Coding Corner

Welcome to Coding Corner, your go-to destination for home health coding and OASIS review tips! In this training series, we will delve into the intricacies of coding in the home health setting, providing you with expert insights and practical guidance to enhance your skills and proficiency. Whether you are a seasoned professional looking to sharpen your knowledge or a newcomer eager to learn the ropes, Coding Corner is designed to empower you with the tools and techniques necessary to excel in this specialized field. Get ready to unlock the secrets of accurate coding and OASIS review, as we embark on this enriching journey together. Let’s dive into the world of home health coding and elevate your expertise with Coding Corner!

What is the OASIS Walk and How is it Used in Home Health?

Clinicians in home health use the OASIS Walk to gather information efficiently during assessments. During this walk, clinicians ask the patient to demonstrate various activities to assess their abilities. Some key aspects clinicians inquire about during the OASIS Walk include: 

By observing these aspects during the OASIS Walk, clinicians can efficiently gather crucial information for accurate assessments and care planning.

Understanding OASIS Item M1845: Toileting Hygiene and Safety

OASIS M Item 1845 is a crucial assessment point that frequently appears in the top 10 assessments. This item is closely related to toileting hygiene and often goes hand in hand with lower body dressing (M1820). It involves considering the logistics of toileting, such as pants removal, personal hygiene, and assistance needs.

Patients’ ability to perform toileting tasks independently without pain or shortness of breath determines the level of assistance required. Some may need minimal support like hygiene setups or wipes, while others may be completely dependent on assistance for toileting activities.

Clinicians sometimes misinterpret responses, marking patients as completely dependent when they may require varying levels of assistance. It’s essential to understand the scale from complete dependence (response 3) to no help needed (response 0) accurately.

In home health settings, clinicians should encourage patients to perform tasks like walking to the bathroom with minimal assistance to assess their functional abilities accurately. Observation plays a vital role in evaluating patients’ actual capabilities beyond what they claim they can do.

Educating clinicians on the importance of safety in toileting tasks is crucial. Ensuring patients can perform these activities safely is so important in OASIS assessments, emphasizing the significance of accurate observation and assessment for overall patient well-being.

COPD Documentation and Patient Safety: What to Look for in Home Health Care

In this video, we delve into the essential aspects of documenting COPD (Chronic Obstructive Pulmonary Disease) and ensuring patient safety in home health care settings. When assessing a patient with COPD, clinicians need to pay attention to various key points within the documentation.

We explore the significance of identifying exacerbations in COPD patients, which may lead to treatments like steroids and antibiotics. Assessing if the patient requires oxygen and ensuring its safe use at home is crucial for patient well-being. Additionally, evaluating respiratory failure levels and monitoring for smoking risks with oxygen use are vital considerations.

 

The video emphasizes the importance of accurately documenting shortness of breath levels (M1400) and assessing the patient’s functional impairment related to COPD. Educating patients on medication adherence, proper inhaler use, and oxygen safety is essential for managing COPD effectively and preventing exacerbations that could result in hospitalizations.

By highlighting the importance of thorough documentation, education, and monitoring in home health care, clinicians can help patients with COPD maintain their independence, safety, and overall well-being while reducing the risk of exacerbations and hospitalizations. Stay tuned for valuable insights on optimizing care for COPD patients in home health settings.

Mastering OASIS Item M1850: Key Insights and Best Practices for Clinicians

Join Tina and Steph in this insightful discussion as they delve into the nuances of OASIS Item M1850. Discover why over 30% of OASIS changes stem from this crucial item and learn how to accurately assess and document patient needs. Uncover common misconceptions, such as the importance of considering both human assistance and assistive devices for accurate scoring.

Explore the significance of patient safety and ability in transferring safely, efficiently, and effectively. Gain valuable tips on avoiding common pitfalls in scoring, understanding the role of physical therapy assessments, and supporting referrals for therapy services based on M items. Enhance your understanding of the assessment process to ensure patients receive the appropriate care they need to thrive at home. 

Don’t miss out on this informative video that will empower clinicians to make informed decisions when responding to OASIS Item M1850 and improve patient outcomes through accurate documentation and care planning.

Mastering M1033: Risk for Hospitalization

Unlock the key insights behind the significance of M1033 in home health. This session delves into the critical impact of M1033 on PDGM and STAR ratings, as well as influencing reimbursement levels. Learn how accurately addressing this item can earn up to 11 points for responses to questions one through seven.

Explore its relevance within the PDGM model, contributing to a patient’s overall risk for hospitalization. Leaders in home health will discover strategies to create a comprehensive patient profile, ensuring maximum reimbursement for the care provided.

The session delves into specific areas, such as the history of falls, emphasizing the inclusion of various injuries beyond fractures. Unintentional weight loss criteria are clarified, emphasizing the importance of BMI inclusion. Multiple hospitalizations are discussed in detail, focusing on the timeframe and admission criteria.

 

Gain insights into identifying and addressing declines in mental, emotional, or behavioral status within the last three months. The session also covers reported difficulties in complying with medical instructions, providing clarity on compliance and documentation requirements.

The importance of assessing medication usage is emphasized, clarifying that it includes prescribed and over-the-counter medications, vitamins, injectables, and the consideration of prescribed quantities. The session addresses patient-reported exhaustion, highlighting its impact on overall engagement in healthcare activities.

Throughout the session, emphasis is placed on educating field staff to enhance patient assessment skills and clinical judgment, ultimately aiding in accurate item capture. Participants are encouraged to review M1033 regularly due to its significance and the functional points it offers.

Decoding CHF: Navigating Complex Coding Scenarios in Heart Failure

Welcome to Coding Corner! In this episode, we delve into a detailed scenario involving CHF (Congestive Heart Failure) and the coding process. Mrs. Jones presented with concerning symptoms such as increased shortness of breath, significant leg swelling, fatigue, and difficulty ambulating, leading to her hospitalization with a diagnosis of decompensated diastolic heart failure.

Our expert coders, Tina and Stephanie, navigate through the complexities of coding this scenario. They emphasize the importance of sequencing codes correctly based on guidance. Hypertension is coded prior to CHF due to their assumed relationship, with the code I11.0 for hypertensive heart disease with CHF.

The concept of acute on chronic conditions is highlighted when coding acute exacerbation of diastolic heart failure as I50.33. The history of systolic heart failure is captured as I50.22 to distinguish between the two types of heart failure in this case.

End stage heart failure (I50.84) and permanent AFib (I48.21) are also meticulously coded in accordance with guidelines, ensuring accurate representation of Mrs. Jones’ complex medical history.

Join us as we unravel the intricacies of medical coding and learn how to accurately document and code complex patient scenarios like Mrs. Jones’. Stay tuned for more insightful discussions on Coding Corner!

Understanding Pathological Fractures and Coding Guidelines in Medical Records

We delve into the crucial aspect of coding fractures accurately by understanding the underlying cause of a fracture. Join us as we explore a case where what may seem like a traumatic fracture due to a fall actually reveals itself as a pathological fracture caused by osteoporosis. Learn why identifying osteoporosis in documentation is pivotal in coding such fractures correctly.

Discover the distinction between trauma fractures and osteoporosis fractures, and how the presence of osteoporosis changes the coding approach. Gain insights into differentiating between various types of fractures based on their etiology and how to interpret medication profiles for clues about underlying conditions like osteoporosis.

Follow along as we discuss the importance of thorough documentation review, recognizing key indicators like osteoporosis mentions, and adjusting coding practices accordingly. Find out why coding fractures with active treatment in hospitals differs from post-treatment at home, and how to prioritize the primary diagnosis while incorporating relevant codes for procedures like hip replacements.