M1840: CMS OASIS Q&As

M1840 – Toilet Transferring does not differentiate between patients who have urinary catheters and those who do not. The item simply asks about the patient’s ability to get to and from the toilet or bedside commode and their ability to transfer on and off toilet/commode. This ability can be assessed whether or not the patient uses the toilet for urinary elimination.

If the patient chooses to use the commode at night (possibly for convenience reasons), but is able to get to the bathroom, then Response 0 would be appropriate.

For M1840 - Toilet Transferring, if the patient’s ability or status varies on the day of assessment, report the patient’s usual status, or what is true greater than 50% of the day of assessment. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home for the visit. If the patient is able to get to and from the toilet safely and independently during the daytime; and if, for this patient, this represents more than 50% of the day of assessment, then M1840 would be Response 0 - Able to get to and from the toilet and transfer independently with or without a device, regardless of what the patient’s status is for the remainder of the day of assessment. If the factors that make the patient not safe getting to/from the bathroom safely (vision and balance in this scenario) were to be present for more than 50% of the day of assessment, and if in your clinical judgment, during these times the patient would be safe walking to the bathroom with supervision, then Response 1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer would be the appropriate response, even if the patient does not have a caregiver available.

The OASIS item response should reflect the patient’s ability to safely perform a task, regardless of the presence or absence of a caregiver. If the patient is able to safely get to and from the toilet and transfer with assistance, then Response 1 should be selected, as this reflects their ability, regardless of the availability of a consistent caregiver in the home.

If the bedfast patient needs assistance to get on/off the bedpan, the appropriate M1840 Response is 4 - Is totally dependent in toileting even if they can place and remove the urinal.

Toilet Transferring Response 1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer means the patient is able to perform the included tasks if they are "assisted" by another person. It is not the appropriate response in a case where the patient is totally dependent on another person to transport them to the toilet and transfer them on and off the toilet. In order to be scored a 1 the patient must be able to effectively participate by contributing effort toward the completion of some of the included tasks, getting to and from and getting on and off the toilet. If the patient can be moved to the toilet and transferred on and off, but cannot effectively participate in the effort required, they are scored a 4 - Is totally dependent in toileting. In your scenario, since the patient cannot effectively participate in the tasks required in the Toilet Transferring item, the patient would be scored a 4 - Is totally dependent in toileting.

Yes, a patient who is able to safely get to and from the toilet and transfer should be scored at response levels 0 or 1, even if they require the use of a commode over the toilet. Note that the location of such a commode is not at the "bedside," and the commode is functioning much like a raised toilet seat.

For M1840 - Toilet Transferring, if the patient cannot access a toilet in the home (or in the absence of a toilet in the home), the assessing clinician would need to determine if the patient is able to use a bedside commode (with or without assistance) (Response 2) or is able to use a bedpan/urinal independently (Response 3). If the patient is not able to use the bedside commode or a bedpan/urinal as defined in the responses, or if such equipment is not present in the home to allow assessment, then Response 4 - Is totally dependent in toileting would be appropriate.

If the patient is unable to get to and from the toilet or bedside commode and they only use a bed pan (i.e., for both voiding and bowel movements), then for M1840 - Toilet Transferring, response code 3 would apply if the patient is independent in safely getting on and off a bed pan.

The current OASIS Guidance Manual, Chapter 1 Conventions explains " When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited to physical contact and can include necessary verbal cues and/or supervision." When completing M1840, Toilet Transferring, if the patient can participate, but requires any degree of hands-on assistance and/or standby assistance and/or verbal cueing/reminders to get to/from the toilet and/or transfer on/off the toilet safely, select Response 1. An example of Response 1 could be a patient who requires verbal cues regarding safe use of walker while ambulating to the toilet. When completing M1850, Transferring, minimal human assistance referenced in Response 1 would include a minimal degree of any combination of verbal cueing, environmental setup and/or actual hands-on assistance. In order for the assistance to be considered minimal, it would mean the individual assisting the patient is contributing less than 25% of the total effort required to perform the transfer. An example of Response 1 could be a patient that requires hands-on assistance during the change in position from supine to sitting at the edge of bed, where the effort contributed by the individual assisting is less than 25% of total effort required to perform the transfer.

When scoring the OASIS, clinicians should avoid applying "always", "never", or "automatically" rules. Each item, the response options contained in the item, and additional available guidance in the form of Q&As and from Chapter 3 should be reviewed and the most accurate response should be selected. It is not a universally true statement to say that if conditions on both sides of the word "OR" pertain to the patient, then the patient should be automatically scored at the next level down. For instance, Response 0 for M1830 - Bathing says, "Able to bathe self in shower or tub independently, including getting in and out of tub/shower”. If the patient was able to bathe in the shower independently AND also able to bathe in the tub independently, it would not be appropriate to score them at the next level down simply because conditions on both sides of the word "OR" are met. When scoring M1860 - Ambulation/Locomotion, response option 3 is selected when the patient requires human supervision or assistance at all times in order to ambulate safely. Response 0 is selected if the patient requires no human assistance and no assistive devices to ambulate safely on even and uneven surfaces. All other combinations of needing assistance intermittently are reported as 2. For M1850 - Transferring, Response 1 - Able to transfer with minimal human assistance or with use of an assistive device, it is true that if the patient requires BOTH minimal human assistance AND an assistive device to transfer safely, then the response option 2 should be selected (See CMS OASIS Q&A Category 4b Questions 151.4.) If a patient requires constant human supervision or assistance in order to ambulate safely, they are scored a 3 for M1860 - Ambulation/Locomotion. A patient can only be scored a 0 for M1840, Toilet Transferring, if they can get to and from the toilet and transfer independently with or without a device. It would be possible for a patient to be a "3" for M1860, Ambulation/Locomotion and also be reported as a "0" for M1840, Toilet Transferring, if the patient required assistance at all times to ambulate but was able to get to and from the toilet and transfer safely and without assistance using a wheelchair.