it is a therapy only case. Since "initial" means first, when nursing orders exist at start of care, the RN must be the first person to see the patient and complete the initial assessment requirements. The Conditions also require that if nursing orders exist at SOC, the RN must complete the SOC comprehensive assessment including the OASIS. This does not necessarily mean the RN will complete this on the SOC date or that the initiation of therapy must be delayed until the RN completes the SOC comprehensive assessment including OASIS. Federal guidelines state the SOC comprehensive assessment including the OASIS must be completed within 5 days after the SOC date. Of course, if your agency policies are more restrictive (e.g., require earlier completion), you must follow your agency policy. Your agency will be out of compliance with the Medicare Conditions of Participation when you allow the therapist to make the initial assessment visit when there are also nursing orders.

It is acceptable for the RN to make a non-billable visit in a PT only case to complete the ROC comprehensive assessment including OASIS if applicable within 48 hours of discharge. The PT may visit to evaluate the patient before or after the RN visit, as long as the PT visit timing meets federal and state requirements, physician’s orders, and is deemed reasonable by professional practice standards. The ROC date (reported in M0032) is the first visit following an inpatient stay, regardless of who provides it, whether or not the visit is billable, and whether or not the ROC comprehensive assessment including OASIS is completed on that first visit.

An agency should discharge a patient in all instances when a qualifying inpatient stay spans the end of a 60-day certification period. If the patient then returns to agency after an inpatient stay that spans the end of the 60-day certification period, CMS requires that the agency complete a new Start of Care (SOC) assessment.

In a situation where the recertification had been completed, the patient experiences a hospitalization in the current 60-day certification period, and now the comprehensive assessment including OASIS is being completed upon the patient’s return home from the qualifying inpatient stay, if the M0090 - Date Assessment Completed is between days 56-60, complete an RFA 3 (ROC). If the M0090 - Date Assessment Completed is after day 60 (M0090 date falls in the subsequent certification period) complete an RFA 1 (SOC).

If the patient had a recertification assessment visit during the last five days of the episode, and then experiences a qualifying hospitalization in the new 60-day certification period, the agency should complete a Transfer assessment. This is true whether or not any home care visits have been made in the new episode. The agency selects RFA 6 or RFA 7, depending on whether the agency anticipates the patient will be returning to service or not. When an RFA 6 Transfer OASIS is submitted, the next expected submission would be a Resumption of Care (ROC) - RFA 3. If the patient did not resume services at your agency, then your internal agency discharge process would occur (with no OASIS collection).

The Conditions of Participation state completion of a comprehensive patient assessment is required, even when the patient is known to only need a single visit in the quality episode. Based on CMS policy, OASIS data collection and submission is not required when only one visit is made in a quality episode (SOC/ROC date to TRN/DC). However, to bill Medicare PPS (PDGM) for a single visit payment period, OASIS data must be collected and submitted to the OASIS system and used to calculate a HIPPS code for inclusion on the Medicare claim. If you choose NOT TO BILL Medicare for the single visit provided, there is no requirement to collect and transmit OASIS data for single visit quality episodes. Agency clinical documentation should note that no further visits occurred. No subsequent discharge comprehensive assessment including OASIS should be collected or submitted.

The comprehensive assessment, including the OASIS and all subsequent home care visits should be completed in the physical presence of the patient in their home or place of residence.

While the PDGM case-mix adjustment is applied to each 30-day period of care, other home health requirements will continue on a 60-day basis. Specifically, certifications and recertifications continue on a 60-day basis and the comprehensive assessment will still be completed within 5 days after the start of care date and completed no less frequently than during the last 5 days of every 60 days beginning with the start of care date, as currently required by the Condition of Participation §484.55.

The OASIS assessment will not be utilized in evaluating for admission source information. Information from the Medicare claims processing system will determine the appropriate admission source for final claim payment.

If the F2F encounter does not occur within the 90 days prior to the SOC, or within 30 days after the SOC, then the Medicare HH eligibility criteria have not been met and the episode is not covered or billable as a Medicare HH episode. Assuming all other Medicare eligibility criteria are met, the F2F encounter (occurring on day 35 in the given scenario) would represent a pay source change to the Medicare HH benefit. Longstanding guidance in Section 80 of Chapter 10 of the Medicare Claims Processing Manual states that in certain instances, a new start of care OASIS assessment can be generated that reflects a start of care date equal to the start of the beneficiary’s change to Medicare FFS. A prior OASIS can be used to generate the new SOC OASIS. The manual allows for this OASIS completion flexibility in targeted situations, to meet both Medicare billing and eligibility rules. A late face-to-face encounter is another of these targeted situations which justifies OASIS completion flexibility. Specifically, where a face-to-face encounter did not occur within the 90 days prior to the start of care or within 30 days after the start of care, a provider may use an existing OASIS assessment to generate another OASIS with a reported start of care date equal to the first visit date after all Medicare HH eligibility criteria are met. If multiple OASIS assessments exist, the data from the assessment conducted closest to the date of Medicare eligibility should be used. This could be a SOC, ROC, or Follow-up Assessment type. In this scenario, the date when all Medicare eligibility was met would be 30 days prior to the F2F encounter (with the F2F encounter date counted as day 0). The (M0090) Date Assessment Completed should be reported as the actual date the new OASIS assessment is being generated, even if no visit is provided on that date. Timing warnings from the OASIS system may be generated based on the difference between the start of care date and the date the assessment was completed (> 5 days), but these warnings may be unavoidable in these situations and can be disregarded. Medicare will not pay for services provided before the date on which all Medicare HH eligibility have been met, which in the scenario described would refer to any services provided in the first five days of care. If the original OASIS assessment had already been submitted to the OASIS system, it should be deleted, and the newly generated SOC OASIS assessment (with modified M0030/M0090 dates, ) submitted. All assessments should be maintained in the agency clinical record, with documentation explaining the situation. Example:

• • • • • • •Agency provides first skilled visit January 1st Face-to-Face encounter occurs February 5th (Day 35) Date when all Medicare eligibility was established January 6th (30 days prior to the F2F encounter, with F2F encounter date counted as "day 0") Non-covered visit period (January 1st-5th) (M0030) SOC Date on generated OASIS (The date of the first visit on or after January 6th) (M0090) Date Assessment Completed on generated OASIS (The actual date new assessment is generated – on or after the February 5th F2F encounter.)

If the F2F encounter does not occur within the 90 days prior to the SOC, or within 30 days after the SOC, then the Medicare HH eligibility criteria have not been met and the episode is not covered or billable as a Medicare HH episode. Assuming all other Medicare HH eligibility criteria are met, the F2F encounter (occurring on day 70 in the given scenario) would represent a pay source change to the Medicare HH benefit. Longstanding guidance in Section 80 of Chapter 10 of the Medicare Claims Processing Manual states that in certain instances, a new start of care OASIS assessment can be generated that reflects a start of care date equal to the start of the beneficiary’s change to Medicare FFS. A prior OASIS can be used to generate the new SOC OASIS. The manual allows for this OASIS completion flexibility in targeted situations, to meet both Medicare billing and eligibility rules. A late face-to-face encounter is another of these targeted situations which justifies OASIS completion flexibility. Specifically, where a face-to-face encounter did not occur within the 90 days prior to the start of care or within 30 days after the start of care, a provider may use an existing OASIS assessment to generate another OASIS with a reported start of care date equal to the first visit date after all Medicare HH eligibility criteria are met. If multiple OASIS assessments exist, the data from the assessment conducted closest to the date of Medicare eligibility should be used. This could be a SOC, ROC, or Follow-up Assessment type. In this scenario, the date when all Medicare eligibility was met would be 30 days prior to the F2F encounter (with the F2F encounter date counted as day 0). The (M0090) Date Assessment Completed should be reported as the actual date the new OASIS assessment is being generated, even if no visit is provided on that date. Timing warnings from the OASIS system may be generated based on the difference between the start of care date and the date the assessment was completed (> 5 days), but these warnings may be unavoidable in these situations and can be disregarded. Medicare will not pay for services provided before the date on which all Medicare HH eligibility have been met, which in the scenario described would refer to any services provided in the first 40 days of care. Any original OASIS assessments which may already have been submitted to the OASIS system, (likely SOC and Recert Assessments in this scenario) should be deleted, and the newly generated SOC OASIS assessment (with modified M0030/M0090 dates) submitted. All assessments should be maintained in the agency clinical record, with documentation explaining the situation. Example:

• • • • • • •Agency provides first skilled visit January 1st Face-to-Face encounter occurs March 12th (Day 70) Date when all Medicare eligibility was established February 10th (30 days prior to the F2F encounter, with F2F encounter date counted as "day 0") Non-covered visit period (January 1st – February 9th) (M0030) SOC Date on generated OASIS (The date of the first visit on or after February 10th) (M0090) Date Assessment Completed on generated OASIS (The actual date new assessment is generated – on or after the March 12th F2F encounter.)

Yes.

A late F2F is treated as a payer change. In the specific situation where a new SOC comprehensive assessment is generated for the sole purpose of changing the payer to Medicare, M0102 – Date of Physician-ordered SOC would be “NA”. For M0104 –Date of Referral, enter the day prior to the new Start of Care date.

No, any clinician qualified to perform comprehensive assessments may generate the new SOC comprehensive assessment from existing OASIS data. Clinical documentation should include the details of the late F2F as well as how and who generated the new SOC assessment.

The Recertification OASIS only includes payment items. Since an incomplete OASIS cannot be submitted to the OASIS system and you may not "create" answers, you will generate your new SOC OASIS based on the existing data from the assessment conducted closest to the date of eligibility. If the closest assessment is a Follow-Up Assessment (i.e., a Recert or Other Follow-up), generate the new SOC using all the available Recert items first, then finish generating the assessment by using items from the SOC or ROC that was conducted closest to the date of eligibility. If the closest assessment is a Discharge, generate the new SOC using all available Discharge items first, continue with generating the new assessment by adding additional items available from the Follow-up assessment (if any) that was conducted closest to the date of eligibility, and then finish generating the assessment by using items from the SOC or ROC that was conducted closest to the date of eligibility. In either case, remember to update specific items, (i.e., M0030, M0090)

A SOC and subsequent OASIS assessments (Transfer, ROC, Recert, Other Follow-up and Discharge) are linked together, once submitted to the OASIS system. Since the original SOC assessment, in the case of the late F2F, must be deleted before the newly "generated" SOC assessment is transmitted to the OASIS system, all of the linked assessments must also be deleted. Once the new SOC is established, all new assessments (e.g., Transfer, ROC, Follow-up, Discharge) that occurred after the new SOC date will need to be generated and transmitted. When generating these new assessments (i.e., Transfer or ROC), copy the OASIS data from the original assessments (i.e., original Transfer or ROC data) except for updating, when appropriate, OASIS items (i.e., M0030, M0090). When the HHA resubmits these assessments, they will then be linked to the new SOC assessment.

Correct, the SOC is the first billable visit by any covered service.

A new Plan of Care (POC) must be developed based on the new SOC date with specific orders for services. The new Plan of Care for the now Medicare-covered episode will have a begin date/SOC date that equals the date of the first billable service provided on or after the patient became eligible for the Medicare home health benefit (30 days prior to the F2F encounter). This POC should match the SOC date on the newly generated SOC OASIS. The new Plan of Care must include all existing orders beginning with the new SOC date as well as any additional orders obtained to cover the 9-week cert period. The orders may have changed over time, and the new POC should reflect all orders relevant to the certification period of the new Medicare-covered episode. The original POC should be kept in the clinical record for reference and documentation should be in the record explaining the late face-to-face and related actions.

No, an OASIS Discharge is not needed, since the original SOC OASIS will be deleted. There will not be a quality episode for that patient for the first period of non-covered service.

Yes, in situations where a definitive answer to an assessing clinician’s question is not contained in published CMS OASIS guidance (OASIS Guidance Manual, Q&As, etc.), the clinician may have to rely on clinical judgment to determine what response to select, taking into consideration all the guidance that is available, and ensuring that the response selected does not conflict with current guidance.