Embracing OASIS E: An early guide for clinicians, with notes on Final Guidance changes

By Jennifer Osburn, RN, HCS-D, COS-C
Senior Clinincal Manager

Purchasing (HHVBP or VBP) and OASIS E. Like many in our industry, you may feel overwhelmed due to the timing of these regulatory changes. With so many changes at once, it can be easy to miss something, such as the publishing of the Final Guidance Manual on Dec. 22, 2022.

Changes in OASIS Final Guidance Manual

When CMS published the finalized OASIS E Guidance Manual, there were several changes from the draft versions. Approximately one-fourth of the changes were typos or minor corrections. The remaining modifications were guidance changes related to the use of the dash, the most significant of which we will review below.

While computer software may calculate responses for the clinician, agency staff should review these changes to ensure the software is following the updated guidance below, as we are seeing in social media groups that rejections and warnings are occurring for some upon OASIS E export.

C0500, BIMS Summary Score

CMS changed the guidance for scoring the BIMS in a couple of scenarios.

If any, but not all, of the BIMS items are coded with a dash (-), the summary score should be coded as “99” unable to complete interview. [Dash means there is no information available.]
If all BIMS items are coded with a dash (-), the summary score would be coded with a dash (-).

This guidance change means that there are three reasons the BIMS Summary Score would be coded as 99, unable to complete the BIMS interview.

1) The patient chooses not to participate in BIMS.
2) The patient either chose not to answer or gave a nonsensical response to four or more of the BIMS items between C0200 and C0400C.
3) A dash was used in any, but not all, of the BIMS items as noted above. This is different from all the BIMS items being coded with a dash.

For example, it sometimes occurs that a patient agrees with a planned discharge but will not allow the clinician to complete the in-home comprehensive assessment visit. In these cases, the last qualified discipline may complete the DC comprehensive assessment using information from their last visit and supplement with visits by other agency staff that occurred in the last 5 days that the patient received visits from the agency. Since BIMS was not part of the comprehensive assessment until implementation of OASIS E, the BIMS items would not have been assessed, so each BIMS item would have to be answered with a dash, and the BIMS Summary Score would be answered with a dash as well.

D0150 Patient Mood Interview:

Response-specific instructions:

When coding the PHQ 2 to 9, “enter code 9 in Column 1 [symptom presence] and leave blank (or skip) Column 2 [symptom frequency] if the patient was unable or chose not to complete an interview item or responded nonsensically.” (Note that CMS removed the guidance “and/or the agency was unable to complete the assessment.”)
Determine whether to complete the [entire] PHQ-9 (i.e., ask the remaining seven questions: D0150C to D0150I). Whether or not further evaluation of a patient’s mood is needed depends on the patient’s responses to the PHQ-2 (D0150A and D0150B).
- The PHQ interview will end under two circumstances described below:
  - IF both D0150A1 and D0150B1 are coded 9 [because the patient was unable or chose not to complete the interview, or responded nonsensically]. In this case, leave D0150A2 and D0150B2 blank, then end the PHQ-2 and skip D0160, Total Severity Score.
  - IF both D0150A2 and D0150B2 are coded 0 or 1. In this case, end the PHQ-2 and enter the sum of both A2 and B2 in D0160, Total Severity Score.
- For all other scenarios, proceed to ask the remaining seven questions (D0150C to D0150I of the PHQ-9 and complete D0160, Total Severity Score.

Similar updates were made to the coding instructions for D0150 Column 1, Symptom Presence and Column 2, Symptom Frequency of the PHQ-2 to 9. Because of these changes, the dash can be used as intended per its definition in the general OASIS Guidance.

As the clinician is asking the patient about the presence of symptoms in the PHQ, if the patient indicates the symptoms are not present, the clinician will enter “0, no”, in column 1. If the patient indicates the symptom is present, the clinician will code “1, yes”, in column 1 and then follow up with coding the frequency of the symptom in column 2. Dash will only be used in column 1, meaning the symptom presence was not assessed. If this is the case, column 2 is to be left blank, as dash is no longer a valid response for column 2 with the revisions published on December 22 in the finalized OASIS E manual.

D0160 Total Severity Score Guidance Changes

Because the instructions above changed how the PHQ-2 to 9 is coded, the scoring instructions also changed. In cases where only the PHQ-2 is completed because the patient was unable or chose not to complete the interview or responded nonsensically, the clinician would follow the instructions above and code A1 and B1 as a 9, leave A2 and B2 blank, end the PHQ interview and skip D0160, Total Severity Score.

In cases where only the PHQ-2 is completed because the patient answered that they have been bothered by little interest or pleasure in doing things (D0150A) and feeling down, depressed, or hopeless (D0150B), but the frequency for these two symptoms were either 0 (never or 1 day) or 1 (2-6 days or several days), the clinician is to add the scores for these two items and that value is to be placed in D0160, Total Severity Score.

Additional guidance changes are related to scoring and consider the number of skipped items (because Column 1 is either coded as 9 or dash) in Column 2, Symptom Frequency:

In cases where the symptom frequency is blank for 3 or more items, the interview is deemed incomplete and D0160 should be coded as “99”.
When less than 3 items in the symptom frequency are skipped, the value of these are omitted when computing the sum at D0160.
Dash is no longer a valid response for D0160 Total Severity Score.

In closing, ensuring clinical staff are aware of and trained on these changes will decrease confusion and incorrect responses. Also, agencies should be sure staff understand that the clinician should attempt to conduct both the BIMS and PHQ assessments unless “the patient is rarely or never understood verbally, in writing, or another method.”

Implementation of OASIS E

The OASIS is designed to collect data for use in quality and payment programs. While it is part of the Comprehensive Assessment mandated by the Home Health Conditions of Participation (CoPs), it is not the entirety of the Comprehensive Assessment. The OASIS is different than the professional discipline assessment in purpose and content. Knowing the purpose, differences, and requirements for each aspect of the Comprehensive Assessment is important for success.

The data we collect and export is compared in numerous ways: beneficiary outcomes, agency best practices and processes, population health analysis, access to care issues, compliance with CoPs, and computation of the functional status of the patient in PDGM, to name a few. As CMS continues to tie together payment and quality, OASIS accuracy has a more significant role in our agencies.

OASIS data is also used to calculate the patient’s functional impairment level in PDGM. In the newly implemented HHVBP, data is used to identify performance benchmarks, achievement thresholds and scores, and improvement thresholds and scores.

Clinically, among other things, this new data set includes additional SPADEs items, several new Social Determinants of Health and cognitive status items. These items will be used to further align data collection across the post-acute care space, allowing analysis of access to care comparisons among Medicare beneficiaries for example. Agencies can also use this additional information to clarify whether patient deficits are due to hearing versus cognitive ailments, or if social determinants such as transportation impairs getting things they need.

When used in the professional process, this additional information will help the clinical team plan appropriately individualized care, geared to meet the patient’s specific needs as required in the COPs.

Embracing OASIS E: What’s in it for the Clinician?

For the clinician, thinking about restructuring the flow of the OASIS items and aligning these items with our professional assessment will help us readjust and streamline our visits. As with any change, this will take more time at first until we have a full understanding of all the guidelines to consider while selecting the appropriate response. Having a good understanding of the difference between what the OASIS is designed for versus the professional assessment’s purpose helps us to ensure accuracy while refining our visit structure.

For the clinician team and, subsequently, the agency, using OASIS E data will help in VBP strategy by assisting the identification of increased risk for hospitalization and ED use. This information can be used to form patient-specific plans of care that address this increased risk, thus showing compliance with the COPs as well.

Success overall will come from accurately collecting the data, studying the data, and using findings to focus efforts on improving patient abilities and outcomes. This will in turn ensure the agency is receiving all the monies they are legally entitled to receive to care for their patients.

Editor’s Note: Author Jennifer Osburn is a frequent conference speaker who has developed scores of educational modules on topics such as PDGM, VBP, and OASIS. She has been helping agencies prepare for OASIS E and VBP in a variety of ways, including webinars, online tutorials, written materials, and on-site training sessions.