OASIS Q&A Updated to Reflect Clarification on the F2F Requirement

The Centers for Medicare & Medicaid Services (CMS) recently released their OASIS Q&A’s for January 2012. In this most recent round of questions, CMS provided clarification on completion of OASIS data in situations where the face-to-face encounter does not occur within the 90 days prior to the start of care (SOC), or within 30 days after the SOC.

Please review the noteworthy information below. It is important for agencies to remember that while CMS now allows some flexibility in collecting and submitting OASIS data, in cases where a late F2F encounter occurs, you need to make sure your documentation is thorough and reflects the fact that a late F2F encounter did occur. This will assist you in explaining any inconsistencies should the patient’s chart be audited:

Question #1: If the F2F does not occur within 30 days after the SOC, but it does occur, for example, on the 35th day, how should OASIS data be collected and submitted?

Answer #1: If the F2F encounter does not occur within the 90 days prior to the SOC, or within 30 days after the SOC, then the Medicare HH eligibility criteria have not been met and the episode is not covered or billable as a Medicare HH episode.

Assuming all other Medicare eligibility criteria are met, the F2F encounter (occurring on day 35 in the given scenario) would represent a pay source change to the Medicare HH benefit. Longstanding guidance in Section 80 of Chapter 10 of the Medicare Claims Processing Manual states that in certain instances, a new start of care OASIS assessment can be generated that reflects a start of care date equal to the start of the beneficiary’s change to Medicare FFS. A prior OASIS can be used to generate the new SOC OASIS. The manual allows for this OASIS completion flexibility in targeted situations, to meet both Medicare billing and eligibility rules. A late face-to-face encounter is another of these targeted situations which justifies OASIS completion flexibility.

Specifically, where a face-to-face encounter did not occur within the 90 days prior to the start of care or within 30 days after the start of care, a provider may use an existing OASIS assessment to generate another OASIS with a reported start of care date equal to the first visit date after all Medicare HH eligibility criteria are met. If multiple OASIS assessments exist, the data from the assessment conducted closest to the date of Medicare eligibility should be used. This could be a SOC, ROC, or Follow-up Assessment type. In this scenario, the date when all Medicare eligibility was met would be 30 days prior to the F2F encounter (with the F2F encounter date counted as day 1). The (M0090) Date Assessment Completed should be reported as the actual date the new OASIS assessment is being generated, even if no visit is provided on that date. Timing warnings from the OASIS state system may be generated based on the difference between the start of care date and the date the assessment was completed (> 5 days), but these warnings may be unavoidable in these situations and can be disregarded.

Based on the new certification period range, it may be necessary to change the response originally reported for (M0110) Episode Timing, and/or (M2200) Therapy Need, to exclude therapy visits provided before the date of eligibility. Medicare will not pay for services provided before the date on which all Medicare HH eligibility have been met, which in the scenario described would refer to any services provided in the first five days of care. If the original OASIS assessment had already been submitted to the State, it should be deleted, and the newly generated SOC OASIS assessment (with modified M0030/M0090 dates, M0110, M2200, etc.) submitted. All assessments should be maintained in the agency clinical record, with documentation explaining the situation.

Example:

    • Agency provides first skilled visit January 1st
    • Face-to-Face encounter occurs February 4th (Day 35)
    • Date when all Medicare eligibility was established January 6th (30 days prior to the F2F encounter, with F2F encounter date counted as “day 1”)
    • Non-covered visit period (January 1st-5th)
    • (M0030) SOC Date on generated OASIS (The date of the first visit on or after January 6th)
    • (M0090) Date Assessment Completed on generated OASIS (The actual date new assessment is generated – on or after the February 4th F2F encounter.)

Question #2: If the F2F does not occur within 30 days after the SOC, but it does occur, for example, on the 70th day, in the next certification period, how should OASIS data be collected and submitted?

Answer #2: If the F2F encounter does not occur within the 90 days prior to the SOC, or within 30 days after the SOC, then the Medicare HH eligibility criteria have not been met and the episode is not covered  or billable as a Medicare HH episode. Assuming all other Medicare HH eligibility criteria are met, the F2F encounter (occurring on day 70 in the given scenario) would represent a pay source change to the Medicare HH benefit. Longstanding guidance in Section 80 of Chapter 10 of the Medicare Claims Processing Manual states that in certain instances, a new start of care OASIS assessment can be generated that reflects a start of care date equal to the start of the beneficiary’s change to Medicare FFS. A prior OASIS can be used to generate the new SOC OASIS. The manual allows for this OASIS completion flexibility in targeted situations, to meet both Medicare billing and eligibility rules. A late face-to-face encounter is another of these targeted situations which justifies OASIS completion flexibility.

Specifically, where a face-to-face encounter did not occur within the 90 days prior to the start of care or within 30 days after the start of care, a provider may use an existing OASIS assessment to generate another OASIS with a reported start of care date equal to the first visit date after all Medicare HH eligibility criteria are met. If multiple OASIS assessments exist, the data from the assessment conducted closest to the date of Medicare eligibility should be used. This could be a SOC, ROC, or Follow-up Assessment type. In this scenario, the date when all Medicare eligibility was met would be 30 days prior to the F2F encounter (with the F2F encounter date counted as day 1). The (M0090) Date Assessment Completed should be reported as the actual date the new OASIS assessment is being generated, even if no visit is provided on that date. Timing warnings from the OASIS state system may be generated based on the difference between the start of care date and the date the assessment was completed (> 5 days), but these warnings may be unavoidable in these situations and can be disregarded.

Based on the new certification period range, it may be necessary to change the response originally reported for (M0110) Episode Timing, and/or (M2200) Therapy Need, to exclude therapy visits provided before the date of eligibility. Medicare will not pay for services provided before the date on which all Medicare HH eligibility have been met, which in the scenario described would refer to any services provided in the first 40 days of care. Any original OASIS assessments which may already have been submitted to the State, (likely SOC and Recert Assessments in this scenario) should be deleted, and the newly generated SOC OASIS assessment (with modified M0030/M0090 dates, M0110, M2200, etc.) submitted. All assessments should be maintained in the agency clinical record, with documentation explaining the situation.

Example:

    • Agency provides first skilled visit January 1st
    • Face-to-Face encounter occurs March 11th (Day 70)
    • Date when all Medicare eligibility was established February 10th (30 days prior to the F2F encounter, with F2F encounter date counted as “day 1”)
    • Non-covered visit period (January 1st – February 9th)
    • (M0030) SOC Date on generated OASIS (The date of the first visit on or after February 10th)
    • (M0090) Date Assessment Completed on generated OASIS (The actual date new assessment is generated – on or after the March 11th F2F encounter.)

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