M2401: CMS OASIS Q&As

M2401c - Intervention Synopsis; Depression interventions, reports whether the physician ordered Plan of Care includes depression interventions and if they were implemented. If the patient has a diagnosis of depression, the presence of an existing antidepressant medication in the medication profile/Plan of Care is considered a depression intervention. If there is an anti-depressant ordered and no diagnosis of depression, the assessing clinician would need to confirm why the medication was prescribed as anti-depressants are often indicated for diagnoses other than depression. If the medication was not prescribed specifically for depression, it would not be considered a depression intervention.

If the clinician determines it would be appropriate for a specific patient and obtains an order for "Skilled observation and assessment for signs and symptoms of depression" from the physician at the time of or any time since the most recent SOC/ROC, M2401c may be answered 1 - Yes even if the formal assessment was negative and/or the patient has not been formally diagnosed with depression. Note, just checking off an intervention on a Plan of Care does not equate to "obtaining a physician order."

In M2401c - Intervention Synopsis; Depression intervention(s), a referral for services for further evaluation or treatment meets the criteria for a response of “Yes” only if there is an order in the physician-ordered Plan of Care for the referral at the time of or since the most recent SOC/ROC AND the referral was made by the agency. The order in the physician-ordered Plan of Care can be a referral for agency services (such as an evaluation by psychiatric nursing or social work). Alternatively, it can be an order for a referral to an external provider or organization (such as for evaluation or treatment by a psychiatrist or to a community mental health center). Merely suggesting the patient seeks further evaluation or treatment, however, does not constitute providing a referral. The agency must provide the patient with sufficient written information (for example: name and phone number) to enable them to make an appointment or obtain the service. Likewise, the HHA can make contact directly with the provider or organization to facilitate an appointment for the patient. Once a referral has been made, it is not required that the patient has followed through or received the services related to the referral by the time of transfer to an inpatient facility or discharge for a response of 1 - Yes in M2401c.

In order to select 1 - Yes for any plan/intervention in M2401 – Intervention Synopsis, there must be a physician order for an intervention(s) that specifically addresses the patient's needs. In order to select 1 -Yes for M2401d – Intervention Synopsis; Interventions to monitor and mitigate pain, the physician-ordered plan of care must include both an order to monitor pain and an order to relieve/mitigate the individual patient's specific pain. Evidence that the order was implemented would also be necessary to select 1 -Yes.

An ordered pain medication is considered an intervention to mitigate pain. Assessing for the effectiveness of the pain medication is considered an intervention to monitor pain. If both the pain medication and an order related to pain assessment are included in the physicianordered Plan of Care, and both orders were implemented at the time of or at any time since the most recent SOC/ROC, M2401d – Intervention Synopsis; Interventions to monitor and mitigate pain would be 1 -Yes.

In the scenario you describe response 1 - Yes is not appropriate because there are no interventions on the plan of care. The response N/A is also not appropriate because the patient does have pressure ulcers for which moist wound healing is indicated. Response 0 - No is the most appropriate.

The clinician would discuss the patient's pressure ulcers with the physician/allowed practitioner and not make the decision regarding appropriate treatment alone. When it is determined by the clinician/physician team or solely by the physician/allowed practitioner that moist wound healing was not appropriate for any pressure ulcer at the time of or any time since the most recent SOC/ROC, the Response "NA" would be chosen.

You may code 1 - Yes to M2401 - Intervention Synopsis b - e, if the specified clinical interventions were included in the physician ordered Plan of Care and implemented at the time of or at any time since the most recent SOC/ROC assessment whether or not a formal assessment was performed.

None of the interventions that the nurse provided on the initial assessment visit would be considered when responding to M2401 - Intervention Synopsis, even if orders existed, because the interventions were completed before the quality episode began on the SOC date.

Since “referral for other treatment” is specifically listed as a qualifying intervention in item M2401 - Intervention Synopsis, then 1 - Yes should be reported for the situation in which the referral is made for other treatment for depression, even if the treatment is never actually provided before the Transfer or Discharge time point. Obtaining the order for the referral is considered to be an implementation of the intervention, whether or not the order was carried out. This is only specifically stated and true for interventions related to depression (row c), not for other treatment areas (e.g., falls prevention interventions, pressure ulcer prevention interventions, etc.)

If the education component of the intervention was ordered, attempted, and not provided because of a documented lack of need for the education, the clinician can answer “Yes” to the Intervention Synopsis item. The intervention was implemented when the attempt to provide it was made, and the lack of need identified. This is distinctly different than stating an attempt was made to educate and the patient refused or otherwise declined to receive the needed instruction with no further attempt, in which case, the refused education should not be reported as being “implemented” on M2401 – Intervention Synopsis.

The response for M2401 Intervention Synopsis is “No” if there are no physician orders present for these best practices during the “look back” time period at transfer or discharge. In order to answer M2401 - Intervention Synopsis "Yes", the current physician-ordered Plan of Care and/or other addendum orders present at the time of or at any time since the most recent SOC/ROC assessment must have included the specified best practice intervention, in addition to evidence that the intervention(s) were implemented.

In order to answer 1 - Yes for M2401d - Intervention Synopsis; Interventions to monitor and mitigate pain the record review at Transfer/Discharge must reveal that at the time of or at any time since the most recent SOC/ROC assessment, there were orders to assess for pain and mitigate pain, as well as evidence that both interventions were implemented. If both interventions were not implemented, you may not answer M2401d as 1 - Yes. If there were orders to relieve pain, e.g., prn analgesic, and record review revealed the clinician assessed pain, educated the patient regarding the pain mitigation intervention, but the patient never had pain that required the ordered analgesic, M2401d may be answered as 1 -Yes. The education regarding the prn pain mitigation would be an implementation of the order.

If there are multiple interventions to address a specific problem included in M2401, (e.g., assess for pain each visit, instruct on non-pharmacological approaches to pain, educate regarding pain medication, etc.), the assessing clinician may answer "Yes" at Transfer/Discharge if there is evidence that the required assessment component was implemented AND evidence that at least one of the pain mitigation orders were implemented.

M2401 - Intervention Synopsis, reads "At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physicianordered plan of care AND implemented? " The time period under consideration is from the current Transfer or Discharge back to and including the most recent SOC/ROC assessment. If there are no orders for the applicable best practices during that time period, the answer to M2401 is 0 - No. If there was an order but there is no evidence of implementation, the M2401 response is 0 - No. In order to select the M2401 Response 1 - Yes for long-term patients, orders for the applicable best practices must be present at the time of or at any time since the most recent SOC/ROC assessment, AND there must be evidence of implementation within the time period beginning with the most recent SOC/ROC and ending with the Transfer/Discharge. During that time period, if specific orders were present, and the clinician confirmed the patient/caregiver possessed the knowledge regarding the best practice, the intervention may be considered implemented.

In situations of planned or unplanned discharges, when completing M2401 Intervention Synopsis on the discharge assessment, the qualified clinician responsible for the assessment can report any ordered interventions that were implemented at the time of or any time since the most recent SOC/ROC up until the time of discharge (the M0906 date). This includes taking credit for education provided at a home visit by an LPN or therapy assistant.