Category 3 - Follow-Up Assessments

Pediatric and maternity patients are exempt from the OASIS data collection requirements; however, the agency must still perform a follow-up comprehensive assessment during the last 5 days of every 60-days beginning with the start of care date.

The Conditions of Participation require that a follow-up comprehensive assessment be conducted during the last 5 days of every 60-day certification period. In your scenario, the follow-up assessment was performed during the required timeframe, but then the patient's condition changed and required what we assume is a transfer to an inpatient facility during the recertification assessment timeframe, for a qualifying inpatient stay (admitted to an inpatient facility for 24 hours or longer for reasons other than diagnostic testing). If your agency completed an RFA 7 - Transfer with Discharge, you may also submit the Recertification assessment, although this is not necessary. When the patient returns home, you would then complete a new Start of Care (SOC). If your agency completed an RFA 6 - Transfer without Discharge, and if the patient returns to your agency in the recertification period, complete a Resumption of Care OASIS if the M0090 date is on or before day 60. Complete a SOC OASIS if the M0090 date is on or after day 61.

If a patient is transferred to the hospital on day 58, before the recertification assessment was completed, and the stay in the inpatient facility meets the criteria for a Transfer, the agency would complete a Transfer OASIS. When the patient returns home, if they have not been discharged from the home care agency, and the timeframe to complete the Resumption of Care (ROC) overlaps with the timeframe to complete the Recertification then complete the ROC. This satisfies both the ROC and the recertification requirements. If the patient's facility stay extends beyond the end of the current certification period when the patient returns home a SOC would be completed. The agency would also need to perform a "paper" discharge from the previous episode (no OASIS DC required).

When the agency learns of a qualifying inpatient stay after the patient returned home, a Transfer and Resumption of Care (ROC) is required within 2 calendar days after learning of the inpatient stay. In this situation, a Transfer is required; and, since the timeframe to complete the ROC overlaps with the timeframe to complete the Recertification, the ROC assessment should be completed, fulfilling both the ROC and Recert requirements.

Collecting uniform data on patients at uniformly defined time points means that certification periods will need to be less flexibly defined. Therefore, for patients requiring OASIS data collection, HHAs must adhere to a 60-day certification period, based on the SOC date. The data specifications have been developed according to this schedule, and agencies are in compliance with the regulations if they adhere to this schedule.

Yes, both the Recert and Discharge must be completed. When a Recertification assessment is missed it should be completed as soon as possible after the oversight is identified. In the situation described, you needed to recertify for the visit that was needed and justified by the patient's condition in the new 60-day certification period. The recertification comprehensive assessment supports the patient’s need for services, and for the Medicare patient, the recertification OASIS drives the payment for that period. If the clinician determined the patient was ready for discharge on the first visit in the new certification period, the Discharge comprehensive assessment is also required. The discharge is the endpoint of the quality episode, which is not captured with a recertification assessment.

Treat this situation as a missed Recertification and complete the Recertification as soon as possible after the patient's return home. 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. Clinical documentation will explain the events leading to the late Recertification.

When the agency becomes aware of a qualifying stay in an inpatient facility, a Transfer OASIS and Resumption of Care (ROC) assessment must be completed within 2 days of gaining the knowledge. In your situation, assuming the Recertification assessment had been performed during the last five days of the prior certification period, the agency would still need to complete a Transfer and send a qualified clinician to the home to perform the missing ROC assessment. You will receive an error message that the assessments have been submitted out of sequence.

Whenever you discover that you have missed completing a recertification assessment within the required timeframe (days 56-60), you should not discharge that patient and readmit or use an assessment that was completed prior to the required assessment window. As soon as you realize that you missed the recert window, conduct a recertification comprehensive assessment including OASIS. You will receive a warning message when submitting the assessment.

Do not discharge the patient. A Transfer assessment (RFA 6) should be completed. If the patient returns to the HHA, a Resumption of Care (ROC) comprehensive assessment should be completed. The ROC will serve as both the Resumption of Care and the Recertification and for the Medicare PPS (PDGM) patient it will establish the PPS payment code for the next period. This demonstrates non-compliance with the Medicare comprehensive assessment update standard of the Conditions of Participation but is the only option available due to the missed recertification.

Treat this situation as a missed Recertification and complete the Recertification as soon as possible after the patient's return home.

Regulations require a Resumption of Care (ROC) visit within 48 hours of the discharge from the inpatient facility or on the physician-order ROC date. In the situation described, since the timeframe to complete the ROC overlaps with the timeframe to complete the Recertification, the ROC assessment should be completed, fulfilling both the ROC and Recert requirements. In the scenario provided, since a visit did not occur within the ROC/recert timeframe, the ROC/recert assessment should be completed as soon after this period as possible. Obviously, this situation should be avoided, as it does demonstrate non-compliance with the comprehensive assessment update standard (of the Conditions of Participation). For the Medicare PPS (PDGM) patient, payment implications may arise from this missed assessment. Any payment implications must be discussed with the agency's Medicare Administrative Coordinator (MAC).

A comprehensive assessment including OASIS is required when there is a major decline or improvement in health status. Each agency must determine its own policies regarding examples of major decline or improvement in health status and ensure that the clinical staff is adhering to these policies. In the event the agency determines that an assessment at a point in time not already required is necessary (based on its own policies), reason for assessment (RFA) 5 under M0100 would be selected.

When the patient experiences an event that meets your agency’s definition of a major decline or improvement in the patient’s health status, you are required to complete the RFA 5, Other Follow-up assessment, in order to be compliant with the Medicare Conditions of Participation §484.55. CMS encouraged each agency to develop its own guidelines and policies for this type of assessment and did not provide written requirements about what constitutes a significant decline or improvement. This requirement to complete an RFA 5 for a patient experiencing a major decline or improvement in health status should not be confused with the Significant Change in Condition (SCIC) payment adjustment which was introduced in the initial Home Health Prospective Pay System (PPS) model, and which no longer exists. You stated that if a patient had a major improvement, you would discharge, but that may not be true if the patient had continuing home care needs. For example, if your patient had a CVA and after the SOC they subsequently experienced a significant resolution of neurological symptoms, this patient may meet the criteria for your agency’s definition of a major improvement. If the patient continued to have nursing needs related to medication management, you may not discharge until those goals were met. The RFA 5 would serve as the vehicle to reassess the patient’s status after the major change in status.

No, similar to PPS, the case mix group cannot be adjusted within each 30-day period, but completion of an RFA 5 - Other follow-up may impact payment for a subsequent 30-day payment period. HHAs must be sure to update the assessment completion date on the second 30-day claim if a follow-up assessment changes the case-mix group to ensure the claim can be matched to the Follow-up assessment. HHAs can submit a claims adjustment if the assessment is received after the claim has been submitted and if the assessment items would change the payment grouping. Questions related to claims processing may be directed to the HHA’s Medicare Administrative Contractor.