OASIS-D – Dealing with New Section J Items

OASIS-D is a major change with the revision of seven items, removal of 28 items and introduction of two new items.  In our last blog we addressed the new Section GG items dealing with Functional Abilities and Goals.  The other new item, Section J, addresses health conditions or more specifically falls, and this blog will review it in further detail.

Section J – Health Conditions

  • J1800

Assessment item, J1800, deals with any falls since start of care (SOC) or since resumption of care (ROC), depending upon which is most recent.  The intent of this item is to identify if the patient had any witnessed or unwitnessed falls since the most recent SOC/ROC.  The time point items include transfer to an inpatient facility, death at home or discharge from agency – not to an inpatient facility.

According to this assessment item, a fall is defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface such as a bed or chair.  The fall may be witnessed or unwitnessed.  It can be reported by the patient or an observer or identified when a patient is found on the floor or ground.  The fall is not a result of an overwhelming external force such as a person pushing the patient.

An intercepted fall is also considered a fall per this assessment item.  An intercepted fall is defined as when the patient would have fallen if he or she had not caught him/herself or had not been intercepted by another person.  However, CMS understands that challenging a patient’s balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention.  Anticipated losses of balance that occur during supervised therapeutic interventions are not considered intercepted falls.

Response specific instructions include reviewing a patient’s home health clinical record, incident reports and any other relevant clinical documentation such as fall logs.  Also, the patient and/or caregiver(s) should be interviewed about the occurrence of falls.

Coding instructions for this assessment item are:

  • Code 0: No – If the patient has not had any fall(s) since the most recent SOC/ROC.
  • Code 1: Yes – If the patient has fallen since the most recent SOC/ROC.
  • A dash is a valid response for this item. CMS expects dash use to be a rare occurrence.
  • J1900

The intent of the second new assessment item, J1900, is to identify the number of falls a patient has had since the most recent SOC/ROC, and any fall related injury.  The time point items are the same as for J1800, which include transfer to an inpatient facility, death at home or discharge from agency – not to an inpatient facility.

The following definitions are used when addressing J1900:

  • Injury related to a fall includes any documented or reported injury that occurred as a result of or was recognized within a short period of time (i.e. hours to a few days) after the fall and can be attributed to the fall.
  • No injury means that there is no evidence of any injury noted on the assessment; no complaints of pain or injury by the patient; no change in the patient’s behavior is noted after the fall.
  • Injury (except major) includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall-related injury that causes the patient to complain of pain.
  • Major injury is defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.

Response specific instructions include review of the home health clinical record, incident reports and any other relevant clinical documentation, such as fall logs. The patient and/or caregiver(s) should be interviewed about the occurrence of the falls.  The number of falls that occurred since the most recent SOC/ROC should be determined, and the level of fall-related injury for each should be coded.  No matter where the fall occurred, it should be coded, but each fall should only be coded once.   If the patient sustains multiple injuries in a single fall, then code the fall for the highest level of injury.

Coding instructions vary based on the type of fall:

  • J1900A – No Injury
    • Code 0, None, if the patient had no injurious falls since the most recent SOC/ROC.
    • Code 1, One, if the patient had one non-injurious fall since the most recent SOC/ROC.
    • Code 2, Two or more, if the patient had two or more non – injurious falls since the most recent SOC/ROC.
    • A dash is a valid response for this item. However, CMS expects dash use to be a rare occurrence.
  • J1900B – Injury, Except Major
    • Code 0, None, if the patient had no falls with injury, except major, since the most recent SOC/ROC.
    • Code 1, One, if the patient had one fall with injury, except major, since the most recent SOC/ROC.
    • Code 2, Two or more, if the patient had two or more falls with injury, except major, since the most recent SOC/ROC.
    • A dash is a valid response for this item. However, CMS expects dash use to be a rare occurrence.
  • J1900C – Major Injury
    • Code 0, None, if the patient had no falls with major injury since the most recent SOC/ROC.
    • Code 1, One, if the patient had one fall with major injury since the most recent SOC/ROC.
    • Code 2, Two or more, if the patient had two or more falls with major injury since the most recent SOC/ROC.
    • A dash is a valid response for this item. However, CMS expects dash use to be a rare occurrence.

Prepare Now
 
With an effective date of January 1, 2019, OASIS-D changes will be here very soon.  5 Star Consultants can help to prepare your staff for these changes with online or on-site training options.  To learn more, please contact us at [email protected] or 866-428-4040.

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