category 4 a - oasis data set forms - Missouri Department of Health ...

[Q&A EDITED 09/09]
Q34. M1010. How would additional inpatient facility diagnoses and ICD-9-CM
codes be entered into M1010 since the field only allows for six sets of codes?
When we include this item in our clinical forms, can we add more lines?
A34. M1010 requests only those diagnoses that required treatment during the inpatient
stay, not all diagnoses that the patient may have. Agencies should carefully consider
whether additional information is needed and, if so, include only the most relevant
diagnoses in M1010. OASIS items must be reproduced in the agency clinical forms
exactly as they are written. If the agency desires additional information, the most
appropriate course of action may be to insert an additional clinical record item
immediately following M1010.
Q35. M1010. It takes days (sometimes even a week) to get the discharge form
from the hospital. How can we complete this item in a timely manner?
A35. Information regarding the condition(s) treated during the inpatient facility stay has
great relevance for the SOC/ROC assessment and for the plan of care. The agency
may instruct intake personnel to gather the information at the time of referral.
Alternatively, the assessing clinician may contact the hospital discharge planner or the
referring physician to obtain the information.
[Q&A EDITED 09/09]
Q36. M1010. Can anyone other than the assessing clinician enter the ICD codes?
A36. Coding may be done in accordance with agency policies and procedures, as long
as the assessing clinician determines the primary and secondary diagnoses and records
the symptom control ratings. The clinician should write-in the medical diagnoses
requested in M1010, M1016, and M1020/1022/1024, if applicable. A coding specialist in
the agency may enter the actual numeric ICD-9 codes once the assessment is
completed. The HHA has the overall responsibility for providing services, assigning ICD-
9-CM codes, and billing. It is expected that each agency will develop their own policies
and procedures and implement them throughout the agency that allows for correction or
clarification of records to meet professional standards. It is prudent to allow for a policy
and procedure that would include completion or correction of a clinical record in the
absence of the original clinician due to vacation, sick time, or termination from the
agency.
Q37. [ Q&A RETIRED 09/09; Duplicative of OASIS-C Guidance Manual]
Q38. [Q&A RETIRED 09/09; Outdated]
Q39. [Q&A RETIRED 09/09; Outdated]
[M number updated 09/09]
Q40. M1016. If the patient had a physician appointment in the past 14 days, or has
a referral for home care services, does that qualify as a medical/treatment regimen
change?
Category 4 – OASIS Data Set – Forms and Items 09/09