OASIS-C2 Manual

OASIS-C2 Guidance Manual 6-17-16.pdf

(CMS-10545) Outcome and Assessment Information Set (OASIS) OASIS–C2/ICD–10

OASIS-C2 Manual

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Outcome and Assessment
Information Set

OASIS-C2
Guidance Manual
Effective January 1, 2017

Centers for Medicare & Medicaid Services

PREFACE
This manual provides guidance for home health agencies (HHAs) on how to ensure the collection of high-quality
(accurate) OASIS data. It includes both general data collection conventions and item-specific guidance, as well as
links to quality-related resources for agencies.
Since OASIS collection was implemented in 1999, national interest in the area of home health care quality
measurement and improvement has been ongoing. CMS received hundreds of comments about OASIS from a
variety of sources: providers, professional organizations (e.g., American Nurses Association and the American
Physical Therapy Association), home care provider organizations, accrediting organizations, researchers, etc. In
addition, individuals and groups with expertise in health care quality measurement, such as the Medicare Payment
Advisory Commission (MedPAC), the National Quality Forum (NQF), and several technical expert panels
commissioned by CMS to guide OASIS evolution have offered suggestions for improving OASIS and expanding the
domains of home health quality measurement to address the six aims (safety, timeliness, effectiveness, efficiency,
equity, and patient-centeredness) articulated by the Institute of Medicine in their 2001 report “Crossing the Quality
Chasm.”
Input from the NQF, a nonprofit organization that endorses national consensus standards for measuring and publicly
reporting on performance, has been especially valuable in guiding the evolution of OASIS and associated
performance reports. NQF-endorsed voluntary consensus standards are widely viewed as the gold standard for
measurement of health care quality. NQF has endorsed a number of OASIS-based quality measures for public
reporting. Endorsed measures are periodically reviewed for continuing endorsement, and, as measure development
continues, new or revised measures are submitted to NQF for review.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

REVISION HISTORY

OASIS C Guidance Manual Original Publication: September 2009

Revision 1: December 2009

Revision 2: January 2011

Revision 3: January 2012

Revision 4: December 2012

OASIS-C1/ICD-9 Guidance Manual: June 2014

Note: Past revisions of the guidance manual have included an “errata” document that indicated where changes had
occurred so that HHAs could replace only those manual pages that had changed. Because this revision is
substantially more extensive than previous updates, this manual was intended to replace in its entirety the OASIS-C
Guidance Manual and as such, changes to specific sections or pages were not tracked. However, there was a table
included at the beginning of Chapter 3 that indicated which OASIS items and which item-by-item guidance sections
had been revised.
7.

OASIS-C1/ICD-9 Guidance Manual: January 2015

Changes in this version included a new Chapter 2, in which the “draft” notation was removed from the OASIS forms
and the OMB number was added to each time point version. The footer date throughout the entire manual was
changed to January 2015.
8.

OASIS-C1/ICD-10 Guidance Manual: October 2015

This version of the manual included changes required to incorporate the newly-implemented ICD-10-CM codes into
both the guidance manual and the corresponding OASIS-C1 data set items. The footer was changed in all chapters,
including those that did not have changes related to the implementation of ICD-10-CM.
9.

OASIS-C2 Guidance Manual: Effective January 1, 2017

This version of the manual replaces the previous version in its entirety. This version includes changes required for
standardization with other post-acute care data sets. Three new standardized items and guidance, and five revised
items and guidance are included in this version. Other changes include guidance for a revised look-back period for
five items, and clarifications in response to questions submitted to the OASIS Help Desk.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

OASIS-C2 Guidance Manual

Table of Contents

CHAPTER 1 — INTRODUCTION

1-1

Manual Overview .......................................................................................................................... 1-1

Why is OASIS Being Revised Now? ............................................................................................. 1-1

What’s New about OASIS C-2? .................................................................................................... 1-1

Collecting OASIS Data .................................................................................................................. 1-1
Eligible Patients ............................................................................................................................. 1-2
Time Points ................................................................................................................................... 1-2
Who Completes OASIS................................................................................................................. 1-2
Comprehensive Assessment and Plan of Care ............................................................................ 1-3
Process of Care Data Items .......................................................................................................... 1-3
Conventions for Completing OASIS .............................................................................................. 1-4

OASIS Data Accuracy ................................................................................................................... 1-5

OASIS Data Encoding and Transmission ..................................................................................... 1-5

CHAPTER 2 — OASIS-C2: ALL ITEMS AND TIME POINT VERSIONS

2-1

All Items.................................................................................................................................................. 2-2
Patient Tracking ................................................................................................................................... 2-29
Start of Care (SOC) – Admission to Home Health Care ...................................................................... 2-31
Resumption of Care (ROC) after Inpatient Facility Stay ...................................................................... 2-52
Follow-up (FU) – Recertification or Other Follow-up ........................................................................... 2-74
Transfer to Inpatient Facility (TRN) ...................................................................................................... 2-84
Discharge (DC) from Home Health Care, not to an Inpatient Facility .................................................. 2-90
Death at Home (DAH) ........................................................................................................................ 2-105

CHAPTER 3 — OASIS ITEM GUIDANCE

3-1

Patient Tracking .....................................................................................................................................3-A
Clinical Record Items .............................................................................................................................3-B
Diagnosis Living Arrangements ............................................................................................................ 3-C
Sensory Status. ..................................................................................................................................... 3-D
Integumentary ........................................................................................................................................3-E
Respiratory Status .................................................................................................................................. 3-F
Cardiac Status ....................................................................................................................................... 3-G
Elimination ............................................................................................................................................. 3-H

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Table of Contents

Neuro, Emotional, and Behavioral Status ............................................................................................... 3-I
ADLs / IADLs .......................................................................................................................................... 3-J
Medications ............................................................................................................................................3-K
Care Management ................................................................................................................................. 3-L
Therapy Need Plan of Care .................................................................................................................. 3-M
Emergent Care ...................................................................................................................................... 3-N
Discharge .............................................................................................................................................. 3-O
Death at Home (DAH) ............................................................................................................................3-P

CHAPTER 4 — ILLUSTRATIVE CLINICAL RECORD FORM PAGES WITH
OASIS-C2 ITEMS INTEGRATED

4-1

Illustration 1 – Start of Care Assessment............................................................................................... 4-2
Illustration 2 – Start of Care Assessment............................................................................................... 4-3
Illustration 3 – Discharge Assessment ................................................................................................... 4-4
Illustration 4 – Transfer to Inpatient Facility ........................................................................................... 4-5

CHAPTER 5 — RESOURCES / LINKS

5-1

Appendices
Appendix A: OASIS and the Comprehensive Assessment ....................................................................A-1
Appendix B: OASIS Data Accuracy .......................................................................................................B-1
Appendix C: OASIS-C2 Items, Time Points and Uses ......................................................................... C-1
Appendix D: (Reserved for Future Use) ................................................................................................ D-1
Appendix E: Data Reporting Regulations ..............................................................................................E-1
Appendix F: OASIS and Quality Improvement....................................................................................... F-1
Appendix G: Description of Changes from OASIS-C1/ICD-10 to OASIS-C2 ....................................... G-1

OASIS-C2 Guidance
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Chapter 1

OASIS Item Guidance Introduction

The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and
refined over two decades through a research and demonstration program funded primarily by the Centers for
Medicare & Medicaid Services (CMS), with additional funding from the Robert Wood Johnson Foundation and the
New York State Department of Health. OASIS data elements were designed to enable systematic comparative
measurement of home health care patient outcomes at two points in time. Outcome measures are the basis for
outcome-based quality improvement (OBQI) efforts that home health agencies (HHAs) can employ to assess and
improve the quality of care they provide to patients. CMS provides HHAs with a) process quality, b) risk-adjusted
outcome, and c) potentially avoidable event reports. In addition, HHAs can access patient-related characteristic
reports and patient tally reports. Reports are provided for up to two time intervals selected by the HHA requesting the
reports. Process quality measures include indicators of how often the HHA follows best practices in assessment, care
planning, education, prevention and clinical intervention to improve patient outcomes. Outcome measures include
end-result functional and physical health improvement/stabilization, health care utilization measures (hospitalization
and emergency department use), and potentially avoidable events. Potentially avoidable events are negative
outcomes that clinical evidence indicates can be influenced (although not necessarily totally avoided) by following
best practices in providing care. In addition to quality measurement, OASIS data are used to adjust per-episode
payment rates for patient conditions that affect care needs.

Manual Overview
Chapter 1

–

The Introduction, which provides contextual information and other general information relevant
to OASIS data collection.

Chapter 2

–

Includes versions of the OASIS data set for each data collection time point. Chapter 3 –
Contains item-specific guidance, subdivided into sections.

Chapter 4

–

Contains partial sample clinical record forms for OASIS data collection time points.

Chapter 5

–

Includes relevant resources for HHAs, with hyperlinks when available.

Appendices –

Include additional contextual information, including sections on OBQI, home health care
regulations related to OASIS data collection, and recommendations for ensuring accuracy of
OASIS data.

Why is OASIS Being Revised Now?
HHAs began collecting and transmitting OASIS data for adult skilled Medicare and Medicaid patients (with the
exception of maternity patients) in 1999. Since 1999, numerous changes have occurred within the health care
system, including specific recommendations for changes in the area of home health care quality measurement.
Currently the main reason for revising OASIS is to increase standardization with assessment item sets for other postacute care (PAC) settings and to enable calculation of standardized, cross-setting quality measures, pursuant to the
provisions of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. There have been
additional minor updates to bring the Manual current for OASIS-C2 (See Appendix G Change Table).

What’s New?
This OASIS version incorporates three new items, modification to item wording, numbering or responses options in
several existing items, and formatting changes. Many item changes are the result of standardization to report
information that supports calculation of a cross-setting IMPACT quality measures. More detail is available in
Appendix G.

Collecting OASIS Data
Techniques for collecting OASIS data have not changed. This section will provide a basic overview for collecting
OASIS data. For more detail on clinical strategies for collecting OASIS data as part of a comprehensive assessment,
refer to Chapter 3 of this manual.

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Chapter 1-1

Chapter 1

OASIS Item Guidance Introduction

Eligible Patients
OASIS data are collected for Medicare and Medicaid patients, 18 years and older, receiving skilled services, with the
exception of patients receiving services for pre- or postnatal conditions. Those receiving only personal care,
homemaker, or chore services are excluded since these are not considered skilled services.

Time Points
OASIS data are collected at the following time points:
Start of care
Resumption of care following inpatient facility stay
Recertification within the last five days of each 60-day recertification period
Other follow-up during the home health episode of care
Transfer to inpatient facility
Discharge from home care
Death at home
All of these assessments, with the exception of transfer to inpatient facility and death at home, require the clinician to
have an in-person encounter with the patient during a home visit. The transfer to an inpatient facility requires
collection of limited OASIS data (most of which may be obtained through a telephone call). Not all OASIS items are
completed at every assessment time point. Some items are completed only at start of care, some only at discharge.
The table of “Items to be Used at Specific Time Points” included at the beginning of the OASIS data set allows the
home health agency to integrate the necessary OASIS items at each time point into clinical documentation forms or
an electronic health record.
At the start of care time point, the comprehensive assessment should be completed within five days after the start of
care date. At the resumption of care, the comprehensive assessment must be completed within 48 hours of return
home after inpatient facility discharge. For the transfer to inpatient facility, discharge from home care, death at home,
and other follow-up, the assessments must be completed within 48 hours of becoming aware of the transfer,
discharge, death, or significant change in condition.

Who Completes OASIS?
As identified in (M0080) Discipline of Person Completing Assessment, the comprehensive assessment and OASIS
data collection should be conducted by a registered nurse (RN) or any of the therapies, including physical therapist
(PT), speech language pathologist/speech therapist (SLP/ST), or occupational therapist (OT). A licensed practical
nurse or licensed vocational nurse (LPN/LVN), physical therapy assistant (PTA), occupational therapy assistant
(OTA), medical social worker (MSW), or Aide may not complete OASIS assessments.
In cases involving nursing, the RN must complete the comprehensive assessment at SOC. Any discipline qualified to
perform assessments—RN, PT, SLP, OT—may complete subsequent assessments. For a therapy-only case, the
therapist usually conducts the comprehensive assessment. It is acceptable for a PT or SLP to conduct and complete
the comprehensive assessment at SOC for a Medicare patient.
An OT may conduct and complete the assessment when the need for occupational therapy establishes program
eligibility. Note: Occupational therapy alone does not establish eligibility for the Medicare home health benefit at the
start of care; however, occupational therapy may establish eligibility under other programs, such as Medicaid. The
Medicare home health patient who is receiving services from multiple disciplines (for example, skilled nursing,
physical therapy, and occupational therapy) during the episode of care, can retain eligibility if, over time, occupational
therapy is the only remaining skilled discipline providing care. At that time, an OT can conduct OASIS assessments.
Multidisciplinary cases may have multiple points of discipline-specific discharge, though there is only one HHA
discharge, which must include completion of the OASIS discharge comprehensive assessment. Other non-OASIS
required documentation for recertification and discharge are specified in the Condition of Participation:
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Chapter 1-2

Chapter 1

OASIS Item Guidance Introduction
1

Comprehensive Assessment of Patients. OASIS items were designed to be discipline-neutral and have been tested
and validated with clinicians from various disciplines.

Comprehensive Assessment and Plan of Care
OASIS data are collected as part of the comprehensive assessment required by the Medicare Conditions of
Participation (see Appendix A of this manual). OASIS is not intended to represent a comprehensive assessment in
and of itself. HHAs are expected to incorporate OASIS items into their comprehensive assessment documentation
and follow their own assessment policies and procedures. Agencies are free to rearrange OASIS item sequence in a
way that permits logical ordering within their own forms, as long as the actual item content, skip patterns, and OASIS
number remain the same. Like other comprehensive assessment documentation, OASIS data are collected using a
variety of strategies, including observation, interview, review of pertinent documentation (for example, hospital
discharge summaries) discussions with other healthcare providers where relevant (for example, phone calls to the
physician to verify diagnoses), and measurement (for example, intensity of pain). OASIS data should be collected at
each time point based on a unique patient assessment, not simply carried over from a previous assessment.
Comprehensive assessment data form the basis of the physician-ordered Plan of Care. Thus, there should be
congruency between documentation of findings from the comprehensive assessment and the Plan of Care. As
specified in the Medicare Conditions of Participation for Home Health (see link to the Conditions of Participation
above and in Chapter 5 of this manual), the Plan of Care should be updated to reflect revised care orders and current
diagnoses throughout the period the patient is receiving home health care services.

Process of Care Data Items
Process of care data items (process items) document whether certain evidence-based practices were implemented.
Process items collected at SOC/ROC document assessment and care planning interventions such as: a) whether the
patient was assessed to be at risk for certain conditions like pain, falls risk, or pressure ulcer risk, and b) whether
interventions to address the conditions were incorporated into the Plan of Care. These items refer to assessments
that were completed and orders included in the Plan of Care within the five-day SOC period or the two-day ROC
period.
Process items collected at transfer and discharge time points include documentation of interventions implemented as
part of patient care at the time of or since the most recent start of care or resumption of care (see example in Table
1). Specific instructions about review periods are included in item guidance for the relevant OASIS questions.
Process items collected at transfer and discharge may require a clinician to review documentation of care provided
during the home health episode in order to accurately complete the items. Note that this review must consider care
provided by all disciplines, and is not limited to care provided by the discipline of the clinician completing the OASIS
assessment. The review can be accomplished in several different ways. The care provider may find it necessary to
review clinical records, including the Plan of Care, updated orders, and visit notes. Alternatively, the agency may
elect to create a flowsheet with the appropriate parameters that are checked off on each visit. Review of the
flowsheet may provide the needed information, such that a review of the clinical record would be unnecessary.
Another strategy for agencies using electronic health records is to create a report template that could pull the needed
information from data fields incorporated into visit notes. Regardless of the technique that an agency chooses, the
process data items completed at transfer and discharge will require knowledge of patient symptoms, initial and
subsequent physician’s orders, and clinical interventions performed to address patient symptoms that were present at
the time of or since the most recent SOC/ROC assessment.

Conventions for Completing OASIS
Listed below are conventions, or general rules, that should be observed when completing OASIS. Item-specific
guidance is provided in Chapter 3. The OASIS Guidance is updated periodically to provide additional clarification

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Chapter 1-3

Chapter 1

OASIS Item Guidance Introduction

based on "Frequently Asked Questions" sent to CMS. (A link to Frequently Asked Questions is provided in Chapter
5). It may not be possible to address all of the situations that arise, due to the rare and unique nature of some of the
questions, and exceptions that may be encountered in clinical practice.
Each patient scenario, clinical status, social and environmental situation is unique, requiring professional/clinical
judgment and care coordination. In the event you cannot resolve your understanding of the OASIS questions, CMS
will continue to provide avenues to accept and respond to questions.

General OASIS Item Conventions
1.

Understand the time period under consideration for each item. Report what is true on the day of assessment
unless a different time period has been indicated in the item or related guidance. Day of assessment is defined
as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.

For OASIS purposes, a quality episode must have a beginning (that is, an SOC or ROC assessment) and a
conclusion (that is, a Transfer or Discharge assessment) to be considered a complete care episode.

If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual status” or what is
true greater than 50% of the assessment time frame, unless the item specifies differently.

Minimize the use of NA and Unknown responses.

Some items allow a dash response. A dash (–) value indicates that no information is available, and/or an item
could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged or dies
before assessment of the item could be completed. CMS expects dash use to be a rare occurrence.

Responses to items documenting a patient’s current status should be based on independent observation of the
patient’s condition and ability at the time of the assessment without referring back to prior assessments. Several
process items require documentation of prior care, at the time of or since the time of the most recent SOC or
ROC OASIS assessment. These instructions are included in item guidance for the relevant OASIS questions.

Combine observation, interview, and other relevant strategies to complete OASIS data items as needed (for
example, it is acceptable to review the hospital discharge summary to identify inpatient procedures and
diagnoses at Start of Care, or to examine the care notes to determine if a physician-ordered intervention was
implemented at Transfer or Discharge). However, when assessing physiologic or functional health status, direct
observation is the preferred strategy.

When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited
to physical contact and can include verbal cues and/or supervision.

Complete OASIS items accurately and comprehensively, and adhere to skip patterns.

10. Understand the definitions of words as used in the OASIS.
11. Follow rules included in the Item Specific Guidance (Chapter 3 of this manual).
12. Stay current with evolving CMS OASIS guidance updates. CMS may post updates to the guidance manual up to
twice per year, and releases OASIS Q&As quarterly.
13. Only one clinician may take responsibility for accurately completing a comprehensive assessment. However, for
selected items, collaboration is appropriate. These exceptions are noted in the item specific guidance.
14. The use of the term “specifically,” means scoring of the item should be limited to only the circumstances listed.
The use of “for example,” means the clinician may consider other relevant circumstances or attributes when
scoring the item.
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Chapter 1

OASIS Item Guidance Introduction

Conventions Specific to ADL/IADL Items
1.

Report the patient’s physical and cognitive ability to perform a task. Do not report on the patient’s preference or
willingness to perform a specified task.

The level of ability refers to the level of assistance (if any) that the patient requires to safely complete a specified
task.

While the presence or absence of a caregiver may impact the way a patient carries out an activity, it does not
impact the assessing clinician’s ability to assess the patient in order to determine and report the level of
assistance that the patient requires to safely complete a task.

Understand what tasks are included and excluded in each item and select the OASIS response based only on
included tasks.

If the patient’s ability varies between the different tasks included in a multi-task item, report what is true in a
majority of the included tasks, giving more weight to tasks that are more frequently performed.

Consider medical restrictions when determining ability. For example, if the physician has ordered activity
restrictions, consider this when selecting the best response to functional items related to ambulation, transferring,
bathing, etc.

OASIS Data Accuracy
In any data-driven system, the quality of the output is only as good as the quality of the data input. OASIS data are
used to produce quality reports for agencies, public reports on the Medicare Home Health Compare website, and to
determine payment. Thus, it is imperative that the OASIS data that HHAs collect and submit be accurate and
complete. Regulatory language specifying accuracy of OASIS data can be found in the Medicare Conditions of
2
Participation Accuracy of Encoded OASIS Data (For additional discussion of OASIS Data Accuracy, see Appendix B
of this manual.)
CMS recommends that agencies develop internal systems for monitoring data accuracy in addition to data checking
features incorporated into CMS-supplied data entry software and other data entry systems. These may include
clinical record audits, data entry audits, reports produced from electronic health record systems or other activities.
HHAs can correct nearly all erroneous assessments themselves following professional standards for correcting
documents. Information related to correction of erroneous OASIS data can be found in Appendix B of this manual.

OASIS Data Encoding and Transmission
HHAs are required to encode and electronically submit OASIS data to CMS within 30 days of the date the
3
assessment was completed. The requirements are specified in the Medicare Conditions of Participation Encoding
OASIS Data, Transmittal of OASIS Data, and Data Format, summarized in Appendix E of this manual. Detailed
instructions on encoding and transmitting OASIS data are found in the HHA System User's Guide and the OASIS
Validation Report Messages and Description Guide (both available at QIES Technical Support Office – OASIS User
4
Guides and Training).

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http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=5aad0315b2e678ef56bbbd491bc8b31b&n=42y5.0.1.1.3&r=
PART&ty=HTML#42:5.0.1.1.3.2.7.7

https://www.qtso.com/hhatrain.html

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Chapter 1-5

CHAPTER 2

ALL TIME POINTS VERSIONS

Chapter 2 contains the following sets of OASIS items:

•
•

•
•
•
•
•
•

All Items: This is the entire set of OASIS Items that are collected at any point in time during a home
health episode of care. At any one point in time, only a subset of OASIS items is collected.
Patient Tracking Sheet: This information is collected at Start of Care and updated as needed at
subsequent time points .Note: Patient Tracking Sheet items are required to be included in the data
submission record for each time point, although they are collected at Start of Care and only updated as
needed at subsequent time points. Refer to the OASIS Data Specifications on the CMS Web site at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/
OASIS/Downloads/OASIS-C2-Data-Submission-Specs-v2-20-0-Draft.zip.
Start of Care (SOC): This information is collected at Start of Care in addition to all OASIS items on the
Patient Tracking Sheet.
Resumption of Care (ROC): This information is collected at Resumption of Care in addition to M0032
Resumption of Care Date on the Patient Tracking Sheet.
Follow-Up (FU): This information is collected at Recertification and Other Follow-up.
Transfer (TRN): This information is collected at Transfer to Inpatient Facility, with or without Discharge
from Home Health Agency.
Discharge (DC): This information is collected at discharge from home health agency other than Death
at Home or Transfer to Inpatient Facility.
Death at Home (Death): This information is collected when the patient dies while on service with the
home health agency, and died somewhere other than an inpatient/outpatient facility or ED.

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Chapter 2-1

Home Health Patient Tracking Sheet
(M0010) CMS Certification Number:
(M0014) Branch State:
(M0016) Branch ID Number:
(M0018) National Provider Identifier (NPI) for the attending physician who has signed the plan of care:

⃞ UK – Unknown or Not Available
(M0020) Patient ID Number:

(M0030) Start of Care Date:
month

/
day

(M0032) Resumption of Care Date:

year

/
month

⃞ NA - Not Applicable

/
day

year

(M0040) Patient Name:

(First)

(M I)

(Last)

(Suffix)

(M0050) Patient State of Residence:
─

(M0060) Patient ZIP Code:

⃞ NA – No Medicare

(M0063) Medicare Number:
(including suffix)
(M0064) Social Security Number:

⃞ UK – Unknown or Not Available
⃞ NA – No Medicaid

(M0065) Medicaid Number:

(M0066) Birth Date:
month

/
day

year

(M0069) Gender
Enter Code

1
2

Male
Female

(M0140) Race/Ethnicity: (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞

1 -

American Indian or Alaska Native

2 -

Asian

3 -

Black or African-American

4 -

Hispanic or Latino

5 -

Native Hawaiian or Pacific Islander

6 -

White

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(M0150) Current Payment Sources for Home Care: (Mark all that apply.)

⃞ 0 - None; no charge for current services
⃞ 1 - Medicare (traditional fee-for-service)
⃞ 2 - Medicare (HMO/managed care/Advantage plan)
⃞ 3 - Medicaid (traditional fee-for-service)
⃞ 4 - Medicaid (HMO/managed care)
⃞ 5 - Workers' compensation
⃞ 6 - Title programs (for example, Title III, V, or XX)
⃞ 7 - Other government (for example, TriCare, VA)
⃞ 8 - Private insurance
⃞ 9 - Private HMO/managed care
⃞ 10 - Self-pay
⃞ 11 - Other (specify)
⃞ UK - Unknown

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Outcome and Assessment Information Set
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care ---------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1036, M1060M1306, M1311, M1320-M1410, M1600-M2003, M2010,
M2020-M2250, GG0170

Start of care—further visits planned
Resumption of Care ---------------------------------------------Resumption of care (after inpatient stay)
Follow-Up -----------------------------------------------------------Recertification (follow-up) assessment
Other follow-up assessment
Transfer to an Inpatient Facility ------------------------------Transferred to an inpatient facility—patient not
discharged from an agency
Transferred to an inpatient facility—patient
discharged from agency

M0032, M0080-M0110, M1000-M1036, M1060-M1306,
M1311, M1320-M1410, M1600-M2003, M2010, M2020M2250, GG0170
M0080-M0100, M0110, M1011, M1021-M1023, M1030,
M1200, M1242, M1306, M1311, M1322-M1342, M1400,
M1610, M1620, M1630, M1810-M1840, M1850, M1860,
M2030, M2200
M0080-M0100, M1041-M1056, M1501, M1511, M2005,
M2016, M2301-M2410, M2430, M0903, M0906

Discharge from Agency — Not to an Inpatient Facility
Death at home --------------------------------------------------

M0080-M0100, M2005, M0903, M0906

Discharge from agency ---------------------------------------

M0080-M0100, M1041-M1056, M1230, M1242, M1306M1342, M1400, M1501-M1620, M1700-M1720, M1740,
M1745, M1800-M1890, M2005, M2016-M2030, M2102,
M2301-M2420, M0903, M0906

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

(M0100) This Assessment is Currently Being Completed for the Following Reason:
Enter Code

Start/Resumption of Care
1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)
Follow-Up
4

Recertification (follow-up) reassessment [Go to M0110 ]

5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
6

Transferred to an inpatient facility–patient not discharged from agency [Go to M1041 ]

7
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]
Discharge from Agency — Not to an Inpatient Facility
8

Death at home [Go to M0903 ]

Discharge from agency [Go to M1041 ]

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/
month

[Go to M0110, if date entered ]

/
day

year

⃞ NA - No specific SOC date ordered by physician
(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was
received by the HHA.

/
month

/
day

year

(M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will
define a case mix group an “early” episode or a “later” episode in the patient’s current sequence of
adjacent Medicare home health payment episodes?
1
2
UK
NA

Enter Code

Early
Later
Unknown
Not Applicable: No Medicare case mix group to be defined by this assessment.

PATIENT HISTORY AND DIAGNOSES
(M1000) From which of the following Inpatient Facilities was the patient discharged within the past 14 days? (Mark
all that apply.)
⃞ 1 - Long-term nursing facility (NF)

⃞ 2
⃞ 3
⃞ 4
⃞ 5
⃞ 6
⃞ 7
⃞ NA

Skilled nursing facility (SNF/TCU)

Short-stay acute hospital (IPPS)

Long-term care hospital (LTCH)

Inpatient rehabilitation hospital or unit (IRF)

Psychiatric hospital or unit

Other (specify)

Patient was not discharged from an inpatient facility [Go to M1017 ]

(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown
(M1011) List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those
conditions actively treated during an inpatient stay having a discharge date within the last 14 days (no V, W,
X, Y, or Z codes or surgical codes):
Inpatient Facility Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

⃞ NA - Not applicable (patient was not discharged from an inpatient facility) [Omit “NA” option on SOC,
ROC]

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(M1017) Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days: List the patient's
Medical Diagnoses and ICD-10-CM codes at the level of highest specificity for those conditions requiring
changed medical or treatment regimen within the past 14 days (no V, W, X, Y, or Z codes or surgical codes):
Changed Medical Regimen Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

⃞ NA - Not applicable (no medical or treatment regimen changes within the past 14 days)
(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If
this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the
past 14 days, indicate any conditions that existed prior to the inpatient stay or change in medical or treatment
regimen. (Mark all that apply.)

⃞ 1 ⃞ 2 ⃞ 3 ⃞ 4 ⃞ 5 ⃞ 6 ⃞ 7 ⃞ NA ⃞ UK -

Urinary incontinence
Indwelling/suprapubic catheter
Intractable pain
Impaired decision-making
Disruptive or socially inappropriate behavior
Memory loss to the extent that supervision required
None of the above
No inpatient facility discharge and no change in medical or treatment regimen in past 14 days
Unknown

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(M1021/1023/1025) Diagnoses, Symptom Control, and Optional Diagnoses: List each diagnosis for which the
patient is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column 2
(diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects the
seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control
for each condition in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for
any diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that is no longer active (a resolved
condition), then optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be completed. Diagnoses reported
in M1025 will not impact payment.
Code each row according to the following directions for each column:
Column 1:

Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each
condition and support the disciplines and services provided.

Column 2:

Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes
allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and
sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes beginning
with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023
(Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the
underlying condition can often be entered in Column 2, as long as it is an active on-going condition
impacting home health care.
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control
rating if the diagnosis code is a V, W, X, Y or Z-code. Choose one value that represents the degree of
symptom control appropriate for each diagnosis using the following scale:
0 - Asymptomatic, no treatment needed at this time
1 - Symptoms well controlled with current therapy
2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring
3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring
4 - Symptoms poorly controlled; history of re-hospitalizations
Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of
the diagnoses listed in Column 1. These are separate items and sequencing may not coincide.

Column 3:

(OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4).
Diagnoses reported in M1025 will not impact payment.
Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when:
•
a Z-code is reported in Column 2 AND
•
the underlying condition for the Z-code in Column 2 is a resolved condition . An example of a
resolved condition is uterine cancer that is no longer being treated following a hysterectomy.

Column 4:

(OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a
resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines,
enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For
example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.

(Form on next page)

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(M1025) Optional Diagnoses (OPTIONAL)
(not used for payment)

(M1021) Primary Diagnosis & (M1023) Other Diagnoses
Column 1

Column 2

Column 3

Column 4

Diagnoses
(Sequencing of diagnoses
should reflect the seriousness
of each condition and support
the disciplines and services
provided)

ICD-10-CM and symptom control
rating for each condition.
Note that the sequencing of these
ratings may not match the
sequencing of the diagnoses

May be completed if a Z-code
is assigned to Column 2 and
the underlying diagnosis is
resolved

Complete only if the Optional
Diagnosis is a multiple coding
situation (for example: a
manifestation code)

Description

ICD-10-CM /
Symptom Control Rating

Description/
ICD-10-CM

V, W, X, Y codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

(M1021) Primary Diagnosis

a.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(M1023) Other Diagnoses

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

)

) (

)

d.
.

) (
e.

) (
c.

) (
f.

) (

(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions – Check all that apply
See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.

⃞
⃞

1 -

Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

2 -

Diabetes Mellitus (DM)

(M1030) Therapies the patient receives at home: (Mark all that apply.)

⃞
⃞
⃞
⃞

1 -

Intravenous or infusion therapy (excludes TPN)

2 -

Parenteral nutrition (TPN or lipids)

3 -

Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the
alimentary canal)
None of the above

4 -

Centers for Medicare & Medicaid Services

)

(

.
V, W, X, Y, Z codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

) (

(

b.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

All ICD-10–C M codes allowed

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(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for
hospitalization? (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞

1 -

History of falls (2 or more falls - or any fall with an injury - in the past 12 months)

2 -

Unintentional weight loss of a total of 10 pounds or more in the past 12 months

3 -

Multiple hospitalizations (2 or more) in the past 6 months

4 -

Multiple emergency department visits (2 or more) in the past 6 months

5 -

Decline in mental, emotional, or behavioral status in the past 3 months

6 7 -

Reported or observed history of difficulty complying with any medical instructions (for example,
medications, diet, exercise) in the past 3 months
Currently taking 5 or more medications

8 -

Currently reports exhaustion

9 -

Other risk(s) not listed in 1 - 8

10 -

None of the above

⃞
⃞
⃞
⃞

(M1034) Overall Status: Which description best fits the patient’s overall status?
Enter Code

The patient is stable with no heightened risk(s) for serious complications and death
(beyond those typical of the patient’s age).
1 The patient is temporarily facing high health risk(s) but is likely to return to being stable
without heightened risk(s) for serious complications and death (beyond those typical of
the patient’s age).
2 The patient is likely to remain in fragile health and have ongoing high risk(s) of serious
complications and death.
3 The patient has serious progressive conditions that could lead to death within a year.
UK The patient’s situation is unknown or unclear.

(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all
that apply.)

⃞ 1
⃞ 2
⃞ 3
⃞ 4
⃞ 5
⃞ UK

Smoking

Obesity

Alcohol dependency

Drug dependency

None of the above

Unknown

(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to
Transfer/Discharge) include any dates on or between October 1 and March 31?
Enter Code

No [Go to M1051 ]

Yes

(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu
season?
Enter Code

1
2
3
4
5
6
7
8

Yes; received from your agency during this episode of care (SOC/ROC to
Transfer/Discharge)
Yes; received from your agency during a prior episode of care (SOC/ROC to
Transfer/Discharge)
Yes; received from another health care provider (for example, physician, pharmacist)
No; patient offered and declined
No; patient assessed and determined to have medical contraindication(s)
No; not indicated - patient does not meet age/condition guidelines for influenza vaccine
No; inability to obtain vaccine due to declared shortage
No; patient did not receive the vaccine due to reasons other than those listed in
responses 4 – 7.

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(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for
example, pneumovax)?
Enter Code

0
1

No
Yes [Go to M1501 at TRN; Go to M1230 at DC ]

(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal
vaccination (for example, pneumovax), state reason:
Enter Code

1
2
3
4

Offered and declined
Assessed and determined to have medical contraindication(s)
Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine
None of the above

(M1060) Height and Weight – While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up
a. Height (in inches). Record most recent height measure since the most recent SOC/ROC

inches

b. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight
consistently, according to standard agency practice (for example, in a.m. after

pounds

voiding, before meal, with shoes off, etc.)

LIVING ARRANGEMENTS
(M1100) Patient Living Situation: Which of the following best describes the patient's residential circumstance and
availability of assistance? (Check one box only.)
Availability of Assistance
Occasional /
Regular
Regular
short-term
daytime
nighttime
assistance

No
assistance
available

Living Arrangement

Around the
clock

a. Patient lives alone

⃞ 01

⃞ 02

⃞ 03

⃞ 04

⃞ 05

b. Patient lives with other
person(s) in the home

⃞ 06

⃞ 07

⃞ 08

⃞ 09

⃞ 10

c. Patient lives in congregate
situation (for example,
assisted living, residential
care home)

⃞ 11

⃞ 12

⃞ 13

⃞ 14

⃞ 15

SENSORY STATUS
(M1200) Vision (with corrective lenses if the patient usually wears them):
Enter Code

Normal vision: sees adequately in most situations; can see medication labels,
newsprint.

Partially impaired: cannot see medication labels or newsprint, but can see obstacles in
path, and the surrounding layout; can count fingers at arm's length.
Severely impaired: cannot locate objects without hearing or touching them, or patient
nonresponsive.

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(M1210) Ability to Hear (with hearing aid or hearing appliance if normally used):
Enter Code

0
1
2
UK

Adequate: hears normal conversation without difficulty.
Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may
need to increase volume or speak distinctly.
Severely Impaired: absence of useful hearing.
Unable to assess hearing.

(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):
Enter Code

0
1

Understands: clear comprehension without cues or repetitions.
Usually Understands: understands most conversations, but misses some part/intent of
message. Requires cues at times to understand.
Sometimes Understands: understands only basic conversations or simple, direct
phrases. Frequently requires cues to understand.
Rarely/Never Understands.

Unable to assess understanding.

(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):
Expresses complex ideas, feelings, and needs clearly, completely, and easily in all
situations with no observable impairment.
1
Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional
errors in word choice, grammar or speech intelligibility; needs minimal prompting or
assistance).
2
Expresses simple ideas or needs with moderate difficulty (needs prompting or
assistance, errors in word choice, organization or speech intelligibility). Speaks in
phrases or short sentences.
3
Has severe difficulty expressing basic ideas or needs and requires maximal assistance
or guessing by listener. Speech limited to single words or short phrases.
4
Unable to express basic needs even with maximal prompting or assistance but is not
comatose or unresponsive (for example, speech is nonsensical or unintelligible).
5
Patient nonresponsive or unable to speak.
(M1240) Has this patient had a formal Pain Assessment using a standardized, validated pain assessment
tool (appropriate to the patient’s ability to communicate the severity of pain)?
Enter Code

Enter Code

0
1
2

No standardized, validated assessment conducted
Yes, and it does not indicate severe pain
Yes, and it indicates severe pain

(M1242) Frequency of Pain Interfering with patient's activity or movement:
Enter Code

0
1
2
3
4

Patient has no pain
Patient has pain that does not interfere with activity or movement
Less often than daily
Daily, but not constantly
All of the time

INTEGUMENTARY STATUS
(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure
Ulcers?
Enter Code

No assessment conducted [Go to M1306 ]

Yes, based on an evaluation of clinical factors (for example, mobility, incontinence,
nutrition) without use of standardized tool
2
Yes, using a standardized, validated tool (for example, Braden Scale, Norton Scale)
(M1302) Does this patient have a Risk of Developing Pressure Ulcers?
Enter Code

0
1

No
Yes

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(M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated
as Unstageable? (Excludes Stage 1 pressure ulcers and healed Stage 2 pressure ulcers)
Enter Code

No [Go to M1322 ]

Yes

(M1307) The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2
Pressure Ulcers)
Enter Code

1
2

Was present at the most recent SOC/ROC assessment
Developed since the most recent SOC/ROC assessment. Record date pressure ulcer
first identified:

/
NA

month
day
year
No Stage 2 pressure ulcers are present at discharge

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Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound
bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
[If 0 at FU/DC Go to M1311B1]
A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or
muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Number of Stage 3 pressure ulcers
[If 0 at FU/DC Go to M1311C1]
B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar
may be present on some parts of the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers
[If 0 at FU/DC Go to M1311D1]
C2. Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
D1. Unstageable: Non-removable dressing: Known but not stageable due to non-removable
dressing/device
Number of unstageable pressure ulcers due to non-removable dressing/device
[If 0 at FU/DC Go to M1311E1
D2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed
by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
[If 0 at FU/DC Go to M1311F1]
E2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
F1. Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution
Number of unstageable pressure ulcers with suspected deep tissue injury in evolution
[ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]
F2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

[Omit “A2, B2, C2, D2, E2 and F2” on SOC/ROC ]

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(M1313) Worsening in Pressure Ulcer Status since SOC/ROC:
Instructions for a-c: Indicate the number of current pressure ulcers that were not present or were at a
lesser stage at the most recent SOC/ROC. If no current pressure ulcer at a given stage, enter 0.

Enter Number
a. Stage 2
b. Stage 3
c. Stage 4
Instructions for e: For pressure ulcers that are Unstageable due to slough/eschar, report the number that are
new or were at a Stage 1 or 2 at the most recent SOC/ROC.
d. Unstageable – Known or likely but
Unstageable due to non-removable
dressing.
e. Unstageable – Known or likely but
Unstageable due to coverage of wound
bed by slough and/or eschar.
f. Unstageable – Suspected deep tissue
injury in evolution.

(M1320) Status of Most Problematic Pressure Ulcer that is Observable: (Excludes pressure ulcer that
cannot be observed due to a non-removable dressing/device)
Enter Code

0
1
2
3
NA

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing
No observable pressure ulcer

(M1322) Current Number of Stage 1 Pressure Ulcers: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or
cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in
dark skin tones only it may appear with persistent blue or purple hues.
Enter Code

0
1
2
3
4 or more

(M1324) Stage of Most Problematic Unhealed Pressure Ulcer that is Stageable: (Excludes pressure
ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by
slough and/or eschar, or suspected deep tissue injury.)
1
Stage 1
2
Stage 2
3
Stage 3
4
Stage 4
NA Patient has no pressure ulcers or no stageable pressure ulcers
(M1330) Does this patient have a Stasis Ulcer?
Enter Code

Enter Code

No [Go to M1340 ]

1
2

Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY

Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to
non-removable dressing/device) [Go to M1340 ]

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(M1332) Current Number of Stasis Ulcer(s) that are Observable:
Enter Code

1
2
3
4

One
Two
Three
Four or more

(M1334) Status of Most Problematic Stasis Ulcer that is Observable:
Enter Code

1
2
3

Fully granulating
Early/partial granulation
Not healing

(M1340) Does this patient have a Surgical Wound?
Enter Code

No [At SOC/ROC, go to M1350 ; At FU//DC, go to M1400 ]

Yes, patient has at least one observable surgical wound

Surgical wound known but not observable due to non-removable dressing/device [At

SOC/ROC, go to M1350 ; At FU/DC, go to M1400 ]
(M1342) Status of Most Problematic Surgical Wound that is Observable
Enter Code

0
1
2
3

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

(M1350) Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those
described above, that is receiving intervention by the home health agency?
Enter Code

0
1

No
Yes

RESPIRATORY STATUS
(M1400) When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0
1
2
3
4

Patient is not short of breath
When walking more than 20 feet, climbing stairs
With moderate exertion (for example, while dressing, using commode or bedpan, walking
distances less than 20 feet)
With minimal exertion (for example, while eating, talking, or performing other ADLs) or
with agitation
At rest (during day or night)

(M1410) Respiratory Treatments utilized at home: (Mark all that apply.)

⃞
⃞
⃞
⃞

1 -

Oxygen (intermittent or continuous)

2 -

Ventilator (continually or at night)

3 -

Continuous / Bi-level positive airway pressure

4 -

None of the above

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CARDIAC STATUS
(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the
patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea,
edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?
Enter Code

No [Go to M2005 at TRN; Go to M1600 at DC ]

Yes

Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]

Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at

DC ]

(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms
indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what
action(s) has (have) been taken to respond? (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞

0 -

No action taken

1 -

Patient’s physician (or other primary care practitioner) contacted the same day

2 -

Patient advised to get emergency treatment (for example, call 911 or go to emergency room)

3 -

Implemented physician-ordered patient-specific established parameters for treatment

4 -

Patient education or other clinical interventions

5 -

Obtained change in care plan orders (for example, increased monitoring by agency, change in visit
frequency, telehealth)

ELIMINATION STATUS
(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0
1
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown [Omit “UK” option on DC ]

(M1610) Urinary Incontinence or Urinary Catheter Presence:
Enter Code

No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Go to M1620 ]

1
2

Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic) [Go to M1620 ]

(M1615) When does Urinary Incontinence occur?
Enter Code

0
1
2
3
4

Timed-voiding defers incontinence
Occasional stress incontinence
During the night only
During the day only
During the day and night

(M1620) Bowel Incontinence Frequency:
Enter Code

0
1
2
3
4
5
NA

Very rarely or never has bowel incontinence
Less than once weekly
One to three times weekly
Four to six times weekly
On a daily basis
More often than once daily
Patient has ostomy for bowel elimination

Unknown [Omit “UK” option on FU, DC ]

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(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the
last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or
treatment regimen?
Enter Code

Patient does not have an ostomy for bowel elimination.

Patient's ostomy was not related to an inpatient stay and did not necessitate change in
medical or treatment regimen.
The ostomy was related to an inpatient stay or did necessitate change in medical or
treatment regimen.

NEURO/EMOTIONAL/BEHAVIORAL STATUS
(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
Enter Code
1
2

3
4

Alert/oriented, able to focus and shift attention, comprehends and recalls task directions
independently.
Requires prompting (cuing, repetition, reminders) only under stressful or unfamiliar
conditions.
Requires assistance and some direction in specific situations (for example, on all tasks
involving shifting of attention) or consistently requires low stimulus environment due to
distractibility.
Requires considerable assistance in routine situations. Is not alert and oriented or is unable
to shift attention and recall directions more than half the time.
Totally dependent due to disturbances such as constant disorientation, coma, persistent
vegetative state, or delirium.

(M1710) When Confused (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
4
NA

Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not constantly
Constantly
Patient nonresponsive

(M1720) When Anxious (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
NA

None of the time
Less often than daily
Daily, but not constantly
All of the time
Patient nonresponsive

(M1730) Depression Screening: Has the patient been screened for depression, using a standardized, validated
depression screening tool?
Enter Code

0
1

No
Yes, patient was screened using the PHQ-2©* scale.
Instructions for this two-question tool: Ask patient: “Over the last two weeks, how often
have you been bothered by any of the following problems?”
Nearly
Several
More than half every day
NA
PHQ-2©*
Not at all
of the days
12 – 14 Unable to
days
0 - 1 day 2 - 6 days
7 – 11 days
days
respond
a) Little interest or pleasure
⃞NA
⃞0
⃞1
⃞2
⃞3
in doing things
b) Feeling down,
⃞NA
⃞0
⃞1
⃞2
⃞3
depressed, or hopeless?

2
3

Yes, patient was screened with a different standardized, validated assessment and the
patient meets criteria for further evaluation for depression.
Yes, patient was screened with a different standardized, validated assessment and the
patient does not meet criteria for further evaluation for depression.

*Copyright© Pfizer Inc. All rights reserved. Reproduced with permission.
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(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week (Reported
or Observed): (Mark all that apply.)

⃞

1 -

⃞

2 -

⃞
⃞
⃞
⃞
⃞

3 4 -

Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24
hours, significant memory loss so that supervision is required
Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop
activities, jeopardizes safety through actions
Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.

5 -

Physical aggression: aggressive or combative to self and others (for example, hits self, throws
objects, punches, dangerous maneuvers with wheelchair or other objects)
Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)

6 -

Delusional, hallucinatory, or paranoid behavior

7 -

None of the above behaviors demonstrated

0
1
2
3
4
5

Never
Less than once a month
Once a month
Several times each month
Several times a week
At least daily

(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric
nurse?
Enter Code

0
1

No
Yes

ADL/IADLs
(M1800) Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and
hands, hair care, shaving or make up, teeth or denture care, or fingernail care).
Enter Code

0
1
2
3

Able to groom self unaided, with or without the use of assistive devices or adapted
methods.
Grooming utensils must be placed within reach before able to complete grooming
activities.
Someone must assist the patient to groom self.
Patient depends entirely upon someone else for grooming needs.

(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including
undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
Enter Code

0
1
2
3

Able to get clothes out of closets and drawers, put them on and remove them from the
upper body without assistance.
Able to dress upper body without assistance if clothing is laid out or handed to the
patient.
Someone must help the patient put on upper body clothing.
Patient depends entirely upon another person to dress the upper body.

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(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including
undergarments, slacks, socks or nylons, shoes:
Enter Code

0
1
2
3

Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed
to the patient.
Someone must help the patient put on undergarments, slacks, socks or nylons, and
shoes.
Patient depends entirely upon another person to dress lower body.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing
hands, and shampooing hair).
Enter Code

0
1
2

3
4
5
6

Able to bathe self in shower or tub independently, including getting in and out of
tub/shower.
With the use of devices, is able to bathe self in shower or tub independently, including
getting in and out of the tub/shower.
Able to bathe in shower or tub with the intermittent assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
Able to participate in bathing self in shower or tub, but requires presence of another
person throughout the bath for assistance or supervision.
Unable to use the shower or tub, but able to bathe self independently with or without the
use of devices at the sink, in chair, or on commode.
Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink,
in bedside chair, or on commode, with the assistance or supervision of another person.
Unable to participate effectively in bathing and is bathed totally by another person.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and
transfer on and off toilet/commode.
Enter Code

0
1
2
3
4

Able to get to and from the toilet and transfer independently with or without a device.
When reminded, assisted, or supervised by another person, able to get to and from the
toilet and transfer.
Unable to get to and from the toilet but is able to use a bedside commode (with or
without assistance).
Unable to get to and from the toilet or bedside commode but is able to use a
bedpan/urinal independently.
Is totally dependent in toileting.

(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or
incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy,
includes cleaning area around stoma, but not managing equipment.
Able to manage toileting hygiene and clothing management without assistance.
Able to manage toileting hygiene and clothing management without assistance if
supplies/implements are laid out for the patient.
2
Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
3
Patient depends entirely upon another person to maintain toileting hygiene.
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in
bed if patient is bedfast.
Enter Code

Enter Code

0
1

0
1
2
3
4
5

Able to independently transfer.
Able to transfer with minimal human assistance or with use of an assistive device.
Able to bear weight and pivot during the transfer process but unable to transfer self.
Unable to transfer self and is unable to bear weight or pivot when transferred by another
person.
Bedfast, unable to transfer but is able to turn and position self in bed.
Bedfast, unable to transfer and is unable to turn and position self.

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Section GG: FUNCTIONAL ABILITIES and GOALS – SOC/ROC
(GG0170C) Mobility
Code the patient’s usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at
SOC/ROC, code the reason.
Code the patient’s discharge goal using the 6-point scale. Do not use codes 07, 09, or 88 to code discharge
goal.
Coding:
1.
2.
Safety and Quality of Performance – If helper assistance is
SOC/ROC
Discharge
required because patient’s performance is unsafe or of poor quality,
Performance
Goal
score according to amount of assistance provided.
Activity may be completed with or without assistive devices.
Enter Codes in Boxes
06 Independent – Patient completes the activity by him/herself
Lying to
with no assistance from a helper.
Sitting on
05 Setup or clean-up assistance – Helper SETS UP or CLEANS
Side of Bed:
UP; patient completes activity. Helper assists only prior to or
The ability to
following the activity.
safely move
04 Supervision or touching assistance – Helper provides
from lying on
VERBAL CUES or TOUCHING/STEADYING assistance as
the back to
patient completes activity. Assistance may be provided
sitting on the
throughout the activity or intermittently.
side of the bed
03 Partial/moderate assistance – Helper does LESS THAN HALF
with feet flat on
the effort. Helper lifts, holds or supports trunk or limbs, but
the floor, and
provides less than half the effort.
with no back
02 Substantial/maximal assistance – Helper does MORE THAN
support.
HALF the effort. Helper lifts or holds trunk or limbs and provides
more than half the effort.
01 Dependent – Helper does ALL of the effort. Patient does none
of the effort to complete the activity. Or, the assistance of 2 or
more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07 Patient refused
09 Not applicable
88 Not attempted due to medical condition or safety concerns

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a
wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

0
1

3
4
5
6

Able to independently walk on even and uneven surfaces and negotiate stairs with or
without railings (specifically: needs no human assistance or assistive device).
With the use of a one-handed device (for example, cane, single crutch, hemi-walker),
able to independently walk on even and uneven surfaces and negotiate stairs with or
without railings.
Requires use of a two-handed device (for example, walker or crutches) to walk alone on
a level surface and/or requires human supervision or assistance to negotiate stairs or
steps or uneven surfaces.
Able to walk only with the supervision or assistance of another person at all times.
Chairfast, unable to ambulate but is able to wheel self independently.
Chairfast, unable to ambulate and is unable to wheel self.
Bedfast, unable to ambulate or be up in a chair.

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(M1870) Feeding or Eating: Current ability to feed self meals and snacks safely. Note: This refers only to
the process of eating, chewing, and swallowing, not preparing the food to be eaten.
Able to independently feed self.
Able to feed self independently but requires:
(a) meal set-up; OR
(b) intermittent assistance or supervision from another person; OR
(c) a liquid, pureed or ground meat diet.
2
Unable to feed self and must be assisted or supervised throughout the meal/snack.
3
Able to take in nutrients orally and receives supplemental nutrients through a nasogastric
tube or gastrostomy.
4
Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or
gastrostomy.
5
Unable to take in nutrients orally or by tube feeding.
(M1880) Current Ability to Plan and Prepare Light Meals (for example, cereal, sandwich) or reheat
delivered meals safely:
Enter Code

0
1

(a)
Able to independently plan and prepare all light meals for self or reheat delivered
meals; OR
(b)
Is physically, cognitively, and mentally able to prepare light meals on a regular
basis but has not routinely performed light meal preparation in the past (specifically: prior
to this home care admission).
1
Unable to prepare light meals on a regular basis due to physical, cognitive, or mental
limitations.
2
Unable to prepare any light meals or reheat any delivered meals.
(M1890) Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers,
and effectively using the telephone to communicate.
Enter Code

Enter Code

0
1
2
3
4
5
NA

Able to dial numbers and answer calls appropriately and as desired.
Able to use a specially adapted telephone (for example, large numbers on the dial,
teletype phone for the deaf) and call essential numbers.
Able to answer the telephone and carry on a normal conversation but has difficulty with
placing calls.
Able to answer the telephone only some of the time or is able to carry on only a limited
conversation.
Unable to answer the telephone at all but can listen if assisted with equipment.
Totally unable to use the telephone.
Patient does not have a telephone.

(M1900) Prior Functioning ADL/IADL: Indicate the patient’s usual ability with everyday activities prior to
his/her most recent illness, exacerbation, or injury.
Enter Code

Self-Care (specifically: grooming, dressing, bathing, and toileting hygiene)
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Ambulation
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Transfer
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Household tasks (specifically: light meal preparation, laundry, shopping, and phone
use )
0 Independent
1 Needed Some Help
2 Dependent

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(M1910) Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated
assessment tool?
Enter Code

0
1
2

No.
Yes, and it does not indicate a risk for falls.
Yes, and it does indicate a risk for falls.

MEDICATIONS
(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?
Enter Code

No - No issues found during review [Go to M2010 ]

Yes - Issues found during review

NA - Patient is not taking any medications [Go to M2040 ]

(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of
the next calendar day and complete prescribed/recommended actions in response to the identified
potential clinically significant medication issues?
Enter Code

0
1

No
Yes

(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee)
prescribed/recommended actions by midnight of the next calendar day each time potential clinically
significant medication issues were identified since the SOC/ROC?
Enter Code

0
1
9

No
Yes
NA – There were no potential clinically significant medication issues identified since
SOC/ROC or patient is not taking any medications

(M2010) Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on
special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and
how and when to report problems that may occur?
Enter Code

0
1
NA

No
Yes
Patient not taking any high-risk drugs OR patient/caregiver fully knowledgeable about
special precautions associated with all high-risk medications

(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most
recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health
care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant
side effects, and how and when to report problems that may occur?
Enter Code

0
1
NA

No
Yes
Patient not taking any drugs

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(M2020) Management of Oral Medications: Patient's current ability to prepare and take all oral medications
reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or
willingness.)
Enter Code

0
1

Able to independently take the correct oral medication(s) and proper dosage(s) at the
correct times.
Able to take medication(s) at the correct times if:
(a) individual dosages are prepared in advance by another person; OR
(b) another person develops a drug diary or chart.
Able to take medication(s) at the correct times if given reminders by another person at
the appropriate times

3
NA

Unable to take medication unless administered by another person.
No oral medications prescribed.

M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed
injectable medications reliably and safely, including administration of correct dosage at the
appropriate times/intervals. Excludes IV medications.
Enter Code

0
1

2
3
NA

Able to independently take the correct medication(s) and proper dosage(s) at the correct
times.
Able to take injectable medication(s) at the correct times if:
(a) individual syringes are prepared in advance by another person; OR
(b) another person develops a drug diary or chart.
Able to take medication(s) at the correct times if given reminders by another person
based on the frequency of the injection
Unable to take injectable medication unless administered by another person.
No injectable medications prescribed.

(M2040) Prior Medication Management: Indicate the patient’s usual ability with managing oral and
injectable medications prior to his/her most recent illness, exacerbation or injury.
Enter Code

Enter Code

Oral medications
0 Independent
1 Needed Some Help
2 Dependent
NA Not Applicable

Injectable medications
0 Independent
1 Needed Some Help
2 Dependent
NA Not Applicable

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CARE MANAGEMENT
(M2102) Types and Sources of Assistance: Determine the ability and willingness of non-agency caregivers
(such as family members, friends, or privately paid caregivers) to provide assistance for the following
activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code
a. ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting,
eating/feeding)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Enter Code
b. IADL assistance (for example, meals, housekeeping, laundry, telephone, shopping,
finances)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Enter Code
c. Medication administration (for example, oral, inhaled or injectable)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Enter Code
d. Medical procedures/ treatments (for example, changing wound dressing, home exercise
program)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Enter Code
e. Management of Equipment (for example, oxygen, IV/infusion equipment, enteral/
parenteral nutrition, ventilator therapy equipment or supplies)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Enter Code
f. Supervision and safety (for example, due to cognitive impairment)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Enter Code
g. Advocacy or facilitation of patient's participation in appropriate medical care (for example,
transportation to or from appointments)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

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(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than
home health agency staff)?
Enter Code

1
2
3
4
5
UK

At least daily
Three or more times per week
One to two times per week
Received, but less often than weekly
No assistance received
Unknown

THERAPY NEED AND PLAN OF CARE
(M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment
will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary
physical, occupational, and speech-language pathology visits combined)? (Enter zero [“000”] if no therapy
visits indicated.)

() Number of therapy visits indicated (total of physical, occupational and speech-language pathology
combined).

⃞ NA - Not Applicable: No case mix group defined by this assessment.
(M2250) Plan of Care Synopsis: (Check only one box in each row.) Does the physician-ordered plan of care
include the following:
No

Yes

⃞0

⃞1

Diabetic foot care including monitoring for
the presence of skin lesions on the lower
extremities and patient/caregiver education
on proper foot care
Falls prevention interventions

⃞0

⃞1

⃞0

⃞1

Depression intervention(s) such as
medication, referral for other treatment, or a
monitoring plan for current treatment and/or
physician notified that patient screened
positive for depression

⃞0

⃞1

Intervention(s) to monitor and mitigate pain

⃞0

⃞1

Intervention(s) to prevent pressure ulcers

⃞0

⃞1

Pressure ulcer treatment based on
principles of moist wound healing OR order
for treatment based on moist wound
healing has been requested from physician

⃞0

⃞1

Plan / Intervention
Patient-specific parameters for notifying
physician of changes in vital signs or other
clinical findings

Centers for Medicare & Medicaid Services

Not Applicable
⃞NA Physician has chosen not to
establish patient-specific
parameters for this patient. Agency
will use standardized clinical
guidelines accessible for all care
providers to reference.
⃞NA Patient is not diabetic or is missing
lower legs due to congenital or
acquired condition (bilateral
amputee).
⃞NA Falls risk assessment indicates
patient has no risk for falls.
⃞NA Patient has no diagnosis of
depression AND depression
screening indicates patient has: 1)
no symptoms of depression; or 2)
has some symptoms of depression
but does not meet criteria for further
evaluation of depression based on
screening tool used.
⃞NA Pain assessment indicates patient
has no pain.
⃞NA Pressure ulcer risk assessment
(clinical or formal) indicates patient
is not at risk of developing pressure
ulcers.
⃞NA Patient has no pressure ulcers OR
has no pressure ulcers for which
moist wound healing is indicated.

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EMERGENT CARE
(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the
patient utilized a hospital emergency department (includes holding/observation status)?
Enter Code

No [Go to M2401 ]

1
2

Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission

Unknown [Go to M2401 ]

(M2310) Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or
without hospitalization)? (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞

1 2 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis
Injury caused by fall

3 -

Respiratory infection (for example, pneumonia, bronchitis)

4 -

Other respiratory problem

5 -

Heart failure (for example, fluid overload)

6 -

Cardiac dysrhythmia (irregular heartbeat)

7 -

Myocardial infarction or chest pain

8 -

Other heart disease

9 -

Stroke (CVA) or TIA

10 -

Hypo/Hyperglycemia, diabetes out of control

11 -

GI bleeding, obstruction, constipation, impaction

12 -

Dehydration, malnutrition

13 -

Urinary tract infection

14 -

IV catheter-related infection or complication

15 -

Wound infection or deterioration

16 -

Uncontrolled pain

17 -

Acute mental/behavioral health problem

18 -

Deep vein thrombosis, pulmonary embolus

19 -

Other than above reasons

UK -

Reason unknown

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DATA ITEMS COLLECTED AT INPATIENT FACILITY ADMISSION OR AGENCY DISCHARGE
ONLY
(M2401) Intervention Synopsis: (Check only one box in each row.) At the time of or at any time since the most
recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan
of care AND implemented?
a.

Plan / Intervention
Diabetic foot care including monitoring
for the presence of skin lesions on the
lower extremities and patient/caregiver
education on proper foot care
Falls prevention interventions

Yes

Not Applicable
⃞NA Patient is not diabetic or is missing
lower legs due to congenital or acquired
condition (bilateral amputee).

⃞0

⃞1

⃞0

⃞1

⃞NA

Depression intervention(s) such as
medication, referral for other treatment,
or a monitoring plan for current
treatment

⃞0

⃞1

⃞NA

Intervention(s) to monitor and mitigate
pain

⃞0

⃞1

⃞NA

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞NA

Pressure ulcer treatment based on
principles of moist wound healing

⃞0

⃞1

⃞NA

Every standardized, validated multifactor fall risk assessment conducted at
or since the most recent SOC/ROC
assessment indicates the patient has no
risk for falls.
Patient has no diagnosis of depression
AND every standardized, validated
depression screening conducted at or
since the most recent SOC/ROC
assessment indicates the patient has: 1)
no symptoms of depression; or 2) has
some symptoms of depression but does
not meet criteria for further evaluation of
depression based on screening tool
used.
Every standardized, validated pain
assessment conducted at or since the
most recent SOC/ROC assessment
indicates the patient has no pain.
Every standardized, validated pressure
ulcer risk assessment conducted at or
since the most recent SOC/ROC
assessment indicates the patient is not
at risk of developing pressure ulcers.
Patient has no pressure ulcers OR has
no pressure ulcers for which moist
wound healing is indicated.

(M2410) To which Inpatient Facility has the patient been admitted?
Enter Code

Hospital [Go to M2430 ]

Rehabilitation facility [Go to M0903 ]

Nursing home [Go to M0903 ]

Hospice [Go to M0903 ]

No inpatient facility admission [Omit “NA” option on TRN ]

(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only
one answer.)
Enter Code

1
2
3
4

Patient remained in the community (without formal assistive services)
Patient remained in the community (with formal assistive services)
Patient transferred to a non-institutional hospice
Unknown because patient moved to a geographic location not served by this agency

Other unknown [Go to M0903 ]

Centers for Medicare & Medicaid Services

OASIS-C2 Item Set-Effective 1/1/17

Page 26 of 27

(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that
apply.)

⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞

1 2 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis
Injury caused by fall

3 -

Respiratory infection (for example, pneumonia, bronchitis)

4 -

Other respiratory problem

5 -

Heart failure (for example, fluid overload)

6 -

Cardiac dysrhythmia (irregular heartbeat)

7 -

Myocardial infarction or chest pain

8 -

Other heart disease

9 -

Stroke (CVA) or TIA

10 -

Hypo/Hyperglycemia, diabetes out of control

11 -

GI bleeding, obstruction, constipation, impaction

12 -

Dehydration, malnutrition

13 -

Urinary tract infection

14 -

IV catheter-related infection or complication

15 -

Wound infection or deterioration

16 -

Uncontrolled pain

17 -

Acute mental/behavioral health problem

18 -

Deep vein thrombosis, pulmonary embolus

19 -

Scheduled treatment or procedure

20 -

Other than above reasons

UK -

Reason unknown

(M0903) Date of Last (Most Recent) Home Visit:

/
month

/
day

year

(M0906) Discharge/Transfer/Death Date: Enter the date of the discharge, transfer, or death (at home) of the patient.

/
month

/
day

year

Centers for Medicare & Medicaid Services

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Home Health Patient Tracking Sheet

(M0010) CMS Certification Number:

(M0014) Branch State:

(M0016) Branch ID Number:
(M0018) National Provider Identifier (NPI) for the attending physician who has signed the plan of care:

⃞ UK – Unknown or Not Available

(M0020) Patient ID Number:

(M0030) Start of Care Date:
month

/
day

(M0032) Resumption of Care Date:

year

/
month

⃞ NA - Not Applicable

/
day

year

(M0040) Patient Name:

(First)

(M I)

(Last)

(Suffix)

(M0050) Patient State of Residence:

─

(M0060) Patient ZIP Code:

⃞ NA – No Medicare

(M0063) Medicare Number:
(including suffix)
(M0064) Social Security Number:

⃞ UK – Unknown or Not Available
⃞ NA – No Medicaid

(M0065) Medicaid Number:

(M0066) Birth Date:
month

/
day

year

(M0069) Gender
Enter Code

1
2

Male
Female

Centers for Medicare & Medicaid Services

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(M0140) Race/Ethnicity: (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞

1 -

American Indian or Alaska Native

2 -

Asian

3 -

Black or African-American

4 -

Hispanic or Latino

5 -

Native Hawaiian or Pacific Islander

6 -

White

(M0150) Current Payment Sources for Home Care: (Mark all that apply.)

Centers for Medicare & Medicaid Services

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Outcome and Assessment Information Set
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care ---------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1036, M1060M1306, M1311, M1320-M1410, M1600-M2003, M2010,
M2020-M2250, GG0170

Discharge from Agency — Not to an Inpatient Facility
Death at home -------------------------------------------------Discharge from agency ---------------------------------------

M0080-M0100, M2005, M0903, M0906
M0080-M0100, M1041-M1056, M1230, M1242, M1306M1342, M1400, M1501-M1620, M1700-M1720, M1740,
M1745, M1800-M1890, M2005, M2016-M2030, M2102,
M2301-M2420, M0903, M0906

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

(M0100) This Assessment is Currently Being Completed for the Following Reason:
Enter Code

Start/Resumption of Care
1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)
Follow-Up
4

Recertification (follow-up) reassessment [Go to M0110 ]

5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
6

Transferred to an inpatient facility—patient not discharged from agency [Go to M1041 ]

7
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]
Discharge from Agency—Not to an Inpatient Facility
8

Death at home [Go to M2005]

Discharge from agency [Go to M1041 ]

OASIS-C2 – SOC Item Set
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Page 1 of 21

/
month

[Go to M0110, if date entered ]

/
day

year

⃞ NA – No specific SOC date ordered by physician
(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was
received by the HHA.

/
month

/
day

year

Enter Code

Early
Later
Unknown
Not Applicable: No Medicare case mix group to be defined by this assessment.

PATIENT HISTORY AND DIAGNOSES
(M1000) From which of the following Inpatient Facilities was the patient discharged within the past 14 days? (Mark all
that apply.)
⃞ 1 - Long-term nursing facility (NF)

⃞ 2
⃞ 3
⃞ 4
⃞ 5
⃞ 6
⃞ 7
⃞ NA

Skilled nursing facility (SNF/TCU)

Short-stay acute hospital (IPPS)

Long-term care hospital (LTCH)

Inpatient rehabilitation hospital or unit (IRF)

Psychiatric hospital or unit

Other (specify)

Patient was not discharged from an inpatient facility [Go to M1017 ]

(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown
(M1011) List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those conditions
actively treated during an inpatient stay having a discharge date within the last 14 days (no V, W, X, Y, or Z
codes or surgical codes):
Inpatient Facility Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

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Page 2 of 21

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

⃞ NA - Not applicable (no medical or treatment regimen changes within the past 14 days)
(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this
patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14
days, indicate any conditions that existed prior to the inpatient stay or change in medical or treatment regimen.
(Mark all that apply.)

⃞ 1
⃞ 2
⃞ 3
⃞ 4
⃞ 5
⃞ 6
⃞ 7
⃞ NA
⃞ UK

Urinary incontinence

Indwelling/suprapubic catheter

Intractable pain

Impaired decision-making

Disruptive or socially inappropriate behavior

Memory loss to the extent that supervision required

None of the above
No inpatient facility discharge and no change in medical or treatment regimen in past 14 days
Unknown

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(M1021/1023/1025) Diagnoses, Symptom Control, and Optional Diagnoses: List each diagnosis for which the patient
is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column 2
(diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects the
seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control for
each condition in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any
diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that is no longer active (a resolved condition), then
optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be completed. Diagnoses reported in M1025 will not
impact payment.
Code each row according to the following directions for each column:
Column 1:

Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each
condition and support the disciplines and services provided.

Column 2:

Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes
allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and
sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes beginning
with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023
(Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the underlying
condition can often be entered in Column 2, as long as it is an active on-going condition impacting home
health care.
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control
rating if the diagnosis code is a V, W, X, Y or Z-code. Choose one value that represents the degree of
symptom control appropriate for each diagnosis using the following scale:
0 - Asymptomatic, no treatment needed at this time
1 - Symptoms well controlled with current therapy
2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring
3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring
4 - Symptoms poorly controlled; history of re-hospitalizations
Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the
diagnoses listed in Column 1. These are separate items and sequencing may not coincide.

Column 3:

Column 4:

(OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a
resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines,
enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For
example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10-CM
code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10-CM code
for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.

(Form on next page)

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(M1025) Optional Diagnoses (OPTIONAL)
(not used for payment)

(M1021) Primary Diagnosis & (M1023) Other Diagnoses
Column 1

Column 2

Diagnoses
(Sequencing of diagnoses
should reflect the seriousness
of each condition and support
the disciplines and services
provided)

(M1021) Primary Diagnosis

Description/
ICD-10-CM

V, W, X, Y codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

(M1023) Other Diagnoses

All ICD-10–C M codes allowed

) (

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

)

) (

)

d.
.

) (
e.

) (
c.

) (
f.

) (

(M1028) Active Diagnoses—Comorbidities and Co-existing Conditions. (Check all that apply.)
See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.

⃞
⃞

1 -

Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

2 -

Diabetes Mellitus (DM)

(M1030) Therapies the patient receives at home: (Mark all that apply.)

⃞
⃞
⃞
⃞

1 -

Intravenous or infusion therapy (excludes TPN)

2 -

Parenteral nutrition (TPN or lipids)

3 -

Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the
alimentary canal)
None of the above

4 -

OASIS-C2 – SOC Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

)

.
V, W, X, Y, Z codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

(

b.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

Complete only if the Optional
Diagnosis is a multiple coding
situation (for example: a
manifestation code)

ICD-10-CM /
Symptom Control Rating

Column 4

ICD-10-CM and symptom control
May be completed if a Z-code
rating for each condition.
is assigned to Column 2 and
Note that the sequencing of these
the underlying diagnosis is
ratings may not match the
resolved
sequencing of the diagnoses

Description

Column 3

Page 5 of 22

(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for
hospitalization? (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞

1 -

History of falls (2 or more falls - or any fall with an injury - in the past 12 months)

2 -

Unintentional weight loss of a total of 10 pounds or more in the past 12 months

3 -

Multiple hospitalizations (2 or more) in the past 6 months

4 -

Multiple emergency department visits (2 or more) in the past 6 months

5 -

Decline in mental, emotional, or behavioral status in the past 3 months

6 7 -

Reported or observed history of difficulty complying with any medical instructions (for example,
medications, diet, exercise) in the past 3 months
Currently taking 5 or more medications

8 -

Currently reports exhaustion

9 -

Other risk(s) not listed in 1–8

10 -

None of the above

⃞
⃞
⃞
⃞

(M1034) Overall Status: Which description best fits the patient’s overall status?
Enter Code

(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all
that apply.)

⃞ 1
⃞ 2
⃞ 3
⃞ 4
⃞ 5
⃞ UK

Smoking

Obesity

Alcohol dependency

Drug dependency

None of the above

Unknown

(M1060) Height and Weight – While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up

inches

a. Height (in inches). Record most recent height measure since the most recent SOC/ROC

b. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weigh
pounds

consistently, according to standard agency practice (for example, in a.m. after voiding, before
meal, with shoes off, etc.)

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No
assistance
available

Living Arrangement

Around the
clock

a. Patient lives alone

⃞ 01

⃞ 02

⃞ 03

⃞ 04

⃞ 05

b. Patient lives with other
person(s) in the home

⃞ 06

⃞ 07

⃞ 08

⃞ 09

⃞ 10

c. Patient lives in congregate
situation (for example, assisted
living, residential care home)

⃞ 11

⃞ 12

⃞ 13

⃞ 14

⃞ 15

SENSORY STATUS
(M1200) Vision (with corrective lenses if the patient usually wears them):
Enter Code

Normal vision: sees adequately in most situations; can see medication labels, newsprint.

(M1210) Ability to Hear (with hearing aid or hearing appliance if normally used):
Enter Code

0
1
2
UK

(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):
Enter Code

0
1

Understands: clear comprehension without cues or repetitions.
Usually Understands: understands most conversations, but misses some part/intent of
message. Requires cues at times to understand.
Sometimes Understands: understands only basic conversations or simple, direct phrases.
Frequently requires cues to understand.
Rarely/Never Understands.

Unable to assess understanding.

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(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):
Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations
with no observable impairment.
1
Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional
errors in word choice, grammar or speech intelligibility; needs minimal prompting or
assistance).
2
Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance,
errors in word choice, organization or speech intelligibility). Speaks in phrases or short
sentences.
3
Has severe difficulty expressing basic ideas or needs and requires maximal assistance or
guessing by listener. Speech limited to single words or short phrases.
4
Unable to express basic needs even with maximal prompting or assistance but is not
comatose or unresponsive (for example, speech is nonsensical or unintelligible).
5
Patient nonresponsive or unable to speak.
(M1240) Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool
(appropriate to the patient’s ability to communicate the severity of pain)?
Enter Code

Enter Code

0
1
2

No standardized, validated assessment conducted
Yes, and it does not indicate severe pain
Yes, and it indicates severe pain

(M1242) Frequency of Pain Interfering with patient's activity or movement:
Enter Code

0
1
2
3
4

Patient has no pain
Patient has pain that does not interfere with activity or movement
Less often than daily
Daily, but not constantly
All of the time

INTEGUMENTARY STATUS
(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?
Enter Code

No assessment conducted [Go to M1306 ]

Yes, based on an evaluation of clinical factors (for example, mobility, incontinence, nutrition)
without use of standardized tool
Yes, using a standardized, validated tool (for example, Braden Scale, Norton Scale)

(M1302) Does this patient have a Risk of Developing Pressure Ulcers?
Enter Code

0
1

No
Yes

(M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as
Unstageable? (Excludes Stage 1 pressure ulcers and healed Stage 2 pressure ulcers)
Enter Code

No [Go to M1322 ]

Yes

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(M1311) Current Number of Unhealed Pressure Ulcers at Each Stage

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound
bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or
muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Number of Stage 3 pressure ulcers
C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar
may be present on some parts of the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers
D1. Unstageable: Non-removable dressing: Known but not stageable due to non-removable
dressing/device
Number of unstageable pressure ulcers due to non-removable dressing/device
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed
by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
F1. Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution
Number of unstageable pressure ulcers with suspected deep tissue injury in evolution

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(M1320) Status of Most Problematic Pressure Ulcer that is Observable: (Excludes pressure ulcer that cannot
be observed due to a non-removable dressing/device)
Enter Code

0
1
2
3
NA

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing
No observable pressure ulcer

(M1322) Current Number of Stage 1 Pressure Ulcers: Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as
compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones
only it may appear with persistent blue or purple hues.
Enter Code

0
1
2
3
4 or more

1
2
3
4
NA

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers or no stageable pressure ulcers

(M1330) Does this patient have a Stasis Ulcer?
Enter Code

No [Go to M1340 ]

1
2

Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY

Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to nonremovable dressing/device) [Go to M1340 ]

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(M1332) Current Number of Stasis Ulcer(s) that are Observable:
Enter Code

1
2
3
4

One
Two
Three
Four or more

(M1334) Status of Most Problematic Stasis Ulcer that is Observable:
Enter Code

1
2
3

Fully granulating
Early/partial granulation
Not healing

(M1340) Does this patient have a Surgical Wound?
Enter Code

No [go to M1350 ]

Yes, patient has at least one observable surgical wound

Surgical wound known but not observable due to non-removable dressing/device [go to

M1350 ]
(M1342) Status of Most Problematic Surgical Wound that is Observable
Enter Code

0
1
2
3

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

(M1350) Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those
described above, that is receiving intervention by the home health agency?
Enter Code

0
1

No
Yes

RESPIRATORY STATUS
(M1400) When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0
1
2
3
4

(M1410) Respiratory Treatments utilized at home: (Mark all that apply.)

⃞
⃞
⃞
⃞

1 -

Oxygen (intermittent or continuous)

2 -

Ventilator (continually or at night)

3 -

Continuous / Bi-level positive airway pressure

4 -

None of the above

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Page 11 of 21

ELIMINATION STATUS
(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0
1
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown

(M1610) Urinary Incontinence or Urinary Catheter Presence:
Enter Code

No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Go to M1620 ]

1
2

Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic) [Go to M1620 ]

(M1615) When does Urinary Incontinence occur?
Enter Code

0
1
2
3
4

Timed-voiding defers incontinence
Occasional stress incontinence
During the night only
During the day only
During the day and night

(M1620) Bowel Incontinence Frequency:
Enter Code

0
1
2
3
4
5
NA
UK

Patient does not have an ostomy for bowel elimination.

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0
1
2

3
4

(M1710) When Confused (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
4
NA

Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not constantly
Constantly
Patient nonresponsive

(M1720) When Anxious (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
NA

None of the time
Less often than daily
Daily, but not constantly
All of the time
Patient nonresponsive

(M1730) Depression Screening: Has the patient been screened for depression, using a standardized, validated
depression screening tool?
Enter Code

0
1

No
Yes, patient was screened using the PHQ-2©* scale.
Instructions for this two-question tool: Ask patient: “Over the last two weeks, how often
have you been bothered by any of the following problems?”
Nearly
Several
More than half every day
NA
PHQ-2©*
Not at all
days
of the days
12 – 14 Unable to
0 - 1 day 2 - 6 days
7 – 11 days
days
respond
a) Little interest or pleasure
⃞NA
⃞0
⃞1
⃞2
⃞3
in doing things
b) Feeling down,
⃞NA
⃞0
⃞1
⃞2
⃞3
depressed, or hopeless?

2
3

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(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week
(Reported or Observed): (Mark all that apply.)

⃞

1 -

⃞

2 -

⃞
⃞
⃞
⃞
⃞

3 4 5 -

6 -

Delusional, hallucinatory, or paranoid behavior

7 -

None of the above behaviors demonstrated

0
1
2
3
4
5

Never
Less than once a month
Once a month
Several times each month
Several times a week
At least daily

(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric
nurse?
Enter Code

0
1

No
Yes

0
1
2
3

Able to groom self unaided, with or without the use of assistive devices or adapted methods.
Grooming utensils must be placed within reach before able to complete grooming activities.
Someone must assist the patient to groom self.
Patient depends entirely upon someone else for grooming needs.

(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments,
pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
Enter Code

0
1
2
3

Able to get clothes out of closets and drawers, put them on and remove them from the upper
body without assistance.
Able to dress upper body without assistance if clothing is laid out or handed to the patient.
Someone must help the patient put on upper body clothing.
Patient depends entirely upon another person to dress the upper body.

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(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments,
slacks, socks or nylons, shoes:
Enter Code

0
1
2
3

Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed to
the patient.
Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
Patient depends entirely upon another person to dress lower body.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing
hands, and shampooing hair).
Enter Code

0
1
2

3
4
5
6

Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
With the use of devices, is able to bathe self in shower or tub independently, including
getting in and out of the tub/shower.
Able to bathe in shower or tub with the intermittent assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
Able to participate in bathing self in shower or tub, but requires presence of another person
throughout the bath for assistance or supervision.
Unable to use the shower or tub, but able to bathe self independently with or without the use
of devices at the sink, in chair, or on commode.
Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in
bedside chair, or on commode, with the assistance or supervision of another person.
Unable to participate effectively in bathing and is bathed totally by another person.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer
on and off toilet/commode.
Enter Code

0
1
2
3
4

Able to get to and from the toilet and transfer independently with or without a device.
When reminded, assisted, or supervised by another person, able to get to and from the toilet
and transfer.
Unable to get to and from the toilet but is able to use a bedside commode (with or without
assistance).
Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal
independently.
Is totally dependent in toileting.

(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or
incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes
cleaning area around stoma, but not managing equipment.
Able to manage toileting hygiene and clothing management without assistance.
Able to manage toileting hygiene and clothing management without assistance if
supplies/implements are laid out for the patient.
2
Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
3
Patient depends entirely upon another person to maintain toileting hygiene.
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if
patient is bedfast.
Enter Code

Enter Code

0
1

0
1
2
3
4
5

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1.
SOC/ROC
Performance

2.
Discharge
Goal

Enter Codes in Boxes
Lying to
Sitting on
Side of Bed:
The ability to
safely move
from lying on
the back to
sitting on the
side of the bed
with feet flat on
the floor, and
with no back
support.

02 Substantial/maximal assistance – Helper does MORE THAN
HALF the effort. Helper lifts or holds trunk or limbs and
provides more than half the effort.
01 Dependent – Helper does ALL of the effort. Patient does none
of the effort to complete the activity. Or, the assistance of 2 or
more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07 Patient refused
09 Not applicable
88 Not attempted due to medical condition or safety concerns

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a
wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

0
1
2

3
4
5
6

Able to independently walk on even and uneven surfaces and negotiate stairs with or without
railings (specifically: needs no human assistance or assistive device).
With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to
independently walk on even and uneven surfaces and negotiate stairs with or without railings.
Requires use of a two-handed device (for example, walker or crutches) to walk alone on a
level surface and/or requires human supervision or assistance to negotiate stairs or steps or
uneven surfaces.
Able to walk only with the supervision or assistance of another person at all times.
Chairfast, unable to ambulate but is able to wheel self independently.
Chairfast, unable to ambulate and is unable to wheel self.
Bedfast, unable to ambulate or be up in a chair.

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(M1870) Feeding or Eating: Current ability to feed self-meals and snacks safely. Note: This refers only to the
process of eating, chewing, and swallowing, not preparing the food to be eaten.
Able to independently feed self.
Able to feed self independently but requires:
(a) meal set-up; OR
(b) intermittent assistance or supervision from another person; OR
(c) a liquid, pureed or ground meat diet.
2
Unable to feed self and must be assisted or supervised throughout the meal/snack.
3
Able to take in nutrients orally and receives supplemental nutrients through a nasogastric
tube or gastrostomy.
4
Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or
gastrostomy.
5
Unable to take in nutrients orally or by tube feeding.
(M1880) Current Ability to Plan and Prepare Light Meals (for example, cereal, sandwich) or reheat delivered
meals safely:
Enter Code

0
1

(a) Able to independently plan and prepare all light meals for self or reheat delivered
meals; OR
(b)
Is physically, cognitively, and mentally able to prepare light meals on a regular basis
but has not routinely performed light meal preparation in the past (specifically: prior to this
home care admission).
1
Unable to prepare light meals on a regular basis due to physical, cognitive, or mental
limitations.
2
Unable to prepare any light meals or reheat any delivered meals.
(M1890) Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and
effectively using the telephone to communicate.
Enter Code

Enter Code

0
1
2
3
4
5
NA

Able to dial numbers and answer calls appropriately and as desired.
Able to use a specially adapted telephone (for example, large numbers on the dial, teletype
phone for the deaf) and call essential numbers.
Able to answer the telephone and carry on a normal conversation but has difficulty with
placing calls.
Able to answer the telephone only some of the time or is able to carry on only a limited
conversation.
Unable to answer the telephone at all but can listen if assisted with equipment.
Totally unable to use the telephone.
Patient does not have a telephone.

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(M1900) Prior Functioning ADL/IADL: Indicate the patient’s usual ability with everyday activities prior to his/her
most recent illness, exacerbation, or injury.
Enter Code

Self-Care (specifically: grooming, dressing, bathing, and toileting hygiene)
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Ambulation
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Transfer
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Household tasks (specifically: light meal preparation, laundry, shopping, and phone use )
0
1
2

Independent
Needed Some Help
Dependent

(M1910) Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated assessment
tool?
Enter Code

0
1
2

No.
Yes, and it does not indicate a risk for falls.
Yes, and it does indicate a risk for falls.

MEDICATIONS
(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?
Enter Code

No - No issues found during review [Go to M2010 ]

Yes - Issues found during review

NA - Patient is not taking any medications [Go to M2040 ]

(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the
next calendar day and complete prescribed/recommended actions in response to the identified potential
clinically significant medication issues?
Enter Code

0
1

No
Yes

(M2010) Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special
precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and
when to report problems that may occur?
Enter Code

0
1
NA

No
Yes
Patient not taking any high-risk drugs OR patient/caregiver fully knowledgeable about
special precautions associated with all high-risk medications

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0
1

2
3
NA

(M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed
injectable medications reliably and safely, including administration of correct dosage at the
appropriate times/intervals. Excludes IV medications.
Enter Code

0
1

2
3
NA

(M2040) Prior Medication Management: Indicate the patient’s usual ability with managing oral and
injectable medications prior to his/her most recent illness, exacerbation or injury.
Enter Code

Enter Code

Oral medications
0 Independent
1 Needed Some Help
2 Dependent
NA Not Applicable

Injectable medications
0 Independent
1 Needed Some Help
2 Dependent
NA Not Applicable

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No assistance needed –patient is independent or does not have needs in this area
Non-agency caregiver(s) currently provide assistance
Non-agency caregiver(s) need training/ supportive services to provide assistance
Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
Assistance needed, but no non-agency caregiver(s) available

Enter Code

Medication administration (for example, oral, inhaled or injectable)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

Enter Code

Management of Equipment (for example, oxygen, IV/infusion equipment, enteral/ parenteral
nutrition, ventilator therapy equipment or supplies)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

Enter Code

Supervision and safety (for example, due to cognitive impairment)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

Enter Code

Advocacy or facilitation of patient's participation in appropriate medical care (for example,
transportation to or from appointments)
0
1
2
3
4

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(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home
health agency staff)?
Enter Code

1
2
3
4
5
UK

At least daily
Three or more times per week
One to two times per week
Received, but less often than weekly
No assistance received
Unknown

THERAPY NEED AND PLAN OF CARE
(M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this
assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable
and necessary physical, occupational, and speech-language pathology visits combined)? (Enter zero
[“000”] if no therapy visits indicated.)

() Number of therapy visits indicated (total of physical, occupational and speech-language pathology
combined).

Yes

⃞0

⃞1

Diabetic foot care including monitoring for
the presence of skin lesions on the lower
extremities and patient/caregiver education
on proper foot care
Falls prevention interventions

⃞0

⃞1

⃞0

⃞1

Depression intervention(s) such as
medication, referral for other treatment, or a
monitoring plan for current treatment and/or
physician notified that patient screened
positive for depression

⃞0

⃞1

Intervention(s) to monitor and mitigate pain

⃞0

⃞1

Intervention(s) to prevent pressure ulcers

⃞0

⃞1

Pressure ulcer treatment based on
principles of moist wound healing OR order
for treatment based on moist wound healing
has been requested from physician

⃞0

⃞1

Plan / Intervention
Patient-specific parameters for notifying
physician of changes in vital signs or other
clinical findings

OASIS-C2 – SOC Item Set
Effective 1/1/17
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Not Applicable
⃞NA Physician has chosen not to
establish patient-specific parameters
for this patient. Agency will use
standardized clinical guidelines
accessible for all care providers to
reference.
⃞NA Patient is not diabetic or is missing
lower legs due to congenital or
acquired condition (bilateral
amputee).
⃞NA Falls risk assessment indicates
patient has no risk for falls.
⃞NA Patient has no diagnosis of
depression AND depression
screening indicates patient has: 1)
no symptoms of depression; or 2)
has some symptoms of depression
but does not meet criteria for further
evaluation of depression based on
screening tool used.
⃞NA Pain assessment indicates patient
has no pain.
⃞NA Pressure ulcer risk assessment
(clinical or formal) indicates patient
is not at risk of developing pressure
ulcers.
⃞NA Patient has no pressure ulcers OR
has no pressure ulcers for which
moist wound healing is indicated.

Page 21 of 21

Outcome and Assessment Information Set
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care ---------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1036, M1060M1306, M1311, M1320-M1410, M1600-M2003, M2010,
M2020-M2250, GG0170

Discharge from Agency — Not to an Inpatient Facility
Death at home -------------------------------------------------Discharge from agency ---------------------------------------

M0080-M0100, M2005, M0903, M0906
M0080-M0100, M1041-M1056, M1230, M1242, M1306M1342, M1400, M1501-M1620, M1700-M1720, M1740,
M1745, M1800-M1890, M2005, M2016-M2030, M2102,
M2301-M2420, M0903, M0906

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

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(M0100) This Assessment is Currently Being Completed for the Following Reason:
Start/Resumption of Care

Enter Code

1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)
Follow-Up
Recertification (follow-up) reassessment [Go to M0110 ]

5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
Transferred to an inpatient facility—patient not discharged from agency [Go to M1041 ]

7
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]
Discharge from Agency — Not to an Inpatient Facility
8

Death at home [Go to M2005]

Discharge from agency [Go to M1041 ]

/
month

[Go to M0110, if date entered ]

/
day

year

⃞ NA - No specific SOC date ordered by physician
(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was
received by the HHA.

/
month

/
day

year

(M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a
case mix group an “early” episode or a “later” episode in the patient’s current sequence of adjacent
Medicare home health payment episodes?
1
2
UK
NA

Enter Code

Early
Later
Unknown
Not Applicable: No Medicare case mix group to be defined by this assessment.

⃞ 2
⃞ 3
⃞ 4
⃞ 5
⃞ 6
⃞ 7
⃞ NA

Skilled nursing facility (SNF/TCU)

Short-stay acute hospital (IPPS)

Long-term care hospital (LTCH)

Inpatient rehabilitation hospital or unit (IRF)

Psychiatric hospital or unit

Other (specify)

Patient was not discharged from an inpatient facility [Go to M1017 ]

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(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown
(M1011) List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those
conditions actively treated during an inpatient stay having a discharge date within the last 14 days (no V,
W, X, Y, or Z codes or surgical codes):
Inpatient Facility Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.
(M1017) Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days: List the patient's
Medical Diagnoses and ICD-10-CM codes at the level of highest specificity for those conditions requiring
changed medical or treatment regimen within the past 14 days (no V, W, X, Y, or Z codes or surgical
codes):
Changed Medical Regimen Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

⃞ 1 ⃞ 2 ⃞ 3 ⃞ 4 ⃞ 5 ⃞ 6 ⃞ 7 ⃞ NA ⃞ UK -

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(M1021/1023/1025) Diagnoses, Symptom Control, and Optional Diagnoses: List each diagnosis for which the
patient is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column
2 (diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects
the seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom
control for each condition in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is
indicated for any diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that is no longer active (a
resolved condition), then optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be completed.
Diagnoses reported in M1025 will not impact payment.
Code each row according to the following directions for each column:
Column 1:

Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each
condition and support the disciplines and services provided.

Column 2:

Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes
allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and
sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes
beginning with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in
M1023 (Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the
underlying condition can often be entered in Column 2, as long as it is an active on-going condition
impacting home health care.
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom
control rating if the diagnosis code is a V, W, X, Y or Z-code. Choose one value that represents the
degree of symptom control appropriate for each diagnosis using the following scale:
0 – Asymptomatic, no treatment needed at this time
1 – Symptoms well controlled with current therapy
2 – Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring
3 – Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring
4 – Symptoms poorly controlled; history of re-hospitalizations
Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of
the diagnoses listed in Column 1. These are separate items and sequencing may not coincide.

Column 3:

Column 4:

(OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a
resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding
guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3
and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description
and ICD-10-CM code for the underlying condition in Column 3 of that row and the diagnosis description
and ICD-10-CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in
that row.

(Form on next page)

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(M1025) Optional Diagnoses (OPTIONAL)
(not used for payment)

(M1021) Primary Diagnosis & (M1023) Other Diagnoses
Column 1

Column 2

Diagnoses
(Sequencing of diagnoses
should reflect the seriousness
of each condition and support
the disciplines and services
provided)

(M1021) Primary Diagnosis

Description/
ICD-10-CM

V, W, X, Y codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

(M1023) Other Diagnoses

All ICD-10–C M codes allowed

) (

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

)

) (

)

d.
.

) (
e.

) (
c.

) (
f.

) (

(M1028) Active Diagnoses—Comorbidities and Co-existing Conditions. (Check all that apply.)
See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.

⃞
⃞

1 -

Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

2 -

Diabetes Mellitus (DM)

(M1030) Therapies the patient receives at home: (Mark all that apply.)

⃞
⃞
⃞
⃞

1 -

Intravenous or infusion therapy (excludes TPN)

2 -

Parenteral nutrition (TPN or lipids)

3 -

Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the
alimentary canal)
None of the above

4 -

OASIS-C2 – ROC Item Set
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)

.
V, W, X, Y, Z codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

(

b.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

Complete only if the Optional
Diagnosis is a multiple coding
situation (for example: a
manifestation code)

ICD-10-CM /
Symptom Control Rating

Column 4

Description

Column 3

Page 5 of 22

(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for
hospitalization? (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞

1 -

History of falls (2 or more falls - or any fall with an injury - in the past 12 months)

2 -

Unintentional weight loss of a total of 10 pounds or more in the past 12 months

3 -

Multiple hospitalizations (2 or more) in the past 6 months

4 -

Multiple emergency department visits (2 or more) in the past 6 months

5 -

Decline in mental, emotional, or behavioral status in the past 3 months

6 7 -

Reported or observed history of difficulty complying with any medical instructions (for example,
medications, diet, exercise) in the past 3 months
Currently taking 5 or more medications

8 -

Currently reports exhaustion

9 -

Other risk(s) not listed in 1–8

10 -

None of the above

⃞
⃞
⃞
⃞

(M1034) Overall Status: Which description best fits the patient’s overall status?
Enter Code

(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all
that apply.)

⃞ 1
⃞ 2
⃞ 3
⃞ 4
⃞ 5
⃞ UK

Smoking

Obesity

Alcohol dependency

Drug dependency

None of the above

Unknown

(M1060) Height and Weight – While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up

inches

a. Height (in inches). Record most recent height measure since the most recent SOC/ROC

b. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weigh
pounds

consistently, according to standard agency practice (for example, in a.m. after voiding, before
meal, with shoes off, etc.)

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No
assistance
available

Living Arrangement

Around the
clock

a. Patient lives alone

⃞ 01

⃞ 02

⃞ 03

⃞ 04

⃞ 05

b. Patient lives with other
person(s) in the home

⃞ 06

⃞ 07

⃞ 08

⃞ 09

⃞ 10

c. Patient lives in congregate
situation (for example, assisted
living, residential care home)

⃞ 11

⃞ 12

⃞ 13

⃞ 14

⃞ 15

SENSORY STATUS
(M1200) Vision (with corrective lenses if the patient usually wears them):
Enter Code

Normal vision: sees adequately in most situations; can see medication labels, newsprint.

(M1210) Ability to Hear (with hearing aid or hearing appliance if normally used):
Enter Code

0
1
2
UK

(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):
Enter Code

0
1

Understands: clear comprehension without cues or repetitions.
Usually Understands: understands most conversations, but misses some part/intent of
message. Requires cues at times to understand.
Sometimes Understands: understands only basic conversations or simple, direct phrases.
Frequently requires cues to understand.
Rarely/Never Understands.

Unable to assess understanding.

(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):
Enter Code

0
1

3
4
5

Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations
with no observable impairment.
Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional
errors in word choice, grammar or speech intelligibility; needs minimal prompting or
assistance).
Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance,
errors in word choice, organization or speech intelligibility). Speaks in phrases or short
sentences.
Has severe difficulty expressing basic ideas or needs and requires maximal assistance or
guessing by listener. Speech limited to single words or short phrases.
Unable to express basic needs even with maximal prompting or assistance but is not
comatose or unresponsive (for example, speech is nonsensical or unintelligible).
Patient nonresponsive or unable to speak.

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(M1240) Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool
(appropriate to the patient’s ability to communicate the severity of pain)?
Enter Code

0
1
2

No standardized, validated assessment conducted
Yes, and it does not indicate severe pain
Yes, and it indicates severe pain

(M1242) Frequency of Pain Interfering with patient's activity or movement:
Enter Code

0
1
2
3
4

Patient has no pain
Patient has pain that does not interfere with activity or movement
Less often than daily
Daily, but not constantly
All of the time

INTEGUMENTARY STATUS
(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?
Enter Code

No assessment conducted [Go to M1306 ]

(M1302) Does this patient have a Risk of Developing Pressure Ulcers?
Enter Code

0
1

No
Yes

(M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as
Unstageable? (Excludes Stage 1 pressure ulcers and healed Stage 2 pressure ulcers)
Enter Code

No [Go to M1322 ]

Yes

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(M1311) Current Number of Unhealed Pressure Ulcers at Each Stage

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound
bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or
muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Number of Stage 3 pressure ulcers
C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar
may be present on some parts of the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers
D1. Unstageable: Non-removable dressing: Known but not stageable due to non-removable
dressing/device
Number of unstageable pressure ulcers due to non-removable dressing/device
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed
by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
F1. Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution
Number of unstageable pressure ulcers with suspected deep tissue injury in evolution

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(M1320) Status of Most Problematic Pressure Ulcer that is Observable: (Excludes pressure ulcer that cannot
be observed due to a non-removable dressing/device)
Enter Code

0
1
2
3
NA

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing
No observable pressure ulcer

(M1322) Current Number of Stage 1 Pressure Ulcers: Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as
compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones
only it may appear with persistent blue or purple hues.
Enter Code

0
1
2
3
4 or more

1
2
3
4
NA

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers or no stageable pressure ulcers

(M1330) Does this patient have a Stasis Ulcer?
Enter Code

No [Go to M1340 ]

1
2

Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY

Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to nonremovable dressing/device) [Go to M1340 ]

(M1332) Current Number of Stasis Ulcer(s) that are Observable:
Enter Code

1
2
3
4

One
Two
Three
Four or more

(M1334) Status of Most Problematic Stasis Ulcer that is Observable:
Enter Code

1
2
3

Fully granulating
Early/partial granulation
Not healing

(M1340) Does this patient have a Surgical Wound?
Enter Code

No [go to M1350 ]

Yes, patient has at least one observable surgical wound

Surgical wound known but not observable due to non-removable dressing/device [go to

M1350 ]

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(M1342) Status of Most Problematic Surgical Wound that is Observable
0
1
2
3

Enter Code

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

(M1350) Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those
described above, that is receiving intervention by the home health agency?
Enter Code

0
1

No
Yes

RESPIRATORY STATUS
(M1400) When is the patient dyspneic or noticeably Short of Breath?
0
1
2

Enter Code

3
4

(M1410) Respiratory Treatments utilized at home: (Mark all that apply.)

⃞
⃞
⃞
⃞

1 -

Oxygen (intermittent or continuous)

2 -

Ventilator (continually or at night)

3 -

Continuous / Bi-level positive airway pressure

4 -

None of the above

ELIMINATION STATUS
(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0
1
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown

(M1610) Urinary Incontinence or Urinary Catheter Presence:
Enter Code

No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Go to M1620 ]

1
2

Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic) [Go to M1620 ]

(M1615) When does Urinary Incontinence occur?
Enter Code

0
1
2
3
4

Timed-voiding defers incontinence
Occasional stress incontinence
During the night only
During the day only
During the day and night

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(M1620) Bowel Incontinence Frequency:
Enter Code

0
1
2
3
4
5
NA
UK

Patient does not have an ostomy for bowel elimination.

3
4

(M1710) When Confused (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
4
NA

Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not constantly
Constantly
Patient nonresponsive

(M1720) When Anxious (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
NA

None of the time
Less often than daily
Daily, but not constantly
All of the time
Patient nonresponsive

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(M1730) Depression Screening: Has the patient been screened for depression, using a standardized, validated
depression screening tool?
Enter Code

0
1

No
Yes, patient was screened using the PHQ-2©* scale.
Instructions for this two-question tool: Ask patient: “Over the last two weeks, how often
have you been bothered by any of the following problems?”
Nearly
Several
More than half every day
NA
PHQ-2©*
Not at all
of the days
days
12 – 14 Unable to
0 - 1 day 2 - 6 days
7 – 11 days
days
respond
a) Little interest or pleasure
⃞NA
⃞0
⃞1
⃞2
⃞3
in doing things
b) Feeling down,
⃞NA
⃞0
⃞1
⃞2
⃞3
depressed, or hopeless?

2
3

*Copyright© Pfizer Inc. All rights reserved. Reproduced with permission.
(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week
(Reported or Observed): (Mark all that apply.)

⃞

1 -

⃞

2 -

⃞
⃞
⃞
⃞
⃞

3 4 5 -

6 -

Delusional, hallucinatory, or paranoid behavior

7 -

None of the above behaviors demonstrated

0
1
2
3
4
5

Never
Less than once a month
Once a month
Several times each month
Several times a week
At least daily

(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric
nurse?
Enter Code

0
1

No
Yes

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0
1
2
3

Able to groom self-unaided, with or without the use of assistive devices or adapted methods.
Grooming utensils must be placed within reach before able to complete grooming activities.
Someone must assist the patient to groom self.
Patient depends entirely upon someone else for grooming needs.

(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments,
pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
Enter Code

0
1
2
3

Able to get clothes out of closets and drawers, put them on and remove them from the upper
body without assistance.
Able to dress upper body without assistance if clothing is laid out or handed to the patient.
Someone must help the patient put on upper body clothing.
Patient depends entirely upon another person to dress the upper body.

(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments,
slacks, socks or nylons, shoes:
Enter Code

0
1
2
3

Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed to
the patient.
Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
Patient depends entirely upon another person to dress lower body.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing
hands, and shampooing hair).
Enter Code

0
1
2

3
4
5
6

Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
With the use of devices, is able to bathe self in shower or tub independently, including
getting in and out of the tub/shower.
Able to bathe in shower or tub with the intermittent assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
Able to participate in bathing self in shower or tub, but requires presence of another person
throughout the bath for assistance or supervision.
Unable to use the shower or tub, but able to bathe self independently with or without the use
of devices at the sink, in chair, or on commode.
Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in
bedside chair, or on commode, with the assistance or supervision of another person.
Unable to participate effectively in bathing and is bathed totally by another person.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer
on and off toilet/commode.
Enter Code

0
1
2
3
4

Able to get to and from the toilet and transfer independently with or without a device.
When reminded, assisted, or supervised by another person, able to get to and from the toilet
and transfer.
Unable to get to and from the toilet but is able to use a bedside commode (with or without
assistance).
Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal
independently.
Is totally dependent in toileting.

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(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or
incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes
cleaning area around stoma, but not managing equipment.
Able to manage toileting hygiene and clothing management without assistance.
Able to manage toileting hygiene and clothing management without assistance if
supplies/implements are laid out for the patient.
2
Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
3
Patient depends entirely upon another person to maintain toileting hygiene.
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if
patient is bedfast.
Enter Code

Enter Code

0
1

0
1
2
3
4
5

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1.
SOC/ROC
Performance

2.
Discharge
Goal

Enter Codes in Boxes
Lying to
Sitting on
Side of Bed:
The ability to
safely move
from lying on
the back to
sitting on the
side of the bed
with feet flat on
the floor, and
with no back
support.

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a
wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

0
1
2

3
4
5
6

Able to independently walk on even and uneven surfaces and negotiate stairs with or without
railings (specifically: needs no human assistance or assistive device).
With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to
independently walk on even and uneven surfaces and negotiate stairs with or without railings.
Requires use of a two-handed device (for example, walker or crutches) to walk alone on a
level surface and/or requires human supervision or assistance to negotiate stairs or steps or
uneven surfaces.
Able to walk only with the supervision or assistance of another person at all times.
Chairfast, unable to ambulate but is able to wheel self independently.
Chairfast, unable to ambulate and is unable to wheel self.
Bedfast, unable to ambulate or be up in a chair.

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0
1

(a) Able to independently plan and prepare all light meals for self or reheat delivered
meals; OR
(b)
Is physically, cognitively, and mentally able to prepare light meals on a regular basis
but has not routinely performed light meal preparation in the past (specifically: prior to this
home care admission).
1
Unable to prepare light meals on a regular basis due to physical, cognitive, or mental
limitations.
2
Unable to prepare any light meals or reheat any delivered meals.
(M1890) Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and
effectively using the telephone to communicate.
Enter Code

Enter Code

0
1
2
3
4
5
NA

Able to dial numbers and answer calls appropriately and as desired.
Able to use a specially adapted telephone (for example, large numbers on the dial, teletype
phone for the deaf) and call essential numbers.
Able to answer the telephone and carry on a normal conversation but has difficulty with
placing calls.
Able to answer the telephone only some of the time or is able to carry on only a limited
conversation.
Unable to answer the telephone at all but can listen if assisted with equipment.
Totally unable to use the telephone.
Patient does not have a telephone.

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(M1900) Prior Functioning ADL/IADL: Indicate the patient’s usual ability with everyday activities prior to his/her
most recent illness, exacerbation, or injury.
Enter Code

Self-Care (specifically: grooming, dressing, bathing, and toileting hygiene)
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Ambulation
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Transfer
0 Independent
1 Needed Some Help
2 Dependent

Enter Code

Household tasks (specifically: light meal preparation, laundry, shopping, and phone use )
0
1
2

Independent
Needed Some Help
Dependent

(M1910) Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated assessment
tool?
Enter Code

0
1
2

No.
Yes, and it does not indicate a risk for falls.
Yes, and it does indicate a risk for falls.

MEDICATIONS
(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?
Enter Code

No - No issues found during review [Go to M2010 ]

Yes - Issues found during review

NA - Patient is not taking any medications [Go to M2040 ]

(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the
next calendar day and complete prescribed/recommended actions in response to the identified potential
clinically significant medication issues?
Enter Code

0
1

No
Yes

(M2010) Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special
precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and
when to report problems that may occur?
Enter Code

0
1
NA

No
Yes
Patient not taking any high-risk drugs OR patient/caregiver fully knowledgeable about
special precautions associated with all high-risk medications

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0
1

2
3
NA

0
1

2
3
NA

(M2040) Prior Medication Management: Indicate the patient’s usual ability with managing oral and
injectable medications prior to his/her most recent illness, exacerbation or injury.
Enter Code

Enter Code

Oral medications
0 Independent
1 Needed Some Help
2 Dependent
NA Not Applicable

Injectable medications
0 Independent
1 Needed Some Help
2 Dependent
NA Not Applicable

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IADL assistance (for example, meals, housekeeping, laundry, telephone, shopping,
finances)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

Enter Code

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(M2102) Types and Sources of Assistance: Determine the ability and willingness of non-agency caregivers
(such as family members, friends, or privately paid caregivers) to provide assistance for the following
activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code
g. Advocacy or facilitation of patient's participation in appropriate medical care (for example,
transportation to or from appointments)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home
health agency staff)?
Enter Code

1
2
3
4
5
UK

At least daily
Three or more times per week
One to two times per week
Received, but less often than weekly
No assistance received
Unknown

THERAPY NEED AND PLAN OF CARE
(M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this
assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable
and necessary physical, occupational, and speech-language pathology visits combined)? (Enter zero
[“000”] if no therapy visits indicated.)

() Number of therapy visits indicated (total of physical, occupational and speech-language pathology
combined).

⃞ NA - Not Applicable: No case mix group defined by this assessment.

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(M2250) Plan of Care Synopsis: (Check only one box in each row.) Does the physician-ordered plan of care
include the following:
a.

Plan / Intervention
Patient-specific parameters for notifying
physician of changes in vital signs or other
clinical findings

Yes

⃞0

⃞1

Diabetic foot care including monitoring for
the presence of skin lesions on the lower
extremities and patient/caregiver education
on proper foot care

⃞0

⃞1

Falls prevention interventions

⃞0

⃞1

⃞NA

Depression intervention(s) such as
medication, referral for other treatment, or a
monitoring plan for current treatment and/or
physician notified that patient screened
positive for depression

⃞0

⃞1

⃞NA

Intervention(s) to monitor and mitigate pain

⃞0

⃞1

⃞NA

Intervention(s) to prevent pressure ulcers

⃞0

⃞1

⃞NA

Pressure ulcer treatment based on
principles of moist wound healing OR order
for treatment based on moist wound healing
has been requested from physician

⃞0

⃞1

⃞NA

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Falls risk assessment indicates
patient has no risk for falls.
Patient has no diagnosis of
depression AND depression
screening indicates patient has: 1) no
symptoms of depression; or 2) has
some symptoms of depression but
does not meet criteria for further
evaluation of depression based on
screening tool used.
Pain assessment indicates patient
has no pain.
Pressure ulcer risk assessment
(clinical or formal) indicates patient is
not at risk of developing pressure
ulcers.
Patient has no pressure ulcers OR
has no pressure ulcers for which
moist wound healing is indicated.

Page 22 of 22

Outcome and Assessment Information Set
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care ---------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1036, M1060M1306, M1311, M1320-M1410, M1600-M2003, M2010,
M2020-M2250, GG0170

Discharge from Agency — Not to an Inpatient
Facility
Death at home -------------------------------------------------Discharge from agency ---------------------------------------

M0080-M0100, M2005, M0903, M0906
M0080-M0100, M1041-M1056, M1230, M1242, M1306M1342, M1400, M1501-M1620, M1700-M1720, M1740,
M1745, M1800-M1890, M2005, M2016-M2030, M2102,
M2301-M2420, M0903, M0906

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

(M0100) This Assessment is Currently Being Completed for the Following Reason:
Enter Code

Start/Resumption of Care
1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)
Follow-Up
4

Recertification (follow-up) reassessment [Go to M0110 ]

5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
6

Transferred to an inpatient facility—patient not discharged from agency [Go to M1041 ]

7
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]
Discharge from Agency — Not to an Inpatient Facility
8

Death at home [Go to M0903 ]

Discharge from agency [Go to M1041 ]

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(M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a
case mix group an “early” episode or a “later” episode in the patient’s current sequence of adjacent
Medicare home health payment episodes?
Enter Code

1
2
UK
NA

Early
Later
Unknown
Not Applicable: No Medicare case mix group to be defined by this assessment.

PATIENT HISTORY AND DIAGNOSES
(M1011) List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those conditions
actively treated during an inpatient stay having a discharge date within the last 14 days (no V, W, X, Y, or Z
codes or surgical codes):
Inpatient Facility Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

⃞ NA - Not applicable (patient was not discharged from an inpatient facility)

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(M1021/1023/1025) Diagnoses, Symptom Control, and Optional Diagnoses: List each diagnosis for which the patient
is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column 2
(diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects the
seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control for
each condition in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any
diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that is no longer active (a resolved condition), then
optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be completed. Diagnoses reported in M1025 will not
impact payment.
Code each row according to the following directions for each column:
Column 1:

Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each
condition and support the disciplines and services provided.

Column 2:

Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes
allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and
sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes beginning
with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023
(Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the underlying
condition can often be entered in Column 2, as long as it is an active on-going condition impacting home
health care.
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control
rating if the diagnosis code is a V, W, X, Y or Z-code. Choose one value that represents the degree of
symptom control appropriate for each diagnosis using the following scale:
0 - Asymptomatic, no treatment needed at this time
1 - Symptoms well controlled with current therapy
2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring
3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring
4 - Symptoms poorly controlled; history of re-hospitalizations
Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the
diagnoses listed in Column 1. These are separate items and sequencing may not coincide.

Column 3:

Column 4:

(OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a
resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines,
enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For
example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10-CM
code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10-CM code
for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.

(Form on next page)

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 3 of 10

(M1025) Optional Diagnoses (OPTIONAL)
(not used for payment)

(M1021) Primary Diagnosis & (M1023) Other Diagnoses
Column 1

Column 2

Diagnoses
(Sequencing of diagnoses
should reflect the seriousness
of each condition and support
the disciplines and services
provided)

(M1021) Primary Diagnosis

Description/
ICD-10-CM

V, W, X, Y codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

(M1023) Other Diagnoses

All ICD-10–C M codes allowed

) (

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(

)

) (

)

d.
.

) (
e.

) (
c.

)

.
V, W, X, Y, Z codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed

(

b.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
⃞0 ⃞1 ⃞2 ⃞3 ⃞4

Complete only if the Optional
Diagnosis is a multiple coding
situation (for example: a
manifestation code)

ICD-10-CM /
Symptom Control Rating

Column 4

Description

Column 3

) (
f.

) (

(M1030) Therapies the patient receives at home: (Mark all that apply.)

⃞
⃞
⃞
⃞

1 -

Intravenous or infusion therapy (excludes TPN)

2 -

Parenteral nutrition (TPN or lipids)

3 -

Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary
canal)
None of the above

4 -

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 4 of 10

SENSORY STATUS
(M1200) Vision (with corrective lenses if the patient usually wears them):
Enter Code

Normal vision: sees adequately in most situations; can see medication labels, newsprint.

(M1242) Frequency of Pain Interfering with patient's activity or movement:
Enter Code

0
1
2
3
4

Patient has no pain
Patient has pain that does not interfere with activity or movement
Less often than daily
Daily, but not constantly
All of the time

INTEGUMENTARY STATUS
(M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as
Unstageable? (Excludes Stage 1 pressure ulcers and healed Stage 2 pressure ulcers)
Enter Code

No [Go to M1322 ]

Yes

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 5 of 10

(M1311) Current Number of Unhealed Pressure Ulcers at Each Stage

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound
bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
[If 0 - Go to M1311 B1]
A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or
muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Number of Stage 3 pressure ulcers
[If 0 - Go to M1311 C1]
B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar
may be present on some parts of the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers
[If 0 - Go to M1311 D1]
C2. Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
D1. Unstageable: Non-removable dressing: Known but not stageable due to non-removable
dressing/device
Number of unstageable pressure ulcers due to non-removable dressing/device
[If 0 - Go to M1311 E1]
D2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed
by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
[If 0 - Go to M1311 F1]
E2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
F1. Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution
Number of unstageable pressure ulcers with suspected deep tissue injury in evolution
[ If 0 - Go to M1322]
F2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 6 of 10

(M1322) Current Number of Stage 1 Pressure Ulcers: Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as
compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones
only it may appear with persistent blue or purple hues.
Enter Code

0
1
2
3
4 or more

1
2
3
4
NA

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers or no stageable pressure ulcers

(M1330) Does this patient have a Stasis Ulcer?
Enter Code

No [Go to M1340 ]

1
2
3

Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY
Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to nonremovable dressing/device) [Go to M1340 ]

(M1332) Current Number of Stasis Ulcer(s) that are Observable:
Enter Code

1
2
3
4

One
Two
Three
Four or more

(M1334) Status of Most Problematic Stasis Ulcer that is Observable:
Enter Code

1
2
3

Fully granulating
Early/partial granulation
Not healing

(M1340) Does this patient have a Surgical Wound?
Enter Code

No [go to M1400 ]

Yes, patient has at least one observable surgical wound

Surgical wound known but not observable due to non-removable dressing/device [go to

M1400 ]
(M1342) Status of Most Problematic Surgical Wound that is Observable
Enter Code

0
1
2
3

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 7 of 10

RESPIRATORY STATUS
(M1400) When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0
1
2
3
4

ELIMINATION STATUS
(M1610) Urinary Incontinence or Urinary Catheter Presence:
Enter Code

0
1
2

No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Go to M1620 ]
Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic) [Go to M1620 ]

(M1620) Bowel Incontinence Frequency:
Enter Code

0
1
2
3
4
5
NA

Patient does not have an ostomy for bowel elimination.

ADL/IADLs
M1810)

Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments,
pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:

Enter Code

0
1
2
3

Able to get clothes out of closets and drawers, put them on and remove them from the upper
body without assistance.
Able to dress upper body without assistance if clothing is laid out or handed to the patient.
Someone must help the patient put on upper body clothing.
Patient depends entirely upon another person to dress the upper body.

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 8 of 10

(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments,
slacks, socks or nylons, shoes:
Enter Code

0
1
2
3

Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed to
the patient.
Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
Patient depends entirely upon another person to dress lower body.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing
hands, and shampooing hair).
Enter Code

0
1
2

3
4
5
6

Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
With the use of devices, is able to bathe self in shower or tub independently, including
getting in and out of the tub/shower.
Able to bathe in shower or tub with the intermittent assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
Able to participate in bathing self in shower or tub, but requires presence of another person
throughout the bath for assistance or supervision.
Unable to use the shower or tub, but able to bathe self independently with or without the use
of devices at the sink, in chair, or on commode.
Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in
bedside chair, or on commode, with the assistance or supervision of another person.
Unable to participate effectively in bathing and is bathed totally by another person.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer
on and off toilet/commode.
Able to get to and from the toilet and transfer independently with or without a device.
When reminded, assisted, or supervised by another person, able to get to and from the toilet
and transfer.
2
Unable to get to and from the toilet but is able to use a bedside commode (with or without
assistance).
3
Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal
independently.
4
Is totally dependent in toileting.
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if
patient is bedfast.
Enter Code

Enter Code

0
1

0
1
2
3
4
5

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 9 of 10

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a
wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

0
1

3
4
5
6

Able to independently walk on even and uneven surfaces and negotiate stairs with or without
railings (specifically: needs no human assistance or assistive device).
With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to
independently walk on even and uneven surfaces and negotiate stairs with or without
railings.
Requires use of a two-handed device (for example, walker or crutches) to walk alone on a
level surface and/or requires human supervision or assistance to negotiate stairs or steps or
uneven surfaces.
Able to walk only with the supervision or assistance of another person at all times.
Chairfast, unable to ambulate but is able to wheel self independently.
Chairfast, unable to ambulate and is unable to wheel self.
Bedfast, unable to ambulate or be up in a chair.

(M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed
injectable medications reliably and safely, including administration of correct dosage at the appropriate
times/intervals. Excludes IV medications.
Enter Code

0
1

2
3
NA

Able to independently take the correct medication(s) and proper dosage(s) at the correct
times.
Able to take injectable medication(s) at the correct times if:
(a) individual syringes are prepared in advance by another person; OR
(b) another person develops a drug diary or chart.
Able to take medication(s) at the correct times if given reminders by another person based
on the frequency of the injection
Unable to take injectable medication unless administered by another person.
No injectable medications prescribed.

() Number of therapy visits indicated (total of physical, occupational and speech-language pathology
combined).

⃞ NA - Not Applicable: No case mix group defined by this assessment year.

OASIS-C2 – Follow Up Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 10 of 10

Outcome and Assessment Information Set
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care ---------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1036, M1060M1306, M1311, M1320-M1410, M1600-M2003, M2010,
M2020-M2250, GG0170

Discharge from Agency — Not to an Inpatient Facility
Death at home -------------------------------------------------Discharge from agency ---------------------------------------

M0080-M0100, M2005, M0903, M0906
M0080-M0100, M1041-M1056, M1230, M1242, M1306M1342, M1400, M1501-M1620, M1700-M1720, M1740,
M1745, M1800-M1890, M2005, M2016-M2030, M2102,
M2301-M2420, M0903, M0906

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

(M0100) This Assessment is Currently Being Completed for the Following Reason:
Enter Code

Start/Resumption of Care
1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)
Follow-Up
4

Recertification (follow-up) reassessment [Go to M0110 ]

5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
6

Transferred to an inpatient facility—patient not discharged from agency [Go to M1041 ]

7
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]
Discharge from Agency — Not to an Inpatient Facility
8

Death at home [Go to M2005]

Discharge from agency [Go to M1041 ]

OASIS-C2 – Transfer Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services
Page 1 of 6

PATIENT HISTORY AND DIAGNOSES
(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to
Transfer/Discharge) include any dates on or between October 1 and March 31?
Enter Code

No [Go to M1051 ]

Yes

(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu
season?
1

Yes; received from your agency during this episode of care (SOC/ROC to
Transfer/Discharge)
2
Yes; received from your agency during a prior episode of care (SOC/ROC to
Transfer/Discharge)
3
Yes; received from another health care provider (for example, physician, pharmacist)
4
No; patient offered and declined
5
No; patient assessed and determined to have medical contraindication(s)
6
No; not indicated - patient does not meet age/condition guidelines for influenza vaccine
7
No; inability to obtain vaccine due to declared shortage
8
No; patient did not receive the vaccine due to reasons other than those listed in
responses 4–7.
(M01051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for
example, pneumovax)?
Enter Code

Enter Code

0
1

No
Yes [Go to M1501 ]

(M01056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal
vaccination (for example, pneumovax), state reason:
Enter Code

1
2
3
4

Offered and declined
Assessed and determined to have medical contraindication(s)
Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine
None of the above

No [Go to M2005 ]

Yes

Not assessed [Go to M2005]

Patient does not have diagnosis of heart failure [Go to M2005 ]

OASIS-C2 – Transfer Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services
Page 2 of 6

⃞
⃞
⃞
⃞
⃞
⃞

0 -

No action taken

1 -

Patient’s physician (or other primary care practitioner) contacted the same day

2 -

Patient advised to get emergency treatment (for example, call 911 or go to emergency room)

3 -

Implemented physician-ordered patient-specific established parameters for treatment

4 -

Patient education or other clinical interventions

5 -

Obtained change in care plan orders (for example, increased monitoring by agency, change in visit
frequency, telehealth)

MEDICATIONS
(M2005) Medication Intervention: Did the agency contact and complete physician (or physiciandesignee) prescribed/recommended actions by midnight of the next calendar day each time
potential clinically significant medication issues were identified since the SOC/ROC?
Enter Code

0
1
9

No
Yes
NA – There were no potential clinically significant medication issues identified since
SOC/ROC or patient is not taking any medications

0
1
NA

No
Yes
Patient not taking any drugs

EMERGENT CARE
(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has
the patient utilized a hospital emergency department (includes holding/observation status)?
Enter Code

No [Go to M2401 ]

1
2

Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission

Unknown [Go to M2401 ]

OASIS-C2 – Transfer Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services
Page 3 of 6

(M2310) Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or
without hospitalization)? (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞

1 2 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis
Injury caused by fall

3 -

Respiratory infection (for example, pneumonia, bronchitis)

4 -

Other respiratory problem

5 -

Heart failure (for example, fluid overload)

6 -

Cardiac dysrhythmia (irregular heartbeat)

7 -

Myocardial infarction or chest pain

8 -

Other heart disease

9 -

Stroke (CVA) or TIA

10 -

Hypo/Hyperglycemia, diabetes out of control

11 -

GI bleeding, obstruction, constipation, impaction

12 -

Dehydration, malnutrition

13 -

Urinary tract infection

14 -

IV catheter-related infection or complication

15 -

Wound infection or deterioration

16 -

Uncontrolled pain

17 -

Acute mental/behavioral health problem

18 -

Deep vein thrombosis, pulmonary embolus

19 -

Other than above reasons

UK -

Reason unknown

OASIS-C2 – Transfer Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services
Page 4 of 6

Yes

Not Applicable
⃞NA Patient is not diabetic or is missing
lower legs due to congenital or acquired
condition (bilateral amputee).

⃞0

⃞1

⃞0

⃞1

⃞NA

Depression intervention(s) such as
medication, referral for other treatment,
or a monitoring plan for current
treatment

⃞0

⃞1

⃞NA

Intervention(s) to monitor and mitigate
pain

⃞0

⃞1

⃞NA

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞NA

Pressure ulcer treatment based on
principles of moist wound healing

⃞0

⃞1

⃞NA

(M2410) To which Inpatient Facility has the patient been admitted?
Enter Code

Hospital [Go to M2430 ]

Rehabilitation facility [Go to M0903 ]

Nursing home [Go to M0903 ]

Hospice [Go to M0903 ]

OASIS-C2 – Transfer Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services
Page 5 of 6

(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that
apply.)

⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞

1 2 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis
Injury caused by fall

3 -

Respiratory infection (for example, pneumonia, bronchitis)

4 -

Other respiratory problem

5 -

Heart failure (for example, fluid overload)

6 -

Cardiac dysrhythmia (irregular heartbeat)

7 -

Myocardial infarction or chest pain

8 -

Other heart disease

9 -

Stroke (CVA) or TIA

10 -

Hypo/Hyperglycemia, diabetes out of control

11 -

GI bleeding, obstruction, constipation, impaction

12 -

Dehydration, malnutrition

13 -

Urinary tract infection

14 -

IV catheter-related infection or complication

15 -

Wound infection or deterioration

16 -

Uncontrolled pain

17 -

Acute mental/behavioral health problem

18 -

Deep vein thrombosis, pulmonary embolus

19 -

Scheduled treatment or procedure

20 -

Other than above reasons

UK -

Reason unknown

(M0903) Date of Last (Most Recent) Home Visit:

/
month

/
day

year

(M0906) Discharge/Transfer/Death Date: Enter the date of the discharge, transfer, or death (at home) of the patient.

/
month

/
day

year

OASIS-C2 – Transfer Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services
Page 6 of 6

Outcome and Assessment Information Set
Discharge from Agency
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care ---------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1036, M1060M1306, M1311, M1320-M1410, M1600-M2003, M2010,
M2020-M2250, GG0170

Discharge from Agency — Not to an Inpatient
Facility
Death at home -------------------------------------------------Discharge from agency ---------------------------------------

M0080-M0100, M2005, M0903, M0906
M0080-M0100, M1041-M1056, M1230, M1242, M1306M1342, M1400, M1501-M1620, M1700-M1720, M1740,
M1745, M1800-M1890, M2005, M2016-M2030, M2102,
M2301-M2420, M0903, M0906

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

OASIS-C2 – Discharge Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 1 of 15

(M0100) This Assessment is Currently Being Completed for the Following Reason:
Start/Resumption of Care
Enter Code

1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)
Follow-Up
4

Recertification (follow-up) reassessment [Go to M0110 ]

5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
6

Transferred to an inpatient facility—patient not discharged from agency [Go to M1041 ]

7
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]
Discharge from Agency—Not to an Inpatient Facility
8

Death at home [Go to M2005]

Discharge from agency [Go to M1041]

(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to
Transfer/Discharge) include any dates on or between October 1 and March 31?
Enter Code

No [Go to M1051]

Yes

(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu season?
Enter Code

1
2
3
4
5
6
7
8

(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example,
pneumovax)?
Enter Code

Yes [Go to M1230]

(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal
vaccination (for example, pneumovax), state reason:
Enter Code

1
2
3
4

Offered and declined
Assessed and determined to have medical contraindication(s)
Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine
None of the above

OASIS-C2 – Discharge Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 2 of 15

(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):
Enter Code

Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations
with no observable impairment.

Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional
errors in word choice, grammar or speech intelligibility; needs minimal prompting or
assistance).

Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance,
errors in word choice, organization or speech intelligibility). Speaks in phrases or short
sentences.

Has severe difficulty expressing basic ideas or needs and requires maximal assistance or
guessing by listener. Speech limited to single words or short phrases.

Unable to express basic needs even with maximal prompting or assistance but is not
comatose or unresponsive (for example, speech is nonsensical or unintelligible).

Patient nonresponsive or unable to speak.

(M1242) Frequency of Pain Interfering with patient's activity or movement:
Enter Code

0
1
2
3
4

Patient has no pain
Patient has pain that does not interfere with activity or movement
Less often than daily
Daily, but not constantly
All of the time

No [Go to M1322 ]

Yes

(M1307) The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2 Pressure
Ulcers)
Enter Code

1
2

Was present at the most recent SOC/ROC assessment
Developed since the most recent SOC/ROC assessment. Record date pressure ulcer first
identified:

/
NA

month
day
year
No Stage 2 pressure ulcers are present at discharge

OASIS-C2 – Discharge Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 3 of 15

(M1311) Current Number of Unhealed Pressure Ulcers at Each Stage

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink
wound bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
If 0 - Go to M1311B1]
A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or
muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Number of Stage 3 pressure ulcers
[If 0 - Go to M1311C1]
B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar
may be present on some parts of the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers
[If 0 - Go to M1311D1]
C2. Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
D1. Unstageable: Non-removable dressing: Known but not stageable due to non-removable
dressing/device
Number of unstageable pressure ulcers due to non-removable dressing/device
[If 0 - Go to M1311E1]
D2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed
by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
[If 0 - Go to M1311F1]
E2. Number of these unstageable pressure ulcers that were present at most recent
SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
F1. Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution
Number of unstageable pressure ulcers with suspected deep tissue injury in evolution
[If 0 - Go to M1313]
F2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

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(M1313) Worsening in Pressure Ulcer Status since SOC/ROC:
Instructions for a-c: Indicate the number of current pressure ulcers that were not present or were at a lesser
stage at the most recent SOC/ROC. If no current pressure ulcer at a given stage, enter 0.

Enter Number
a. Stage 2
b. Stage 3
c. Stage 4

Instructions for e: For pressure ulcers that are Unstageable due to slough/eschar, report the number that are
new or were at a Stage 1 or 2 at the most recent SOC/ROC.

Enter Number
d.

Unstageable—Known or likely but Unstageable due to nonremovable dressing.

Unstageable—Known or likely but Unstageable due to coverage of
wound bed by slough and/or eschar.

Unstageable—Suspected deep tissue injury in evolution.

(M1320) Status of Most Problematic Pressure Ulcer that is Observable: (Excludes pressure ulcer that cannot
be observed due to a non-removable dressing/device)
Enter Code

0
1
2
3
NA

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing
No observable pressure ulcer

(M1322) Current Number of Stage 1 Pressure Ulcers: Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as
compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones
only it may appear with persistent blue or purple hues.
Enter Code

0
1
2
3
4 or more

1
2
3
4
NA

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers or no stageable pressure ulcers

OASIS-C2 – Discharge Item Set
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Centers for Medicare & Medicaid Services

Page 5 of 15

(M1330) Does this patient have a Stasis Ulcer?
Enter Code

No [Go to M1340 ]

1
2

Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY

Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to nonremovable dressing/device) [Go to M1340 ]

(M1332) Current Number of Stasis Ulcer(s) that are Observable:
Enter Code

1
2
3
4

One
Two
Three
Four or more

(M1334) Status of Most Problematic Stasis Ulcer that is Observable:
Enter Code

1
2
3

Fully granulating
Early/partial granulation
Not healing

(M1340) Does this patient have a Surgical Wound?
Enter Code

No [go to M1400 ]

1
2

Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device
[go to M1400 ]

(M1342) Status of Most Problematic Surgical Wound that is Observable
Enter Code

0
1
2
3

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

RESPIRATORY STATUS
(M1400) When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0
1
2
3
4

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Centers for Medicare & Medicaid Services

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CARDIAC STATUS
(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient
exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or
weight gain) at the time of or at any time since the most recent SOC/ROC assessment?
Enter Code

No [Go to M1600]

Yes

Not assessed [Go to M1600]

Patient does not have diagnosis of heart failure [Go to M1600]

⃞
⃞
⃞
⃞
⃞
⃞

0 -

No action taken

1 -

Patient’s physician (or other primary care practitioner) contacted the same day

2 -

Patient advised to get emergency treatment (for example, call 911 or go to emergency room)

3 -

Implemented physician-ordered patient-specific established parameters for treatment

4 -

Patient education or other clinical interventions

5 -

Obtained change in care plan orders (for example, increased monitoring by agency, change in visit
frequency, telehealth)

ELIMINATION STATUS
(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0
1
NA

No
Yes
Patient on prophylactic treatment

(M1610) Urinary Incontinence or Urinary Catheter Presence:
Enter Code

No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Go to

M1620 ]
1
2

Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic) [Go to M1620 ]

(M1615) When does Urinary Incontinence occur?
Enter Code

0
1
2
3
4

Timed-voiding defers incontinence
Occasional stress incontinence
During the night only
During the day only
During the day and night

(M1620) Bowel Incontinence Frequency:
Enter Code

0
1
2
3
4
5
NA

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Effective 1/1/17
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1
2

3
4

(M1710) When Confused (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
4
NA

Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not constantly
Constantly
Patient nonresponsive

(M1720) When Anxious (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
NA

None of the time
Less often than daily
Daily, but not constantly
All of the time
Patient nonresponsive

(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week (Reported
or Observed): (Mark all that apply.)

⃞

1 -

Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24
hours, significant memory loss so that supervision is required

⃞

2 -

Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop
activities, jeopardizes safety through actions

⃞

3 -

Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.

⃞

4 -

Physical aggression: aggressive or combative to self and others (for example, hits self, throws
objects, punches, dangerous maneuvers with wheelchair or other objects)

⃞

5 -

Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)

⃞

6 -

Delusional, hallucinatory, or paranoid behavior

⃞

7 -

None of the above behaviors demonstrated

0
1
2
3
4
5

Never
Less than once a month
Once a month
Several times each month
Several times a week
At least daily

OASIS-C2 – Discharge Item Set
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0
1
2
3

(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments,
pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
Enter Code

0
1
2
3

Able to get clothes out of closets and drawers, put them on and remove them from the upper
body without assistance.
Able to dress upper body without assistance if clothing is laid out or handed to the patient.
Someone must help the patient put on upper body clothing.
Patient depends entirely upon another person to dress the upper body.

(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments,
slacks, socks or nylons, shoes:
Enter Code

0
1
2
3

Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed to
the patient.
Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
Patient depends entirely upon another person to dress lower body.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing
hands, and shampooing hair).
Enter Code

0
1
2

3
4
5
6

Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
With the use of devices, is able to bathe self in shower or tub independently, including
getting in and out of the tub/shower.
Able to bathe in shower or tub with the intermittent assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
Able to participate in bathing self in shower or tub, but requires presence of another person
throughout the bath for assistance or supervision.
Unable to use the shower or tub, but able to bathe self independently with or without the use
of devices at the sink, in chair, or on commode.
Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in
bedside chair, or on commode, with the assistance or supervision of another person.
Unable to participate effectively in bathing and is bathed totally by another person.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer
on and off toilet/commode.
Enter Code

0
1
2
3
4

Able to get to and from the toilet and transfer independently with or without a device.
When reminded, assisted, or supervised by another person, able to get to and from the toilet
and transfer.
Unable to get to and from the toilet but is able to use a bedside commode (with or without
assistance).
Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal
independently.
Is totally dependent in toileting.

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(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or
incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes
cleaning area around stoma, but not managing equipment.
Able to manage toileting hygiene and clothing management without assistance.
Able to manage toileting hygiene and clothing management without assistance if
supplies/implements are laid out for the patient.
2
Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
3
Patient depends entirely upon another person to maintain toileting hygiene.
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if
patient is bedfast.
Enter Code

0
1

Able to independently transfer.
Able to transfer with minimal human assistance or with use of an assistive device.
Able to bear weight and pivot during the transfer process but unable to transfer self.
Unable to transfer self and is unable to bear weight or pivot when transferred by another
person.
4
Bedfast, unable to transfer but is able to turn and position self in bed.
5
Bedfast, unable to transfer and is unable to turn and position self.
(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a
wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

0
1
2
3

Able to independently walk on even and uneven surfaces and negotiate stairs with or without
railings (specifically: needs no human assistance or assistive device).
1
With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to
independently walk on even and uneven surfaces and negotiate stairs with or without
railings.
2
Requires use of a two-handed device (for example, walker or crutches) to walk alone on a
level surface and/or requires human supervision or assistance to negotiate stairs or steps or
uneven surfaces.
3
Able to walk only with the supervision or assistance of another person at all times.
4
Chairfast, unable to ambulate but is able to wheel self independently.
5
Chairfast, unable to ambulate and is unable to wheel self.
6
Bedfast, unable to ambulate or be up in a chair.
(M1870) Feeding or Eating: Current ability to feed self meals and snacks safely. Note: This refers only to the
process of eating, chewing, and swallowing, not preparing the food to be eaten.
Enter Code

Enter Code

0
1

2
3
4
5

Able to independently feed self.
Able to feed self independently but requires:
(a) meal set-up; OR
(b) intermittent assistance or supervision from another person; OR
(c) a liquid, pureed or ground meat diet.
Unable to feed self and must be assisted or supervised throughout the meal/snack.
Able to take in nutrients orally and receives supplemental nutrients through a nasogastric
tube or gastrostomy.
Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or
gastrostomy.
Unable to take in nutrients orally or by tube feeding.

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Page 10 of 15

(M1880) Current Ability to Plan and Prepare Light Meals (for example, cereal, sandwich) or reheat delivered
meals safely:
0

(a)
Able to independently plan and prepare all light meals for self or reheat delivered
meals; OR
(b)
Is physically, cognitively, and mentally able to prepare light meals on a regular basis
but has not routinely performed light meal preparation in the past (specifically: prior to this
home care admission).
1
Unable to prepare light meals on a regular basis due to physical, cognitive, or mental
limitations.
2
Unable to prepare any light meals or reheat any delivered meals.
(M1890) Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and
effectively using the telephone to communicate.
Enter Code

Enter Code

0
1
2
3
4
5
NA

Able to dial numbers and answer calls appropriately and as desired.
Able to use a specially adapted telephone (for example, large numbers on the dial, teletype
phone for the deaf) and call essential numbers.
Able to answer the telephone and carry on a normal conversation but has difficulty with
placing calls.
Able to answer the telephone only some of the time or is able to carry on only a limited
conversation.
Unable to answer the telephone at all but can listen if assisted with equipment.
Totally unable to use the telephone.
Patient does not have a telephone.

MEDICATIONS
(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee)
prescribed/recommended actions by midnight of the next calendar day each time potential clinically
significant medication issues were identified since the SOC/ROC?
Enter Code

0
1
9

No
Yes
NA – There were no potential clinically significant medication issues identified since
SOC/ROC or patient is not taking any medications

(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent
SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care
provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side
effects, and how and when to report problems that may occur?
Enter Code

0
1
NA

No
Yes
Patient not taking any drugs

OASIS-C2 – Discharge Item Set
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Page 11 of 15

0
1

Unable to take medication unless administered by another person.

No oral medications prescribed.

(M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed
injectable medications reliably and safely, including administration of correct dosage at the appropriate
times/intervals. Excludes IV medications.
Enter Code

0
1

2
3
NA

Able to independently take the correct medication(s) and proper dosage(s) at the correct
times.
Able to take injectable medication(s) at the correct times if:
(a) individual syringes are prepared in advance by another person; OR
(b) another person develops a drug diary or chart.
Able to take medication(s) at the correct times if given reminders by another person based
on the frequency of the injection
Unable to take injectable medication unless administered by another person.
No injectable medications prescribed.

Enter Code

ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they
will provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
IADL assistance (for example, meals, housekeeping, laundry, telephone, shopping, finances)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Medication administration (for example, oral, inhaled or injectable)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

OASIS-C2 – Discharge Item Set
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Page 12 of 15

Enter Code

Medical procedures/ treatments (for example, changing wound dressing, home exercise
program)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Management of Equipment (for example, oxygen, IV/infusion equipment, enteral/ parenteral
nutrition, ventilator therapy equipment or supplies)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Supervision and safety (for example, due to cognitive impairment)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
Advocacy or facilitation of patient's participation in appropriate medical care (for example,
transportation to or from appointments)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

OASIS-C2 – Discharge Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 13 of 15

No [Go to M2401 ]

1
2

Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission

Unknown [Go to M2401 ]

(M2310) Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or
without hospitalization)? (Mark all that apply.)

⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞
⃞

1 2 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis
Injury caused by fall

3 -

Respiratory infection (for example, pneumonia, bronchitis)

4 -

Other respiratory problem

5 -

Heart failure (for example, fluid overload)

6 -

Cardiac dysrhythmia (irregular heartbeat)

7 -

Myocardial infarction or chest pain

8 -

Other heart disease

9 -

Stroke (CVA) or TIA

10 -

Hypo/Hyperglycemia, diabetes out of control

11 -

GI bleeding, obstruction, constipation, impaction

12 -

Dehydration, malnutrition

13 -

Urinary tract infection

14 -

IV catheter-related infection or complication

15 -

Wound infection or deterioration

16 -

Uncontrolled pain

17 -

Acute mental/behavioral health problem

18 -

Deep vein thrombosis, pulmonary embolus

19 -

Other than above reasons

UK -

Reason unknown

OASIS-C2 – Discharge Item Set
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Centers for Medicare & Medicaid Services

Page 14 of 15

Yes

Not Applicable
Patient is not diabetic or is missing
⃞NA lower legs due to congenital or acquired
condition (bilateral amputee).

⃞0

⃞1

⃞0

⃞1

⃞NA

Depression intervention(s) such as
medication, referral for other treatment,
or a monitoring plan for current
treatment

⃞0

⃞1

⃞NA

Intervention(s) to monitor and mitigate
pain

⃞0

⃞1

⃞NA

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞NA

Pressure ulcer treatment based on
principles of moist wound healing

⃞0

⃞1

⃞NA

(M2410) To which Inpatient Facility has the patient been admitted?
1
Hospital [Go to M2430 ]
2
Rehabilitation facility [Go to M0903 ]
3
Nursing home [Go to M0903 ]
4
Hospice [Go to M0903 ]
NA No inpatient facility admission
(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one
answer.)
Enter Code

Enter Code

1
2
3
4
UK

(M0903) Date of Last (Most Recent) Home Visit:

/
month

/
day

year

(M0906) Discharge/Transfer/Death Date: Enter the date of the discharge, transfer, or death (at home) of the patient.

/
month

/
day

year

OASIS-C2 – Discharge Item Set
Effective 1/1/17
Centers for Medicare & Medicaid Services

Page 15 of 15

Outcome and Assessment Information Set
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care ---------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1036, M1060M1306, M1311, M1320-M1410, M1600-M2003, M2010,
M2020-M2250, GG0170

Discharge from Agency — Not to an Inpatient Facility
Death at home -------------------------------------------------Discharge from agency ---------------------------------------

M0080-M0100, M2005, M0903, M0906
M0080-M0100, M1041-M1056, M1230, M1242, M1306M1342, M1400, M1501-M1620, M1700-M1720, M1740,
M1745, M1800-M1890, M2005, M2016-M2030, M2102,
M2301-M2420, M0903, M0906

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

(M0100) This Assessment is Currently Being Completed for the Following Reason:
Enter Code

Start/Resumption of Care
1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)
Follow-Up
4

Recertification (follow-up) reassessment [Go to M0110 ]

5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
6

Transferred to an inpatient facility—patient not discharged from agency [Go to M1041 ]

7
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]
Discharge from Agency — Not to an Inpatient Facility
8

Death at home [Go to M2005]

Discharge from agency [Go to M1041 ]

OASIS-C2 – Death at Home Item Set
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Page 2 of-1

0
1
9

No
Yes
NA – There were no potential clinically significant medication issues identified since
SOC/ROC or patient is not taking any medications

(M0903) Date of Last (Most Recent) Home Visit:

/
day

month

year

(M0906) Discharge/Transfer/Death Date: Enter the date of the discharge, transfer, or death (at home) of the patient.

/
month

/
day

year

OASIS-C2 – Death at Home Item Set
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Page 2 of-2

CHAPTER 3

OASIS Item Guidance

Chapter 3 contains item-by-item guidance for all OASIS items. For each data item, guidance is provided on the
following topics:

•

OASIS ITEM text.

•

ITEM INTENT: Describes the rationale for collecting the information, in the context of outcome and
process quality measurement, care planning, outcome risk adjustment, or prospective payment rate
adjustment.

•

TIME POINTS COMPLETED: Describes when the information is to be collected during the patient’s
home health episode of care.

•

RESPONSE-SPECIFIC INSTRUCTIONS: Describes how the clinician should decide which of the
possible responses should apply. These instructions may not always provide definitive guidance for
selecting responses in every case, because clinical judgment may be required to determine the most
accurate response to a specific item.

•

DATA SOURCES/RESOURCES: Describes the potential sources of information that may be accessed
during the assessment to determine the most accurate response to this specific item. This may include
other clinicians, administrative records, online guidance regarding coding or other assessment
guidelines, or standards promulgated by professional or accrediting organizations.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3-1

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0010) CMS Certification Number:

ITEM INTENT
•

Specifies the agency’s Centers for Medicare & Medicaid Services (CMS) certification number
(CCN/Medicare provider number).

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet).

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter the agency’s CMS certification (Medicare provider) number, if applicable. If agency is not Medicarecertified, leave blank.

•

This is NOT the Provider’s NPI number.

•

Preprinting this number on clinical documentation is allowed and recommended.

DATA SOURCES / RESOURCES
•

Agency administrator and billing staff.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-1

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0014) Branch State:

ITEM INTENT
•

Specifies the State where the agency branch office is located.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet) and updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter the two-letter postal service abbreviation of the State in which the branch office is located. If a branch
ID (not N or P) is entered in M0016, then M0014 cannot be blank.

•

Preprinting this abbreviation on clinical documentation is allowed and recommended.

DATA SOURCES / RESOURCES
•

Agency or branch administrator.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-2

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0016) Branch ID:

ITEM INTENT
•

Specifies the branch identification code, as assigned by CMS. The identifier consists of 10 digits – the State
code as the first two digits, followed by Q (upper case), followed by the last four digits of the current
Medicare provider number, ending with the three-digit CMS-assigned branch number.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet) and updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•
•
•
•

Enter the Federal branch identification number specified for this branch as assigned by CMS.
If you are an HHA with no branches, enter "N" followed by 9 blank boxes.
If you are a parent HHA that has branches, enter "P" followed by 9 blank boxes.
Preprinting this number on clinical documentation is allowed and recommended.

DATA SOURCES / RESOURCES
•

Agency or branch administrator.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-3

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0018) National Provider Identifier (NPI) for the attending physician who has
signed the plan of care:

⃞ UK – Unknown or Not Available

ITEM INTENT
•

Identifies the physician who will sign the Plan of Care.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet).

RESPONSE—SPECIFIC INSTRUCTIONS
•

The NPI is a ten-digit numeric identifier.

DATA SOURCES / RESOURCES
•
•

Agency medical records department.
For more information see the link for NPI registry in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-4

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0020) Patient ID Number:

ITEM INTENT
•

Identifies the agency-specific patient identifier. This is the identification code the agency assigns to the
patient and uses for record keeping purposes for this episode of care. The patient ID number may stay the
same from one admission to the next or may change with each subsequent admission, depending on
agency policy. However, it should remain constant throughout a single episode of care (for example, from
admission to discharge).

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet).

RESPONSE—SPECIFIC INSTRUCTIONS
•

If there are fewer digits than boxes provided, leave boxes at the end blank.

DATA SOURCES / RESOURCES
•

Agency medical records department.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-5

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0030) Start of Care Date:

month

day

year

ITEM INTENT
•

Specifies the start of care date, which is the date that the first reimbursable service is delivered.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet).

RESPONSE—SPECIFIC INSTRUCTIONS
•

In multidiscipline cases, regulatory requirements, coverage criteria (such as the Conditions of Participation),
and agency policy establish which discipline’s visit is considered the start of care. A reimbursable service
must be delivered to be considered the start of care. All other coverage criteria must be met for this initial
service to be billable and to establish the start of care.

•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits of the year.

•

For skilled PT or SLP to perform the start of care visit for a Medicare patient:
-

the HHA is expected to have orders from the patient’s physician indicating the need for physical therapy
or SLP prior to the initial assessment visit;

no orders are present for nursing at the start of care;

a reimbursable service must be provided; and

the need for this service establishes program eligibility for the Medicare home health benefit.

•

Accuracy of this date is essential; many other aspects of data collection are based on this date.

•

When the agency’s policy/practice is for an RN to perform the SOC assessment in a therapy-only case, the
nursing assessment visit must be made the same day or within five days after the therapist’s first visit.
-

If questions exist as to the start of care date, clarify the exact date with agency administrative
personnel.

DATA SOURCES / RESOURCES
•

Agency administrative staff.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-6

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0032) Resumption of Care Date:

month

day

year

ITEM INTENT
•

Specifies the date of the first visit following an inpatient stay by a patient receiving service from the home
health agency.

TIME POINTS ITEM(S) COMPLETED
•

ROC.

•

The resumption of care date must be updated on the Patient Tracking Sheet each time a patient returns to
service following an inpatient facility stay.

RESPONSE—SPECIFIC INSTRUCTIONS
•

At start of care, mark “NA.”

•

The most recent resumption of care date should be entered.

•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits of the year.
o

Assessment strategies: If question exists as to the resumption of care date, clarify with the agency
administrative staff.

DATA SOURCES / RESOURCES
•

Agency administrative staff.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-7

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0040) Patient Name:

(First)

(M I)

(Last)

(Suffix)

ITEM INTENT
•

Specifies the full name of the patient: first name, middle initial, last name, and suffix (for example, Jr., III,
etc.).

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet) and updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter all letters of the first and last names, the middle initial, and the abbreviated suffix. Correct spelling is
important.

•

If no suffix, leave blank. If middle initial is not known, leave blank.

•

The name entered should be exactly as it appears on the patient’s Medicare or other insurance card.

•

The name entered should be the patient’s legal name, even if the patient consistently uses a nickname.

•

The sequence of the names may be reordered (that is, last name, first name, etc.) in agency forms, if
desired.

DATA SOURCES / RESOURCES
•

Patient’s Medicare card, private insurance card, HMO identification card, etc.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-8

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0050) Patient State of Residence:

ITEM INTENT
•

Specifies the State in which the patient is currently residing while receiving home care.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet) and updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter the two-letter postal service abbreviation of the State in which the patient is CURRENTLY residing,
even if this is not the patient’s usual (or legal) residence.

DATA SOURCES / RESOURCES
•

Clarify the exact (State) location of the residence with municipal, county, or State officials, if necessary.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-9

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0060) Patient ZIP Code:
–

ITEM INTENT
•

Specifies the ZIP code for the address at which the patient is currently residing while receiving home care.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet); updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter the ZIP code for the address of the patient’s CURRENT residence, even if this is not the patient’s
usual (or legal) residence.

•

Enter at least five digits (nine digits if known).

•

The patient’s ZIP code is used for Home Health Compare to determine places where your agency provided
service. Be sure to use the ZIP code where the service is provided.

DATA SOURCES / RESOURCES
•

Verify the ZIP code with the local post office, if necessary.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-10

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0063) Medicare Number:

(including suffix)

⃞ NA – No Medicare

ITEM INTENT
•
•
•

For Medicare patients only.
Specifies the patient’s Medicare number, including any prefixes or suffixes.
Use RRB number for railroad retirement program.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet); updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter the number identified as “Claim No.” on the patient’s Medicare card. (NOTE: This may or may not be
the patient’s Social Security number.)

•

If the patient does not have Medicare, mark "NA – No Medicare."

•

If the patient is a member of a Medicare HMO, another Medicare Advantage plan, or Medicare Part C, enter
the Medicare number if available. If not available, mark “NA – No Medicare.” Do not enter the HMO
identification number.

•

Enter Medicare number (if known) whether or not Medicare is the primary payment source for this episode of
care.

•

If there are fewer digits than boxes provided, leave boxes at the end blank.

DATA SOURCES / RESOURCES
•

Patient’s Medicare card. Referral information may include the number, but it should be verified with the
patient.

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: A-11

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0064) Social Security Number:
–

–

⃞ UK – Unknown or Not Available

ITEM INTENT
•

Specifies the patient’s Social Security number.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet).

RESPONSE—SPECIFIC INSTRUCTIONS
•

Include all nine numbers. Mark “UK” if unknown or not available (for example, information cannot be
obtained or patient refuses to provide information).

DATA SOURCES / RESOURCES
•

Patient’s Social Security card, if available. Referral information may include the number, but it should be
verified with the patient.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-12

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0065) Medicaid Number:

⃞ NA – No Medicaid

ITEM INTENT
•

Specifies the patient’s Medicaid number.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet); updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Include all digits and letters. If patient does not have Medicaid coverage or Medicaid coverage is pending,
mark “NA - No Medicaid.”

•

If the patient has Medicaid, answer this item whether or not Medicaid is the payer source for the home care
episode.

•

This number is assigned by an individual state and is found on the patient's Medicaid card.

DATA SOURCES / RESOURCES
•

Patient’s Medicaid card or other verifying documentation. Make sure that the coverage is still in effect, such
as checking the expiration date. Depending on specific State regulations or procedures, you may need to
verify coverage and effective dates with the social services agency.

•

Referral information may include the number, but it should be verified with the patient.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-13

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0066)

Birth Date:

month

day

year

ITEM INTENT
•

Specifies the birth date of the patient, including month, day, and four digits for the year.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet).

RESPONSE—SPECIFIC INSTRUCTIONS
•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits of the year.

DATA SOURCES / RESOURCES
•

Patient or caregiver report.

•

Other legal documents (for example, driver’s license, state-issued ID card, etc).

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: A-14

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0069) Gender
Enter Code

1
2

Male
Female

ITEM INTENT
•

Specifies the gender of the patient.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet).

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter response for patient’s gender.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

If the patient does not self-identify, referral information (including hospital or physician office clinical record
data); observation.

•

Physical assessment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-15

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0140) Race/Ethnicity: (Mark all that apply.)

⃞1

American Indian or Alaska Native

⃞2

Asian

⃞3

Black or African-American

⃞4

Hispanic or Latino

⃞5

Native Hawaiian or Pacific Islander

⃞6

White

ITEM INTENT
•

Specifies the racial/ethnic groups or populations with which the patient is affiliated, as identified by the
patient or caregiver. Office of Management and Budget (OMB) regulations state that “unknown” is not a
permissible response for this item. The major purpose of this item is to track health disparities.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet); updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Response 1 – American Indian or Alaska Native. A person having origins in any of the original peoples of
North and South America (including Central America), and who maintains tribal affiliation or community
attachment.

•

Response 2 – Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia,
or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.

•

Response 3 – Black or African American. A person having origins in any of the black racial groups of Africa.
Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."

•

Response 4 – Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to
"Hispanic or Latino."

•

Response 5 – Native Hawaiian or Other Pacific Islander. A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

•

Response 6 – White. A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.

DATA SOURCES / RESOURCES
•

Patient/family interview.

•

If the patient does not self-identify, referral information (including hospital or physician office clinical record
data); observation.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-16

Chapter 3

Section A – Patient Tracking

OASIS ITEM
(M0150) Current Payment Sources for Home Care: (Mark all that apply.)

⃞0

None; no charge for current services

⃞1

Medicare (traditional fee-for-service)

⃞2

Medicare (HMO/managed care/Advantage plan)

⃞3

Medicaid (traditional fee-for-service)

⃞4

Medicaid (HMO/managed care)

⃞5

Workers' compensation

⃞6

Title programs (for example, Title III, V, or XX)

⃞7

Other government (for example, TriCare, VA)

⃞8

Private insurance

⃞9

Private HMO/managed care

⃞ 10

Self-pay

⃞ 11

Other (specify) ___________________________________________________________

⃞ UK

Unknown

ITEM INTENT
•

This item is limited to identifying payers to which any services provided during this home care episode and
included on the Plan of Care will be billed by your home health agency.

TIME POINTS ITEM(S) COMPLETED
•

SOC (Patient Tracking Sheet); updated if change occurs during the episode.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Exclude "pending" payment sources.

•

Accurate recording of this item is important because assessments for Medicare and Medicaid patients are
handled differently than assessments for other payers. If the patient’s care is being reimbursed by multiple
payers (for example, Medicare and Medicaid; private insurance and self-pay; etc.), include all sources. If one
or more payment sources are known but additional sources are uncertain, mark those that are known.

•

Mark all current pay sources, whether considered primary or secondary.

•

Do not consider any equipment, medications, or supplies being paid for by the patient, in part or in full.

•

Select Response 2 if the payment source is a Medicare HMO, another Medicare Advantage Plan, or
Medicare Part C.

•

Select Response 3 if the patient is receiving services provided as part of a Medicaid waiver or home and
community-based waiver (HCBS) program.

•

Select Response 6 if the patient is receiving services through one of the following programs:

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Chapter 3: A-17

Chapter 3

Section A – Patient Tracking

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M0150)
-

Title III – State Agency on Aging grants, which encourage State Agencies on Aging to develop and
implement comprehensive and coordinated community-based systems of service for older individuals
via Statewide planning and area planning. The objective of these services and centers is to maximize
the informal support provided to older Americans to enable them to remain in their homes and
communities. This program insures that elders receive the services they need to remain independent by
providing transportation services, in-home services, and caregiver support services;

Title V – State programs to maintain and strengthen their leadership in planning, promoting,
coordinating and evaluating health care for pregnant women, mothers, infants, and children, and
children with special health care needs in providing health services for mothers and children who do not
have access to adequate health care;

Title XX – Social service block grants available to states to provide homemaking, chore service, home
management or home health aide services and enable each State to furnish social services best suited
to the needs of the individuals residing in the State. Federal block grant funds may be used to provide
services directed toward one of the following five goals specified in the law: (1) To prevent, reduce, or
eliminate dependency, (2) to achieve or maintain self-sufficiency, (3) to prevent neglect, abuse, or
exploitation of children and adults, (4) to prevent or reduce inappropriate institutional care, and (5) to
secure admission or referral for institutional care when other forms of care are not appropriate.

•

Select Response 7 if the patient is a member of a Tri-Care program, which replaced CHAMPUS.

•

Select Response 10 if patient is self-pay for all or part of the care (for example, copayments).

DATA SOURCES / RESOURCES
•
•

Referral information regarding coverage. This can be verified with patient/caregiver.
Copies of health insurance identification cards. The card(s) will provide the patient ID number as well as
current status of coverage.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: A-18

Chapter 3

Section B – Clinical Record items

OASIS ITEM
(M0080) Discipline of Person Completing Assessment
Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

ITEM INTENT
•

Specifies the discipline of the clinician completing the comprehensive assessment during an actual visit to
the patient’s home at the specified OASIS time point or the clinician reporting the transfer to an inpatient
facility or death at home

TIME POINTS ITEM(S) COMPLETED
•

All.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter the response associated with the discipline of the individual completing the assessment.

•

Only one individual completes the comprehensive assessment. Even if two disciplines are seeing the patient
at the time a comprehensive assessment is due, while care coordination and consultation are needed, only
one individual actually completes and records the assessment.

•

According to the comprehensive assessment regulation, when both the RN and PT/SLP are ordered on the
initial referral, the RN must perform the SOC comprehensive assessment. An RN, PT, SLP, or OT may
perform subsequent assessments.

•

LPNs, PTAs, COTAs, MSWs, and home health aides do not meet the requirements specified in the
comprehensive assessment regulation for disciplines authorized to complete the comprehensive
assessment or collect OASIS data.

•

When both the RN and qualified therapist are scheduled to conduct discharge visits on the same day, the
last qualified clinician to see the patient is responsible for conducting the discharge comprehensive
assessment

DATA SOURCES / RESOURCES
•
•

Agency policy.
Conditions of Participation.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: B-1

Chapter 3

Section B – Clinical Record items

OASIS ITEM
(M0090) Date Assessment Completed:

month

day

year

ITEM INTENT
•

Specifies the actual date the assessment is completed.

TIME POINTS ITEM(S) COMPLETED
•

All.

RESPONSE—SPECIFIC INSTRUCTIONS
●

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits of the year.

●

Date Assessment Completed cannot be before the SOC date.

●

If agency policy allows assessments to be performed over more than one visit date, the last date (when the
final assessment data are collected) is the appropriate date to record.

●

If the clinician needs to follow-up, off site, with the patient’s family or physician in order to complete an
OASIS or non-OASIS portion of the comprehensive assessment, M0090 should reflect the date that last
needed information is collected.

●

If the original assessing clinician gathers additional information during the SOC 5-day assessment time
frame that would change a data item response, the M0090 date would be changed to reflect the date the
information was gathered and the response change was made.

●

If an error is identified at any time, it should be corrected following the agency’s correction policy and M0090
would not necessarily be changed.

●

For the following OASIS time points, Transfer to Inpatient Facility—patient not discharged from agency;
Transfer to Inpatient Facility—patient discharged from agency or Death at Home, record the date the
agency completes the data collection after learning of the event, as a visit is not necessarily associated with
these events.

•

See information on M0100 Reason for Assessment for additional clarification.

DATA SOURCES / RESOURCES
•

Calendar.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: B-2

Chapter 3

Section B – Clinical Record items

OASIS ITEM
(M0100) This Assessment is Currently Being Completed for the Following Reason:
Start/Resumption of Care
Enter Code

1
3

Start of care—further visits planned
Resumption of care (after inpatient stay)

Follow-Up
4
Recertification (follow-up) reassessment [Go to M0110 ]
5
Other follow-up [Go to M0110 ]
Transfer to an Inpatient Facility
6
7

Transferred to an inpatient facility—patient not discharged from agency [Go to M1041 ]
Transferred to an inpatient facility—patient discharged from agency [Go to M1041 ]

Discharge from Agency—Not to an Inpatient Facility
8
Death at home [Go to M0903 ]
9
Discharge from agency [Go to M1041 ]

ITEM INTENT
•

Identifies the “time point” - reason why the assessment data are being collected and reported. Accurate
recording of this response is important as the logic in the data reporting software will accept or reject certain
data according to the specific response that has been entered for this item.

TIME POINTS ITEM(S) COMPLETED
•

All.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter only one response.
-

Response 1: This is the start of care comprehensive assessment. A Plan of Care is being established,
whether or not further visits will be provided after the start of care visit. This is the appropriate response
anytime an initial HIPPS code (for a Home Health Resource Group) is required.

Response 3: This comprehensive assessment is conducted when the patient resumes care following
an inpatient stay of 24 hours or longer for reasons other than diagnostic tests. Remember to update the
Patient Tracking Sheet ROC date (M0032) when this response is entered. When a patient is discharged
from an inpatient facility and care is resumed within the last 5 days of the episode (that is, a
recertification assessment is due), a ROC assessment, rather than a recertification assessment, is
completed.

Response 4: This comprehensive follow-up assessment is conducted during the last five days of the
60-day certification period and is completed to continue the patient’s services for an additional 60 day
episode of care.

Response 5: This comprehensive assessment is conducted due to a major decline or improvement in
patient’s health status occurring at a time other than during the last five days of the episode. This
assessment is done to re-evaluate the patient’s condition, allowing revision to the patient’s care plan as
appropriate.

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Effective 1/1/2017
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Chapter 3: B-3

Chapter 3

Section B – Clinical Record items

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M0100)

•

Response 6: This “Transfer to an Inpatient Facility” OASIS is completed when the home care patient is
admitted to an inpatient facility for 24 hours or longer for reasons other than diagnostic tests with the
expectation that home health care will be resumed following inpatient discharge; thus the patient is not
discharged from the agency. (When the patient resumes care, a Resumption of Care comprehensive
assessment is conducted.) This response does not require a home visit; a telephone call may provide
the information necessary to complete the required data items. Short stay observation periods in a
hospital, regardless of duration, do not meet the definition for transfer to an inpatient facility.

Response 7: This “Transfer to an Inpatient Facility” OASIS is only completed when the home care
patient is admitted to an inpatient facility for 24 hours or longer (for reasons other than diagnostic tests)
and the agency does NOT anticipate the patient will be returning to care. The patient is discharged from
the agency. This response does NOT require a home visit; a telephone call may provide the information
necessary to complete the required data items. No additional OASIS discharge data are required. Short
stay observation periods in a hospital, regardless of duration, do not meet the definition for transfer to
an inpatient facility.

Response 8: Data regarding patient death anywhere other than death in an emergency department or
inpatient facility. A patient who dies before being treated in an emergency department or before being
admitted to an inpatient facility would have this response entered. Note the “skip pattern” included in the
response. A home visit is not required to enter this response; the information necessary to complete the
data items may be obtained by telephone.

Response 9: This comprehensive assessment is conducted when a patient is discharged from the
agency for any reason other than transfer to an inpatient facility or death at home. This response
includes transfer and discharge to another home health agency or an in-home hospice. A patient visit
is required to complete this assessment. Note the “skip pattern” present in the response. The Discharge
OASIS is not required when only a single visit is made in a care episode (SOC/ROC and TRF/DC).

Assessment strategies: Why is the assessment being conducted (or the information being recorded)? What
has happened to the patient? Accuracy of this response is critical.

DATA SOURCES / RESOURCES
•
•
•

Agency case manager or other care team provider.
Clinical record.
Hospital or other health care provider information regarding transfer to inpatient facility or death at home.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: B-4

Chapter 3

Section B – Clinical Record items

OASIS ITEM
(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific
start of care (resumption of care) date when the patient was referred for home health services, record the
date specified.
[Go to M0110, if date entered ]
month

day

year

⃞ NA – No specific SOC date ordered by physician

ITEM INTENT
•

Specifies the date that home care services are ordered to begin, if the date was specified by the physician.
The item refers to the order to start home care services (that is, provide the first covered service), regardless
of the type of services ordered (for example, therapy only).

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

If the originally ordered Start of Care (SOC) is delayed due to the patient’s condition or physician request
(for example, extended hospitalization), then the date specified on the updated/revised order to start home
care services would be considered the date of physician-ordered SOC/Resumption of Care (ROC). For
example, a patient discharged home on May 15 but for whom the physician orders home care to begin May
20 for a specified order (for example, PT or administration of a subcutaneous drug), would have a physicianordered SOC date of May 20.

•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits of the year.

•

Mark “N/A” if the initial orders did not specify a SOC date.

•

Because the State Operations Manual (SOM) requires a visit within 48 hours of ROC following
hospitalization, mark "N/A" if the physician orders a ROC date that extends beyond 2 calendar days of the
inpatient facility discharge.

•

In order to be considered a physician-ordered SOC date, the physician must give a specific date to initiate
care, not a range of dates. If a single date to initiate services is not provided, the initial contact (via the initial
assessment visit) must be conducted within 48 hours of the referral or within 48 hours of the patient's return
home from the inpatient facility.

DATA SOURCES / RESOURCES
•

Physician orders to initiate home care or resume home care following inpatient facility stay.

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Effective 1/1/2017
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Chapter 3: B-5

Chapter 3

Section B – Clinical Record items

OASIS ITEM
(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care
was received by the HHA.

month

day

year

ITEM INTENT
•

Specifies the referral date, which is the most recent date that verbal, written, or electronic authorization to
begin home care was received by the home health agency.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

A valid referral is considered to have been received when the agency has received adequate information
about a patient (name, address/contact info, and diagnosis and/or general home care needs) and the
agency has ensured that the referring physician, or another physician, will provide the plan of care and
ongoing orders. In cases where home care is requested by a hospitalist who will not be providing an ongoing
plan of care for the patient, the agency must contact an alternate, or attending physician, and upon
agreement from this following physician for referral and/or further orders, the agency will note this as the
referral date in M0104 (unless referral details are later updated or revised).

•

If Start of Care is delayed due to the patient’s condition or physician request (for example, extended
hospitalization), then the date the agency received updated/revised referral information for home care
services to begin would be considered the date of referral. This does not refer to calls or documentation from
others such as assisted living facility staff or family who contact the agency to prepare the agency for
possible admission.

•

The date authorization was received from the patient's payer is NOT the date of the referral (for example,
the date the Medicare Advantage case manager authorized service is not considered a referral date).

•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits of the year.

DATA SOURCES / RESOURCES
•
•
•

Agency referral form.
Agency records specifying the date the referral was received by the agency.
Hospital or nursing home discharge information.

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Chapter 3: B-6

Chapter 3

Section B – Clinical Record items

OASIS ITEM
(M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a
case mix group an “early” episode or a “later” episode in the patient’s current sequence of adjacent
Medicare home health payment episodes?
Enter Code

1
2
UK
NA

Early
Later
Unknown
Not Applicable: No Medicare case mix group to be defined by this assessment.

ITEM INTENT
•

Identifies the placement of the current Medicare PPS payment episode in the patient’s current sequence of
adjacent Medicare PPS payment episodes.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Follow-up.

RESPONSE—SPECIFIC INSTRUCTIONS
•

A “sequence of adjacent Medicare home health payment episodes” is a continuous series of Medicare PPS
payment episodes, regardless of whether the same home health agency provided care for the entire series.
-

Low utilization payment adjustment (LUPA) episodes (less than 5 total visits) are counted.

“Adjacent” means that there was no gap between Medicare-covered episodes of more than 60 days.

Periods of time when the patient is "outside" a Medicare payment episode but on service with a different
payer - such as HMO, Medicaid, or private pay - are counted as gap days when counting the sequence
of Medicare payment episodes.

•

“Early” includes the only PPS episode in a single episode case OR the first or second PPS episode in a
sequence of adjacent PPS episodes. Enter Response 1 – Early – if the episode of care you are
assessing the patient for is the patient’s first or second episode of care in a current sequence of
adjacent Medicare home health PPS payment episodes.

•

“Later” means the third or later PPS episode in a sequence of adjacent episodes. Enter Response 2 –
Later – if this episode is the third or later episode of care in a current sequence of adjacent Medicare
home health PPS payment episodes.

•

Enter “UK - Unknown” if the placement of this PPS payment episode in the sequence of adjacent episodes
is unknown. For the purposes of assigning a case mix code to the episode, this will have the same effect as
entering the “Early” response.

•

Enter “NA” if no Medicare case mix group is to be defined for this episode.

•

If the patient needs a case mix code for billing purposes (a HIPPS code), a response other than “NA” is
required to generate the code. Some payment sources that are not Medicare-fee-for-service payers will use
this information in setting an episode payment rate.

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Chapter 3: B-7

Chapter 3

Section B – Clinical Record items

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M0110)
•

Assessment strategies: Consult all available sources of information to answer this item. Medicare systems,
such as Health Insurance Query for Home Health (HIQH), can provide this information. If calculating
manually, note that the Medicare home health payment episode ordinarily comprises 60 days beginning with
the start of care date, or 60 days beginning with the recertification date, and that there can be a gap of up to
60 days between episodes in the same sequence, counting from the last day of one episode until the first
day of the next. Remember that a sequence of adjacent Medicare payment episodes continues as long as
there is no 60-day gap, even if Medicare episodes are provided by different home health agencies. Episodes
where Medicare fee-for-service is not the payer (such as HMO, Medicaid, or private pay) do NOT count as
part of a sequence. If the period of service with those payers is 60 days or more, the next Medicare home
health payment episode would begin a new sequence. Remember that the 60-day gap is counted from the
end of the Medicare payment episode, not from the date of the last visit or discharge, which can occur
earlier. (If the episode is ended by an intervening event that causes it to be paid as a partial episode
payment [PEP] adjustment, then the last visit date is the end of the episode).

DATA SOURCES / RESOURCES
•

Medicare systems, such as Health Insurance Query for Home Health (HIQH).

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Chapter 3: B-8

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1000) From which of the following Inpatient Facilities was the patient discharged within the past 14 days?
(Mark all that apply.)

⃞1

Long-term nursing facility (NF)

⃞2

Skilled nursing facility (SNF / TCU)

⃞3

Short-stay acute hospital

⃞4

Long-term care hospital (LTCH)

⃞5

Inpatient rehabilitation hospital or unit (IRF)

⃞6

Psychiatric hospital or unit

⃞7

Other (specify) _______________________________________________

⃞8

Patient was not discharged from an inpatient facility [Go to M1017]

ITEM INTENT
•

Identifies whether the patient has been discharged from an inpatient facility within the 14 days (two-week
period) immediately preceding the Start of Care/Resumption of Care date. The purpose of this item is to
establish the patient’s recent health care history before formulating the Plan of Care. This determination
must be made with sufficient accuracy to allow appropriate care planning. For example, the amount and
types of rehabilitation treatment the patient has received and the type of institution that delivered the
treatment are important to know when developing the home health Plan of Care.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Mark all that apply. For example, patient may have been discharged from both a hospital and a rehabilitation
facility within the past 14 days.

•

An inpatient facility discharge that occurs on the day of the assessment does fall within the 14-day period.

•

The term “past 14 days” is the two-week period immediately preceding the Start/Resumption of Care date.
This means that for purposes of counting the 14-day period, the Start of Care date is day 0 and the day
immediately prior to the Start of Care date is day 1. For example, if the patient’s SOC date is August 20, any
inpatient discharges falling on or after August 6 and prior to the HHA admission would be reported.
Discharges on Day 0 should be included.

•

Facility type is determined by the facility’s state license.

•

If the patient was discharged from a Medicare-certified skilled nursing facility, but did not receive care under
the Medicare Part A benefit in the 14 days prior to home health care, select Response 1 - Long-term
nursing facility.

•

Response 2 – Skilled nursing facility means a (a) Medicare certified nursing facility where the patient
received a skilled level of care under the Medicare Part A benefit or (b) transitional care unit (TCU) within a
Medicare-certified nursing facility.

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Chapter 3: C-1

Chapter 3

Section C – Diagnosis

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1000)
•

Determine responses to the questions below. If all three of the criteria below apply, select Response 2:
-

Was the patient discharged from a Medicare-certified skilled nursing facility? If yes;

While in the skilled nursing facility was the patient receiving skilled care under the Medicare Part A
benefit? If yes; and

Was the patient receiving skilled care under the Medicare Part A benefit during the 14 days prior to the
home health care Start of Care date? Yes.

•

Response 3 – Short-stay acute hospital applies to most hospitalizations.

•

Response 4 – Long-term care hospital, applies to a hospital that has an average inpatient length of stay of
greater than 25 days.

•

Response 5 – Inpatient rehabilitation hospital or unit (IRF) means a freestanding rehab hospital or a
rehabilitation bed in a rehabilitation distinct part unit of a general acute care hospital.

•

Intermediate care facilities for individuals with intellectual disabilities (ICF/IID) should be considered
Response 7 – Other.

•

If patient has been discharged from a swing-bed hospital, it is necessary to determine whether the patient
was occupying a designated hospital bed (Response 3), a skilled nursing bed under Medicare Part A
(Response 2), or a nursing bed at a lower level of care (Response 1). The referring hospital can answer this
question regarding the bed status.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Referral Information.

•

For Medicare patients, Medicare's Common Working File (CWF) can be accessed to assist in determining
the type of inpatient services received and the date of inpatient facility discharge if the claim for inpatient
services has been received by Medicare.

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: C-2

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1005)

Inpatient Discharge Date (most recent):

month

day

year

⃞ UK – Unknown or Not Available

ITEM INTENT
•

Identifies the date of the most recent discharge from an inpatient facility (within last 14 days). (Past 14 days
encompasses the two-week period immediately preceding the Start/Resumption of Care date.)

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

•

Even though the patient may have been discharged from more than one facility in the past 14 days, use the
most recent date of discharge from any inpatient facility.

•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2014 = 05/04/2017).
Enter all four digits of the year.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Referral information.

•

For Medicare patients, data in Medicare's Common Working File (CWF) can be accessed to assist in
determining the type of inpatient services received and the date of inpatient facility discharge if the claim for
inpatient services has been received by Medicare.

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Chapter 3: C-3

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1011) List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those
conditions actively treated during an inpatient stay having a discharge date within the last 14 days
(no V, W, X, Y, or Z codes or surgical codes):
Inpatient Facility Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

⃞ NA - Not applicable (patient was not discharged from an inpatient facility) [Omit “NA” option on SOC, ROC]
ITEM INTENT
•

Identifies diagnosis(es) for which patient was actively receiving treatment in an inpatient facility within the
past 14 days. This list of diagnoses is intended to include only those diagnoses that required active
treatment during the inpatient stay and may or may not correspond with the hospital admitting diagnosis.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

RESPONSE—SPECIFIC INSTRUCTIONS
•

“Actively treated” should be defined as receiving something more than the regularly scheduled medications
and treatments necessary to maintain or treat an existing condition.

•

The term “past 14 days” is the two-week period immediately preceding the Start/Resumption of Care date
(or for Follow-Up, the M0090 Date Assessment Completed). This means that for purposes of counting the
14-day period, the date of Start of Care date is day 0 and the day immediately prior to the Start of Care date
is day 1. For example, if the patient’s SOC date is August 20, any diagnoses related to inpatient stays with
discharges falling on or after August 6 and prior to the HHA admission would be reported.

•

If a diagnosis was not treated during an inpatient admission, it should not be listed. (Example: The patient
has a long-standing diagnosis of “osteoarthritis,” but was treated during hospitalization only for “peptic ulcer
disease.” Do not list “osteoarthritis” as an inpatient diagnosis.)

•

No surgical codes. List the underlying diagnosis that was surgically treated. If a joint replacement was done
for osteoarthritis, list the disease, not the procedure.

•

No V, W, X, Y, or Z codes. List the underlying diagnosis.

•

It is not necessary to fill in every line (a-f) if the patient had fewer than six inpatient diagnoses.

•

Select “NA” at follow-up if the patient was not discharged from an inpatient facility within the past 14 days.

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Chapter 3: C-4

Chapter 3

Section C – Diagnosis

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Referral information (may include inpatient facility discharge summary, physician history and physical,
progress notes, etc.).

•

Physician.

•

The current ICD-10-CM List of Codes and Descriptions and the ICD-10-CM Official Guidelines for Coding
and Reporting should be the source for coding (see Chapter 5 for link).

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Chapter 3: C-5

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1017) Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days: List the
patient's Medical Diagnoses and ICD-10-CM codes at the level of highest specificity for those
conditions requiring changed medical or treatment regimen within the past 14 days (no V, W, X, Y,
or Z codes or surgical codes):
Changed Medical Regimen Diagnosis

ICD-10-CM Code

a.
b.
c.
d.
e.
f.

⃞ NA - Not applicable (no medical or treatment regimen changes within the past 14 days)
ITEM INTENT
•

Identifies if any change has occurred to the patient’s treatment regimen, health care services, or medications
within the past 14 days. The purpose of this question is to help identify the patient’s recent history by
identifying new diagnoses or diagnoses that have exacerbated over the past 2 weeks.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

No surgical codes - list the underlying diagnosis.

•

No V, W, X, Y, or Z codes - list the appropriate diagnosis.

•

A diagnosis reported in M1011 – Inpatient Diagnosis may also be reported in M1017 if within the 14 days
prior to the SOC/ROC date the condition was new or exacerbated, required changes in the treatment
regimen, AND the patient was discharged from an inpatient facility where the condition was actively treated.

•

Mark "NA" if no medical or treatment regimen changes were made within the past 14 days OR all changes in
the medical or treatment regimen were made because a diagnosis improved.

•

The term “past 14 days” is the two-week period immediately preceding the Start/Resumption of Care date.
This means that for purposes of counting the 14-day period, the SOC/ROC date is day 0 and the day
immediately prior to the SOC/ROC date is day 1. For example, if the patient’s SOC date is August 20, any
diagnoses requiring medical or treatment regimen change on or after August 6 and prior to the HHA
admission would be reported.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Physician orders.

•

Referral information.

•

The current ICD-10-CM List of Codes and Descriptions and the ICD-10-CM Official Guidelines for Coding
and Reporting should be the source for coding (see Chapter 5 for link).

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Chapter 3: C-6

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14
Days: If this patient experienced an inpatient facility discharge or change in medical or treatment
regimen within the past 14 days, indicate any conditions that existed prior to the inpatient stay or
change in medical or treatment regimen. (Mark all that apply.)

⃞1

Urinary incontinence

⃞2

Indwelling/suprapubic catheter

⃞3

Intractable pain

⃞4

Impaired decision-making

⃞5

Disruptive or socially inappropriate behavior

⃞6

Memory loss to the extent that supervision required

⃞7

None of the above

⃞ NA

No inpatient facility discharge and no change in medical or treatment regimen in past 14 days

⃞ UK

Unknown

ITEM INTENT
•

Identifies existence of condition(s) prior to medical regimen change or inpatient stay within past 14 days.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Select Response 7 – None of the above – if the patient experienced an inpatient facility discharge or change
in medical or treatment regimen within the past 14 days, and none of the indicated conditions existed prior to
the inpatient stay or change in medical or treatment regimen.

•

Select Response “NA” if no inpatient facility discharge and no change in medical or treatment regimen in
past 14 days. Note that both situations must be true for this response to be marked “NA.”

•

Select Response “Unknown” if the patient experienced an inpatient facility discharge or change in medical or
treatment regimen within the past 14 days, and it is unknown whether the indicated conditions existed prior
to the inpatient stay or change in medical or treatment regimen.

•

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Referral information (for example, history and physical).

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Chapter 3: C-7

Chapter 3

Section C – Diagnosis

(M1021/1023/1025)
Diagnoses, Symptom Control, and Optional Diagnoses: List each diagnosis for
which the patient is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest
specificity in Column 2 (diagnosis codes only—no surgical or procedure codes allowed). Diagnoses are listed
in the order that best reflects the seriousness of each condition and supports the disciplines and services
provided. Rate the degree of symptom control for each condition in Column 2. ICD-10-CM sequencing
requirements must be followed if multiple coding is indicated for any diagnoses. If a Z-code is reported in
Column 2 in place of a diagnosis that is no longer active (a resolved condition), then optional item M1025
(Optional Diagnoses – Columns 3 and 4) may be completed. Diagnoses reported in M1025 will not impact
payment.
Code each row according to the following directions for each column.
Column 1:

Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each
condition and support the disciplines and services provided.

Column 2:

Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the
diagnosis code is a V, W, X, Y or Z-code. Choose one value that represents the degree of symptom control
appropriate for each diagnosis using the following scale:
0 – Asymptomatic, no treatment needed at this time
1 – Symptoms well controlled with current therapy
2 – Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring
3 – Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring
4 – Symptoms poorly controlled; history of re-hospitalizations
Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of
the diagnoses listed in Column 1. These are separate items and sequencing may not coincide.
Column 3:

Column 4:

a Z-code is reported in Column 2 AND

•

the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a
resolved condition is uterine cancer that is no longer being treated following a hysterectomy.

(OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a
resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding
guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3
and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description
and ICD-10-CM code for the underlying condition in Column 3 of that row and the diagnosis description
and ICD-10-CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in
that row. (Form on next page)

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Effective 1/1/2017
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Chapter 3: C-8

Chapter 3

Section C – Diagnosis

OASIS ITEM (M1021/1023/1025) Diagnoses, Symptom Control, and Optional Diagnoses
(M1021) Primary Diagnosis & (M1023) Other Diagnoses
Column 1

Column 2

Diagnoses (Sequencing of
ICD-10-CM and symptom control
diagnoses should reflect the
rating for each condition. Note that
seriousness of each condition and the sequencing of these ratings may
support the disciplines and
not match the sequencing of the
services provided)
diagnoses.
Description
ICD-10-CM / Symptom Control
Rating
(M1021) Primary Diagnosis

(M1023) Other Diagnoses

May be completed if a Z-code is
assigned to Column 2 and the
underlying diagnosis is resolved.

Complete only if the Optional
Diagnosis is a multiple coding
situation (for example: a
manifestation code).

Description/ ICD-10-CM

V, W, X, Y, Z codes
NOT allowed
a.

(

) (

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4
d.

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4
e.

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4
f.

(

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

OASIS-C2 Guidance Manual
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Centers for Medicare & Medicaid Services

(

)

) (

)

) (

)

e.
.

f.
f.

e.
e.

) (
c.

d.
d.

)

c.
c.

.
V, W, X, Y, Z codes
NOT allowed

V, W, X, Y, Z codes
NOT allowed
b.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

V, W, X, Y, Z codes
NOT allowed

All ICD-10–C M codes allowed

Column 4

Column 3

V, W, X, Y codes
NOT allowed

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(M1025) Optional Diagnoses (OPTIONAL)
(not used for payment)

) (
f.

) (

Chapter 3: C-9

Chapter 3

Section C – Diagnosis

ITEM INTENT
•

M1021: the intent of this item is to accurately report and code the patient’s primary home health diagnosis
and document the degree of symptom control for that diagnosis. The patient’s primary home health
diagnosis is defined as the chief reason the patient is receiving home care and the diagnosis most related to
the current home health Plan of Care.

•

M1023: the intent of this item is to accurately report and code the patient’s secondary home health
diagnoses and document the degree of symptom control for each diagnosis. Secondary diagnoses are
comorbid conditions that exist at the time of the assessment, that are actively addressed in the patient’s
Plan of Care, or that have the potential to affect the patient’s responsiveness to treatment and rehabilitative
prognosis.

•

M1025 (OPTIONAL): the intent of this item is to provide the agency with the option of documenting a
resolved underlying condition in Columns 3 and 4, if a Z-code is reported as a primary or secondary
diagnosis in Columns 1 and 2, and the underlying condition is no longer active.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

RESPONSE—SPECIFIC INSTRUCTIONS
•

•

HHA clinicians and coders must comply with the ICD-10-CM Official Guidelines for Coding and Reporting
when assigning primary and secondary diagnoses to the OASIS items M1021 and M1023. See Chapter 5
for link.
-

The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses
and reason for care in all health care settings. The ICD-10-CM is based on the ICD-10, the international
classification of disease published by the World Health Organization (WHO).

The ICD-10-CM Official Guidelines for Coding and Reporting were developed by the Centers for
Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). These
guidelines are a set of rules that have been developed to accompany and complement the official
conventions and instructions provided within the ICD-10-CM itself and should be used as a companion
document to the official version of the ICD-10-CM List of Codes and Descriptions.

Adherence to the ICD-10-CM Official Guidelines for Coding and Reporting when assigning ICD-10-CM
diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). It is
expected that each agency will ensure that diagnoses and ICD-10-CM codes reported in the OASIS
data set meet these guidelines.

Identifying the patient’s Primary and Secondary Home Health Diagnoses
-

The assessing clinician is expected to complete the patient’s comprehensive assessment and
understand the patient’s overall medical condition and care needs before selecting and assigning
diagnoses.

The determination of the patient’s primary and secondary home health diagnoses must be made by the
assessing clinician based on the findings of the assessment, information in the medical record, and
input from the physician.

As noted in the Item Intent, the patient’s primary diagnosis is defined as the chief reason the patient is
receiving home care and the diagnosis most related to the current home health Plan of Care. The
primary diagnosis may or may not relate to the patient’s most recent hospital stay, but must relate to the
skilled

OASIS-C2 Guidance Manual
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Chapter 3: C-10

Chapter 3

Section C – Diagnosis

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1021/1023/1025)
-

services (skilled nursing, physical therapy, occupational therapy, and speech language pathology)
rendered by the HHA.

As noted in the Item Intent, the secondary diagnoses include coexisting conditions actively addressed in
the patient’s Plan of Care, and any comorbid conditions having the potential to affect the patient’s
responsiveness to treatment and rehabilitative prognosis. The secondary diagnoses may or may not be
related to a patient’s recent hospital stay, but must have the potential to impact the skilled services
provided by the HHA.

When determining secondary diagnoses, the assessing clinician should consider diagnoses that are
actively addressed in the Plan of Care as well as diagnoses that affect the patient’s responsiveness to
treatment and rehabilitative prognosis, even if the condition is not the focus of any home health
treatment itself.

Diagnoses may change during the course of the home health stay due to a change in the patient’s
health status or a change in the focus of home health care. At each required OASIS time point, the
clinician must assess the patient’s clinical status and determine the primary and secondary diagnoses
based on patient status and treatment plan at the time of the assessment.

Only current medical diagnoses should be reported as primary or secondary diagnoses in M1021 and
M1023. Diagnoses should be excluded if they are resolved or do not have the potential to impact the
skilled services provided by the HHA. An example of a resolved condition is cholecystitis following a
cholecystectomy.

•

In addition to following the ICD-10-CM Official Guidelines for Coding and Reporting, selection of home
health diagnoses must be performed in compliance with Medicare’s rules and regulations for coverage and
payment to ensure provider compliance with Section 1862(a)(1)(A) of the Social Security Act. Section
1862(a)(1)(A) excludes provider services from Medicare coverage and payment that “are not reasonable
and necessary for diagnosis or treatment of illness or injury or to improve the functioning of a malformed
body member.”

•

Reporting Primary and Secondary Diagnoses in M1021 and M1023

•

At each required OASIS time point, the assessing clinician should enter the patient’s current primary
and secondary diagnoses in Column 1 of M1021 and M1023. Complete Column 1 from top to bottom,
leaving any blank entries at the bottom.

The order that secondary diagnoses are entered should be determined by the degree that they impact
the patient’s health and need for home health care, rather than the degree of symptom control. For
example, if a patient is receiving home health care for Type 2 diabetes that is “controlled with difficulty,”
this diagnosis would be listed above a diagnosis of a fungal infection of a toenail that is receiving
treatment, even if the fungal infection is “poorly controlled.”

Reporting ICD-10-CM Codes in Column 2 of M1021 and M1023
-

The assessing clinician can enter the actual numeric ICD-10-CM codes for each diagnosis listed in
Column 1 and 2 of M1021 and M1023, once the assessment is completed and the diagnosis is entered
in Column 1. Alternatively, a coding specialist in the agency may enter the actual numeric ICD-10-CM
codes in Column 2, as long as the assessing clinician has determined the primary and secondary
diagnoses in Column 1.

The correct process for selecting an ICD-10-CM code using the Alphabetic Index and the Tabular List is
described in the ICD-10-CM Official Guidelines for Coding and Reporting. Follow the official
conventions and instructions provided within the ICD-10-CM List of Codes and Descriptions and the
Official Guidelines to code each row in Column 2.

Each ICD-10-CM code must be entered at its highest level of specificity (diagnosis codes only - no
surgical or procedure codes allowed).

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Chapter 3

Section C – Diagnosis

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1021/1023/1025)

•

ICD-10-CM does not allow external cause codes (ICD-10-CM codes beginning with V, W, X, or Y) to be
reported in M1021 (Primary Diagnosis) but they may be reported in M1023 (Secondary Diagnoses).

Also note that when a Z-code is reported in Column 2, the code for the underlying condition may be
entered in Column 2, as long as it is a current on-going condition that has a potential to impact the
skilled services provided by the HHA. See the ICD-10-CM Official Guidelines for Coding and Reporting
for complete instructions on code assignment and sequencing related to the use of Z-codes and use of
multiple coding for a single condition (such as manifestation/etiology pairs).

Reporting the Symptom Control Rating in Column 2 of M1021 and M1023
-

At each required time point, the assessing clinician should record the symptom control ratings for each
primary and secondary diagnosis in column 2 of M1021 and M1023.

Assessing degree of symptom control includes review of presenting signs and symptoms, type and
number of medications, frequency of treatment readjustments, and frequency of contact with health
care provider. Inquire about the degree to which each condition limits daily activities. Assess the patient
to determine if symptoms are controlled by current treatments. Clarify which diagnoses/symptoms have
been poorly controlled in the recent past.

Choose one value that represents the degree of symptom control appropriate for each diagnosis using
the scale provided in the M1021/M1023 instructions.

M1025 (OPTIONAL)
-

If a Z-code is reported in Column 2 and the underlying condition for the Z-code is resolved, then the
resolved condition may be reported in Columns 3 and 4 at the agency’s discretion.

If an agency chooses to report a diagnosis in Columns 3 and 4, then the instructions that accompany
items M1021/M1023/M1025 in the OASIS-C1 data set should be followed to code each row in Column 3
and/or 4. If a diagnosis and ICD-10-CM code is entered in Columns 3 and/or 4, it must be placed in the
same row as the corresponding Z-code. Note that external cause codes (ICD-10-CM codes beginning
with V, W, X, or Y) may not be reported in M1025.

Refer to the ICD-10-CM Official Guidelines for Coding and Reporting for instructions on multiple coding for a
single condition (such as manifestation/etiology pairs).

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Physician orders.

•

Referral information.

•

Current medication list.

•

The current ICD-10-CM List of Codes and Descriptions and the ICD-10-CM Official Guidelines for Coding
and Reporting should be the source for coding (see Chapter 5 for link).
-

For degree of symptom control, data sources may include patient/caregiver interview, physician,
physical assessment, and review of past health history.

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Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions—Check all that apply
See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.

⃞

1 – Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

⃞

2 – Diabetes Mellitus (DM)

ITEM INTENT
•

This item identifies whether two specific diagnoses are present, and active. These diagnoses influence a
patient's functional outcomes or increase a patient's risk for development or worsening of pressure ulcer(s).

Item Rationale
•

Disease processes can have a significant adverse effect on an individual’s health status and quality of life.

•

This section identifies active diagnoses that are associated with a patient’s home health episode of care.

TIME POINTS ITEM(S) COMPLETED
•

Start of Care.

•

Resumption of Care.

Steps for Assessment
•

Identify diagnoses: The diseases and conditions in this item require a physician (or nurse practitioner,
physician assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state
licensure laws) documented diagnosis at the time of assessment.
-

Medical record sources for physician (or nurse practitioner, physician assistant, clinical nurse specialist,
or other authorized licensed staff if allowable under state licensure laws) diagnoses include, but are not
limited to, transfer documents, physician progress notes, recent history and physical, discharge
summary, medication sheets, physician orders, consults and official diagnostic reports,
diagnosis./problem list(s), and other resources as available.

Available documentation may be limited at admission/start of care. Admission/start of care assessment
may indicate symptoms associated with one of this item’s listed conditions while a documented
diagnosis is not present in available records. The clinician should contact the physician (or other, as
listed above) to ask if the patient has the diagnosis. Once a diagnosis has been identified, determine if
the diagnosis is active.

Although open communication regarding diagnostic information between the physician and other clinical
staff is important, it is also essential that diagnoses communicated verbally be documented in the
medical record by the physician (or nurse practitioner, physician assistant, clinical nurse specialist, or
other licensed staff if allowable under state licensure laws) to ensure follow-up and coordination of care.

•

Diagnostic information, including past medical and surgical history obtained from family members and close
contacts, must also be documented in the medical record by the physician (or nurse practitioner, physician
assistant, clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws)
to ensure validity, follow-up and coordination of care.

•

Only diagnoses confirmed and documented by the physician (or nurse practitioner, physician assistant,
clinical nurse specialist, or other authorized licensed staff if allowable under state licensure laws) should be
considered when coding this item.

•

Determine whether diagnoses are active: Once a diagnosis has been identified, determine if the
diagnosis is active.

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Chapter 3
-

•

Section C – Diagnosis

Active diagnoses are diagnoses that have a direct relationship to the patient’s current functional,
cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of
assessment. Do not include diseases or conditions that have been resolved or do not affect the
patient’s current functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or
risk of death at the time of assessment.

Medical record sources to identify active diagnoses at the time of assessment include, but are not limited to,
transfer documents, physician progress notes, recent history and physical, discharge summary, medication
sheets, physician orders, consults and other official diagnostic reports, diagnosis/problem list(s), and other
resources as available.
-

Only diagnoses confirmed by the physician (or nurse practitioner, physician assistant, clinical nurse
specialist, or other authorized licensed staff if allowable under state licensure laws) that are active
should be coded on the OASIS Data Set.

If information regarding active diagnoses is learned after the Assessment Completed Date, the OASIS
Data Set should not be revised to reflect this new information. The OASIS Data Set should reflect what
was known and documented at the time of the assessment. If, however, it comes to light that a
documented active diagnosis was not indicated on the OASIS Data Set, the Home Health Agency
should modify the OASIS Data Set in accordance with the instructions in the Survey and Certification
Memo #15-18-HHA, Outcome and Assessment Information Set (OASIS) transition to the Automated
Submission and Processing System (ASAP) and OASIS Correction policy (available at
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policyand-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-18.html?DLPage=1&DLFilter=1518&DLSort=3&DLSortDir=descending ) and the OASIS Submission User’s guide (available at
https://www.qtso.com/hhatrain.html)

A dash (–) value is a valid response for this item. A dash (–) value indicates that no information is available
and /or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred,
discharged or dies before the assessment of the item could be completed. CMS expects dash use to be a
rare occurrence.

Definitions
•

Nurse monitoring Nurse monitoring includes clinical monitoring by a licensed nurse (e.g., serial blood
pressure evaluations, medication management).

RESPONSE SPECIFIC INSTRUCTIONS
•

Complete only if M0100 = 01 Start of care or 03 Resumption of care.

•

Select Response 1 if the patient has an active diagnosis of Peripheral Vascular Disease (PVD) or Peripheral
Arterial Disease (PAD), indicated by any of the following diagnosis codes:
-

Codes that start with the first 4 characters of:
o

I70.2 – Atherosclerosis of native arteries of the extremities

I70.3 – Atherosclerosis of bypass graft(s) of the extremities

I70.4 – Atherosclerosis of autologous vein bypass graft(s) of the extremities

I70.5 – Atherosclerosis of nonautologous biological bypass graft(s) of the extremities

I70.6 – Atherosclerosis of nonbiological bypass graft(s) of the extremities

I70.7 – Atherosclerosis of other type of bypass graft(s) of the extremities

I70.91 – Generalized atherosclerosis

I70.92 – Chronic total occlusion of artery of the extremities

Codes that start with the first 3 characters of
o

I73. – Other peripheral vascular diseases

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Chapter 3

Section C – Diagnosis

RESPONSE SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM 1028)
•

Select Response 2 if the patient has an active diagnosis of Diabetes Mellitus (DM) indicated by any of the
following diagnosis codes:
-

Codes that start with the first 3 characters of:
o

E08. – Diabetes mellitus due to underlying condition

E09. – Drug or chemical induced diabetes mellitus

E10. – Type 1 diabetes mellitus

E11. – Type 2 diabetes mellitus

E13. – Other specific diabetes mellitus

Tips
•

The following tips may assist staff in determining whether a disease or condition may be identified as an
active diagnosis on the OASIS.
-

There must be specific documentation in the medical record by a physician (or nurse practitioner,
physician assistant, clinical nurse specialist, or other authorized staff if allowable under state licensure
laws) of the disease or condition being an active diagnosis.

The physician (nurse practitioner, physician assistant, clinical nurse specialist, authorized licensed staff
if allowable under state licensure laws) may specifically indicate that a diagnosis is active. Specific
documentation areas in the medical record may include, but are not limited to, progress notes,
admission history and physical, transfer notes, and the hospital discharge summary.

The physician (nurse practitioner, physician assistant, clinical nurse specialist or other authorized
licensed staff if allowable under state licensure laws) for example, documents at the time of assessment
that the patient has inadequately controlled diabetes and requires adjustment of the medication
regimen. This would be sufficient documentation of an active diagnosis and would require no additional
confirmation because the physician documented the diagnosis and also confirmed that the mediation
regimen needed to be modified.

For the purposes of the OASIS Data Set, Home Health Agencies should consider only the documented
active diagnoses. A diagnosis should not be inferred by association with other conditions (e.g., “weight
loss” should not be inferred to mean “malnutrition”).

Examples of Active Diagnoses
•

Example 1: Mr. A is prescribed insulin for diabetes mellitus. He requires regular blood glucose monitoring
to determine whether blood glucose goals are achieved by the current medication regimen. The physician
progress note documents diabetes mellitus.

•

Response 2: Diabetes Mellitus would be checked.

•

Rationale: This would be considered an active diagnosis because the physician progress note documents
the diabetes mellitus diagnosis, and because there is ongoing medication management and glucose
monitoring.

•

Example 2: Mrs. I underwent a below the knee amputation due to gangrene associated with peripheral
vascular disease. She requires dressing changes to the stump and monitoring for wound healing. In
addition, peripheral pulse monitoring is ordered. The nurse practitioner’s progress note documents
peripheral vascular disease and left below the knee amputation.

•

Response 1: Peripheral Vascular Disease (PVD) would be checked.

•

Rationale: This would be considered an active diagnosis because the nurse practitioner’s note documents
the peripheral vascular disease diagnosis, with peripheral pulse monitoring and recent below the knee
amputation, with dressing changes and wound status monitoring.

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Chapter 3: C-15

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1030) Therapies the patient receives at home: (Mark all that apply.)

⃞1

Intravenous or infusion therapy (excludes TPN)

⃞2

Parenteral nutrition (TPN or lipids)

⃞3
⃞4

Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the
alimentary canal)
None of the above

ITEM INTENT
•

Identifies whether the patient is receiving intravenous, parenteral nutrition, or enteral nutrition therapy at
home, whether or not the home health agency is administering the therapy. This item is not intended to
identify therapies administered in outpatient facilities or by any provider outside the home setting.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

RESPONSE—SPECIFIC INSTRUCTIONS
•

This item addresses only therapies administered at home, defined as the patient’s place of residence.
Exclude therapies administered in outpatient facilities or by any provider outside the home setting.

•

If the patient will receive such therapy as a result of this SOC/ROC or follow-up assessment (for example,
the IV will be started at this visit or a specified subsequent visit; the physician will be contacted for an enteral
nutrition order; etc.), mark the applicable therapy.

•

Select Response 1 if a patient receives intermittent medications or fluids via an IV line (including heparin or
saline flushes). If IV catheter is present but not active (for example, site is observed only or dressing
changes are provided), do not mark Response 1.

•

Select Response 1 if ongoing infusion therapy is being administered at home via central line, subcutaneous
infusion, epidural infusion, intrathecal infusion, or insulin pump.

•

Select Response 1 if the patient receives hemodialysis or peritoneal dialysis in the home.

•

Do not select Response 1 if there are orders for an IV infusion to be given when specific parameters are
present (for example, weight gain), but those parameters are not met on the day of the assessment.

•

An irrigation or infusion of the bladder is not included when completing M1030, Therapies at Home.

•

Select Response 3 if any enteral nutrition is provided. If a feeding tube is in place, but not currently used for
nutrition, Response 3 does not apply. A flush of a feeding tube does not provide nutrition.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician orders.

•

Referral information.

•

Physical assessment.

•

Review of past health history.

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Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at
risk for hospitalization? (Mark all that apply.)

⃞1

History of falls (2 or more falls—or any fall with an injury—in the past 12 months)

⃞2

Unintentional weight loss of a total of 10 pounds or more in the past 12 months

⃞3

Multiple hospitalizations (2 or more) in the past 6 months

⃞4

Multiple emergency department visits (2 or more) in the past 6 months

⃞5

Decline in mental, emotional, or behavioral status in the past 3 months

⃞6

Reported or observed history of difficulty complying with any medical instructions (for example,
medications, diet, exercise) in the past 3 months

⃞7

Currently taking 5 or more medications

⃞8

Currently reports exhaustion

⃞9

Other risk(s) not listed in 1–8

⃞ 10

None of the above

ITEM INTENT
•

Identifies patient characteristics that may indicate the patient is at risk for hospitalization.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Select all Responses 1-9 that apply.

•

If Response 10 is selected, none of the other responses should be selected.

•

Response 1 includes witnessed and reported (unwitnessed) falls.

•

In Response 5, decline in mental, emotional, or behavioral status refers to significant changes occurring
within the past 3 months that may impact the patient’s ability to remain safely in the home and increase the
likelihood of hospitalization. In Response 7, medications includes OTC medications.

•

Response 9 – Other risk(s), may be selected if the assessing clinician finds characteristics other than those
listed in Responses 1-8 that may indicate risk for hospitalization (for example, slower movements during sit
to stand and walking).

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Review of health history.

•

Referral information.

•

Physical assessment.

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Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1034) Overall Status: Which description best fits the patient’s overall status?
0
Enter Code

ITEM INTENT
•

Identifies the general potential for health status stabilization, decline, or death in the care provider’s
professional judgment.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Use information from other providers and clinical judgment to enter the response that best identifies the
patient’s status.

•

Consider current health status, medical diagnoses, and information from the physician and patient/family on
expectations for recovery or life expectancy.

•

A “Do Not Resuscitate” order does not need to be in place for Response 2 or 3.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Review of health history.

•

Referral information.

•

Physical assessment.

•

Advance Directive.

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Chapter 3: C-18

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:
(Mark all that apply.)

⃞1

Smoking

⃞2

Obesity

⃞3

Alcohol dependency

⃞4

Drug dependency

⃞5

None of the above

⃞ UK

Unknown

ITEM INTENT
•

Identifies specific factors that may exert a substantial impact on the patient’s health status, response to
medical treatment, and ability to recover from current illnesses, in the care provider’s professional judgment.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Select all Responses 1-4, that apply.

•

If Response 5 is selected, none of the other responses should be selected.

•

CMS does not provide a specific definition for each of these factors.

•

Amount and length of exposure should be considered when responding (for example, smoking one cigarette
a month may not be considered a risk factor).

•

Care providers should use judgment in evaluating risks to current health conditions from behaviors that were
stopped in the past.

•

For determination of obesity, consider using Body Mass Index guidelines.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Review of past health history.

•

Physical assessment.

•

Links to Body Mass Index guidelines for obesity can be found in Chapter 5 of this manual.

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Chapter 3: C-19

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to
Transfer/Discharge) include any dates on or between October 1 and March 31?
Enter Code

No [Go to M1051 ]

Yes

ITEM INTENT
•

Identifies whether the patient was receiving services from the home health agency during the time period for
which influenza vaccine data are collected (October 1 and March 31).

TIME POINTS ITEM(S) COMPLETED
•

Transfer to inpatient facility.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

A care episode is one that includes both SOC/ROC and Transfer/Discharge. Therefore, when completing
this item at Transfer or Discharge, only go back to the most recent SOC or ROC to determine if the patient
was receiving home health agency services on or between October 1 through March 31.

•

If no part of the care episode (from SOC/ROC to Transfer or Discharge) occurred during the time period
from October 1 and March 31, enter the response for “No”.

DATA SOURCES / RESOURCES
•

Clinical record and calendar.

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Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu
season?
1
Enter Code

2
3
4
5
6
7
8

Yes; received from your agency during this episode of care (SOC/ROC to
Transfer/Discharge)
Yes; received from your agency during a prior episode of care (SOC/ROC to
Transfer/Discharge)
Yes; received from another health care provider (for example, physician, pharmacist)
No; patient offered and declined
No; patient assessed and determined to have medical contraindication(s)
No; not indicate—patient does not meet age/condition guidelines for influenza vaccine
No; inability to obtain vaccine due to declared shortage
No; patient did not receive the vaccine due to reasons other than those listed in
responses 4–7.

ITEM INTENT
•

For a patient with any part of the home health episode (SOC/ROC to Transfer/Discharge) occurring between
October 1 and March 31, identifies whether the patient received an influenza vaccine for this year’s flu
season, and if not, the reason why.

TIME POINTS ITEM(S) COMPLETED
•

Transfer to an inpatient facility.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Complete if Response 1 –Yes is entered for M1041. Enter only one response.

•

Enter Response 1 if your agency provided the influenza vaccine to the patient during this episode of care
(SOC/ROC to Transfer/Discharge).

•

Enter Response 2 if your agency provided the flu vaccine for this year’s flu season prior to this home health
episode, (for example, if the SOC/ROC for this episode was in winter, but your agency provided the vaccine
for the current flu season during a previous home health episode in the fall when the vaccine for the current
flu season became available).
-

You may enter Response 2 if a current patient was given a flu vaccine by your agency during a previous
roster billing situation during this year’s flu season.

•

Enter Response 3 if the patient or caregiver reports (or there is documentation in the clinical record) that the
patient received the influenza vaccine for the current flu season from another provider. The provider can be
the patient’s physician, a clinic, or health fair providing influenza vaccines, etc.

•

Response 1, 2, or 3 may be entered even if the flu vaccine for this year’s influenza season was provided
prior to October 1 (that is, flu vaccine was made available early).

•

Enter Response 4 if the patient and/or healthcare proxy (for example, someone with power of attorney)
refused the vaccine.

•

Note: It is not required that the agency offered the vaccine. Enter Response 4 only if the patient was offered
the vaccine and he/she refused.

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Chapter 3

Section C – Diagnosis

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1046)
•

Enter Response 5 if the influenza vaccine is contraindicated for medical reasons. Medical contraindications
include anaphylactic hypersensitivity to eggs or other component(s) of the vaccine, history of Guillain-Barre
Syndrome within 6 weeks after a previous influenza vaccination, or bone marrow transplant within 6 months.

•

Enter Response 6 if age/condition guidelines indicate that influenza vaccine is not indicated for this patient.
Age/condition guidelines are updated as needed by the CDC. Detailed information regarding current
influenza age/condition guidelines is posted to the CDC website (see link in Chapter 5). It is the agency’s
responsibility to make current guidelines available to clinicians.

•

Enter Response 7 only in the event that the vaccine is unavailable due to a CDC-declared shortage.

•

Enter Response 8 only if the patient did not receive the vaccine due to a reason other than Responses 4–7,
including situations where the assessing clinician is unable to determine whether the patient received the
influenza vaccination.

DATA SOURCES / RESOURCES
•

Clinical record.

•

Patient/caregiver interview.

•

Physician or other health care provider.

•

A link to CDC Guidelines can be found in Chapter 5 of this manual.

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Chapter 3: C-22

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for
example, pneumovax)?
Enter Code

0
1

No
Yes [Go to M1501 at TRN; Go to M1230 at DC ]

ITEM INTENT
•

Identifies whether the patient has ever received the pneumonia vaccine.

TIME POINTS ITEM(S) COMPLETED
•

Transfer to an inpatient facility.

•

Discharge from agency - not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter Response 1 if the patient has ever received the pneumococcal vaccine.

•

Enter Response 0 if the patient has never received the pneumococcal vaccine, or if the assessing clinician is
unable to determine whether the patient has ever received the pneumococcal vaccine.

DATA SOURCES / RESOURCES
•

Clinical record.

•

Patient/caregiver interview.

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Chapter 3: C-23

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal
vaccination (for example, pneumovax), state reason:
Enter Code

1
2
3
4

Offered and declined
Assessed and determined to have medical contraindication(s)
Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine
None of the above

ITEM INTENT
•

Explains why the patient has never received the pneumococcal vaccination.

TIME POINTS ITEM(S) COMPLETED
•

Transfer to an inpatient facility.

•

Discharge from agency - not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter Response 1 if the patient and/or healthcare proxy (for example, someone with power of attorney)
refused the vaccine.

•

Enter Response 2 if pneumococcal vaccine administration is medically contraindicated for this patient.
Medical contraindications include anaphylactic hypersensitivity to component(s) of the vaccine, acute febrile
illness, bone marrow transplant within past 12 months, or receiving course of chemotherapy or radiation
therapy within past 2 weeks.

•

Enter Response 3 if CDC age/condition guidelines indicate that pneumococcal vaccination is not indicated
for this patient. Age/condition guidelines are updated as needed by the CDC. Detailed information regarding
current pneumococcal vaccination age/condition guidelines are posted to the CDC’s website (see link in
Chapter 5). It is the agency’s responsibility to make current guidelines available to clinicians.

•

Enter Response 4 only if the agency did not provide the vaccine due to a reason other than Responses 1-3
including situations where the assessing clinician is unable to determine whether the patient has ever
received the pneumococcal vaccine.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Clinical Record.

•

A link to CDC Guidelines for pneumococcal vaccine administration can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: C-24

Chapter 3

Section C – Diagnosis

OASIS ITEM
(M1060) Height and Weight—While measuring, if the number is X.1 – X.4 round down; X.5 or greater round
up

a. Height (in inches). Record most recent height measure since the most recent SOC/ROC
inches
b. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight
consistently, according to standard agency practice (for example, in a.m. after voiding, before meal,
with shoes off, etc.).

pounds

ITEM INTENT
•

These items support calculation of the patient’s body mass index (BMI) using the patient’s height and
weight.

Item Rationale
•

Diminished nutritional and hydration status can lead to debility that can adversely affect wound healing and
increase risk for the development of pressure ulcers.

•

Height and weight measurements (and BMI calculation) assist staff in assessing the patient’s nutrition and
hydration status by providing a mechanism for monitoring stability of weight and BMI over a period of time.
The measurement of height and weight for the calculation of BMI is one guide for determining nutritional
status.

•

Weight measurement is also used in assessment of heart failure.

TIME POINTS ITEMS COMPLETED
Start of care.
Resumption of care.
Steps for Assessment for M1060 – a, Height
1.

Measure height in accordance with the agency’s policies and procedures, which should reflect current
standards of practice (shoes off, etc.).

Measure and record height in inches.

When reporting height for a patient with bilateral lower extremity amputation, measure and record the
patient’s current height (i.e., height after bilateral amputation).

Instructions for M1060 – a, Height
•

Complete only if M0100 = 1 Start of Care or 3 Resumption of Care.

•

Record the patient’s height to the nearest whole inch.

•

Use mathematical rounding (i.e., if height measurement is X.5 inches or greater, round height upward to the
nearest whole inch. If height measurement number is X.1 to X.4 inches, round down to the nearest whole
inch). For example, a height of 62.5 inches would be rounded to 63 inches, and a height of 62.4 inches
would be rounded to 62 inches.

•

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: C-25

Chapter 3

Section C – Diagnosis

Steps for Assessment for M1060 – b, Weight
1.

Weight should be measured in accordance with the agency’s policies and procedures, which should reflect
current standards of practice (shoes off, etc.).

Measure and record the patient’s weight in pounds.

If a patient cannot be weighed, for example, because of extreme pain, immobility, or risk of pathological
fractures, enter the dash value (“-“) and document the rationale on the patient’s medical record.

Instructions for M1060 – b, Weight
Complete only if M0100 = 1 Start of Care, or 3 Resumption of Care
•

Use mathematical rounding (e.g., if weight is X.5 pounds [lbs.] or more, round weight upward to the nearest
whole pound. If weight is X.1 to X.4 lbs., round down to the nearest whole pound). For example, a weight of
152.5 lbs. would be rounded to 153 lbs. and a weight of 152.4 lbs. would be rounded to 152 lbs.

•

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: C-26

Chapter 3

Section D – Living Arrangements

OASIS ITEM
(M1100)

Patient Living Situation: Which of the following best describes the patient's residential
circumstance and availability of assistance? (Check one box only.)
Availability of Assistance

Around the
clock

Regular
daytime

Regular
nighttime

Occasional /
short-term
assistance

No
assistance
available

a. Patient lives alone

⃞ 01

⃞ 02

⃞ 03

⃞ 04

⃞ 05

b. Patient lives with other
person(s) in the home

⃞ 06

⃞ 07

⃞ 08

⃞ 09

⃞ 10

c. Patient lives in congregate
situation (for example, assisted
living, residential care home)

⃞ 11

⃞ 12

⃞ 13

⃞ 14

⃞ 15

Living Arrangement

ITEM INTENT
•

This item identifies, using the care provider’s professional judgment, a) whether the patient is living alone or
with other(s) and b) the availability of caregiver(s) (other than home health agency staff) to provide in-person
assistance.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

•

To answer this question:
-

First, determine living arrangement—whether the patient normally lives alone, in a home with others,
or in a congregate setting.

Second, determine availability of assistance—how frequently caregiver(s) are in the home and
available to provide assistance if needed.

Only one response should be marked. Select the appropriate row (a, b, or c) to reflect the patient’s
living situation, then select the one response in the column that best describes the availability of inperson assistance at the time of the OASIS assessment.

Living Arrangement
-

Select a response from Row a if the patient lives alone in an independent (non-assisted) setting. For
example, the patient lives alone in a home, in their own apartment, or in their own room at a boarding
house. A patient with only live-in paid help is considered to be living alone. A patient who normally lives
alone but temporarily has a caregiver staying in the home to provide assistance is considered to be
living alone. A patient who lives alone but can obtain emergency help by phone or life-line, is still living
alone.

Select a response from Row b if the patient lives with others in an independent (non-assisted) setting.
For example, the patient lives with a spouse, family member or another significant other in an
independent (non-assisted) setting. A patient who normally lives with others but is occasionally alone
because caregiver(s) are traveling out of town is still considered to be living with others.

Select a response from Row c if the patient lives in an “assisted living” setting (assistance, supervision
and/or oversight are provided as part of the living arrangement). For example, the patient lives alone or
with a spouse or partner in an apartment or room that is part of an assisted living facility, residential
care home, or personal care home.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: D-1

Chapter 3

Section D – Living Arrangements

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1100)
o

•

If the patient has recently changed their living arrangement due to their condition, report the usual
living arrangement prior to the illness, injury or exacerbation for which the patient is receiving care,
unless the new living arrangement is expected to be permanent.

Availability of Assistance
-

Identify the frequency with which any in-person assistance is available:
o

Around the clock means there is someone available in the home to provide assistance to the
patient 24 hours a day.

Regular daytime means someone is in the home and available to provide assistance during
daytime hours every day with infrequent exceptions.

Regular nighttime means someone is in the home and available to provide assistance during
nighttime hours every night with infrequent exceptions.

Occasional/short-term assistance means someone is available to provide in-person assistance
only for a few hours a day or on an irregular basis, or may be only able to help occasionally.

No assistance available means there is no one available to provide any in-person assistance.

Clinical judgment must be used to determine which hours constitute "regular daytime" and "regular
nighttime" based on the patient’s specific activities and routines. No hours are specifically designated as
daytime or nighttime.

Availability of assistance refers to in-person assistance provided in the home of the patient. It includes
any type of in-person assistance, including but not limited to ADLs and IADLs. If a person is in an
assisted living or congregate setting with a call-bell that summons onsite, in-person help, this is
considered in-person assistance. If its use is restricted to emergencies only, report the availability as
occasional/short-term assistance unless other caregiver’s availability meets a higher level.

The caregiver(s) need not live in the home with the patient, but assistance via telephone is not included
in this question.

This item documents the time caregiver(s) are in the home and available without regard to the amount
or types of assistance the patient requires, or whether the caregiver(s) are able to meet all or only some
of the patient’s needs. Adequacy of caregiver assistance for different types of needs is captured in
M2100.

Use your professional judgment to determine if someone will be available to provide any assistance to
the patient. If a person is living in the patient’s home but is completely unable to or unwilling to
provide any assistance to the patient, do not count them as a caregiver.

Availability of assistance refers to the expected availability and willingness of caregiver(s) for this
upcoming care episode.

Examples:
-

Patient lives alone in her own apartment. Since her discharge from the hospital, her two daughters
alternate staying with her during the day and night so that one of them is always there, except for the
times when one goes out to run an errand or pick up a child at day care. Response = 01 (Patient still
considered to be living alone, since daughters are only staying there temporarily. Daughters are
providing round-the-clock care, even if one occasionally needs to be out of the house for brief periods.)

Patient lives alone in her home but her son and daughter-in-law live across the street. They bring the
patient dinner every night and are available around the clock by telephone. Response = 04 (Son and
daughter-in-law are not there to provide in-person assistance consistently, day or evening, even if they
live across the street and are available by phone.)

Patient lives with her daughter who works during the day but is home every evening and sleeps there
every night. A paid aide comes in 3 days a week to assist with ADLs. Daughter has back problems that
prevent her from lifting patient, but she assists the patient with dressing every morning and takes the
patient to doctor’s appointments. Response = 08 (Patient lives in a home with others who are available
every night to offer in-person assistance. Even if the daughter can’t meet all of patient’s needs, she is
available all night.)

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: D-2

Chapter 3

Section D – Living Arrangements

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1100)
-

Patient lives with her husband who has significant cognitive and functional impairments, is wheelchair
bound, and is unable to provide the patient with any assistance. A member of the church comes by one
evening a week and brings groceries. Response = 09 (Patient lives in a home with another person who
is there 24 hours but is unavailable to provide assistance. Caregiver from church provides occasional
assistance.)

Patient lives alone in an apartment that is part of an ALF. The apartment does not have a call-bell but
her contract with the ALF includes having a home health aide assist her with ADLs 2 hours every
morning. Her son also comes over occasionally to assist with bills, groceries, and errands. Response =
14 (Patient is living in a congregate setting; one caregiver is available to assist for some part of every
day on a regular basis, but not all day, another caregiver offers occasional assistance.)

DATA SOURCES / RESOURCES
•
•
•
•
•

Patient/caregiver interview.
Physical assessment.
Observation.
Referral information.
Assisted Living Facility agreement or contract.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: D-3

Chapter 3

Section E – Sensory Status

OASIS ITEM
(M1200) Vision (with corrective lenses if the patient usually wears them):

Enter Code

Normal vision: sees adequately in most situations; can see medication labels, newsprint.

Partially impaired: cannot see medication labels or newsprint, but can see obstacles in
path, and the surrounding layout; can count fingers at arm's length.

Severely impaired: cannot locate objects without hearing or touching them, or patient
nonresponsive.

ITEM INTENT
•

Identifies the patient’s ability to see and visually manage (function) safely within his/her environment,
wearing corrective lenses if these are usually worn.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Follow-up.
Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Be sensitive to requests to read, as patient may not be able to read though vision is adequate.

•

“Nonresponsive” means that the patient is not able to respond.

•

As specified within the OASIS question, only assess functional vision with corrective lenses if the patient
usually wears corrective lenses.

•

A magnifying glass (as might be used to read newsprint) is not an example of corrective lenses.

•

Reading glasses (including "grocery store" reading glasses) are considered to be corrective lenses.

•

Physical deficits or impairments that limit the patient’s ability to use their existing vision in a functional way
should be considered. For example, if a physical deficit/impairment (like limited neck range of motion)
prevents a patient from seeing objects in his path, affecting safe function in his environment, M1200 should
be Response 2 – Severely impaired.

•

Assessment strategies: In the health history interview, ask the patient about vision problems (for example,
cataracts) and whether or not the patient uses glasses. Observe ability to locate signature line on consent
form, to count fingers at arm’s length and ability to differentiate between medications, especially if
medications are self-administered.

DATA SOURCES / RESOURCES
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information (for example, history and physical).

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: E-1

Chapter 3

Section E – Sensory Status

OASIS ITEM
(M1210) Ability to Hear (with hearing aid or hearing appliance if normally used):
Enter Code

0
1
2
UK

ITEM INTENT
•

Identifies the patient’s ability to hear spoken language and other sounds (for example, alarms).

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Hearing is evaluated with the patient wearing hearing aids or devices if he/she usually uses them.

•

If the patient is not able to respond or if the patient’s condition makes it impossible to assess hearing (for
example, severe dementia, schizophrenia, unconscious).

•

If evaluating ability to hear with hearing aids, be sure that the devices are in place, turned on, and that the
hearing aids are working (for example, batteries are functional).

DATA SOURCES / RESOURCES
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information (for example, history and physical).

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: E-1

Chapter 3

Section E – Sensory Status

OASIS ITEM
(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):

Enter Code

0
1

Understands: clear comprehension without cues or repetitions.
Usually Understands: understands most conversations, but misses some part/intent of
message. Requires cues at times to understand.
Sometimes Understands: understands only basic conversations or simple, direct phrases.
Frequently requires cues to understand.
Rarely/Never Understands.

Unable to assess understanding.

ITEM INTENT
•

Identifies the patient’s functional ability to comprehend spoken words and instructions in the patient’s
primary language. Both hearing and cognitive abilities may impact a patient's ability to understand verbal
content.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•
•
•

Enter “UK” if the patient is not able to respond or if it is otherwise impossible to assess understanding of
spoken words.
For patients whose primary language differs from the clinician’s, an interpreter may be necessary.
If a patient can comprehend lip reading, they have the ability to understand verbal content, even if they are
deaf.

DATA SOURCES / RESOURCES
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information (for example, history and physical).
Interpreter.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: E-2

Chapter 3

Section E – Sensory Status

OASIS ITEM
(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):
0
Enter Code

3
4
5

Expresses complex ideas, feelings, and needs clearly, completely, and easily in all
situations with no observable impairment.
Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional
errors in word choice, grammar or speech intelligibility; needs minimal prompting or
assistance).
Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance,
errors in word choice, organization or speech intelligibility). Speaks in phrases or short
sentences.
Has severe difficulty expressing basic ideas or needs and requires maximal assistance or
guessing by listener. Speech limited to single words or short phrases.
Unable to express basic needs even with maximal prompting or assistance but is not
comatose or unresponsive (for example, speech is nonsensical or unintelligible).
Patient nonresponsive or unable to speak.

ITEM INTENT
•

Identifies the patient’s physical and cognitive ability to communicate with words in the patient’s primary
language. The item does not address communicating in sign language, in writing, or by any nonverbal
means.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Augmented speech (for example, a trained esophageal speaker, use of an electrolarynx) is considered
verbal expression of language.

•

Presence of a tracheostomy requires further evaluation of the patient’s ability to speak. Can the trach be
covered to allow speech? If so, to what extent can the patient express him/herself?

•

Enter Response 5 for a patient who communicates entirely nonverbally (for example, by sign language or
writing) or is unable to speak.

•

“Nonresponsive” means that the patient is not able to respond.

DATA SOURCES / RESOURCES
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information (for example, history and physical).
Interpreter.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: E-3

Chapter 3

Section E – Sensory Status

OASIS ITEM
(M1240) Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool
(appropriate to the patient’s ability to communicate the severity of pain)?
Enter Code

0
1
2

No standardized, validated assessment conducted
Yes, and it does not indicate severe pain
Yes, and it indicates severe pain

ITEM INTENT
•

Identifies if a standardized, validated pain assessment is conducted and whether a clinically significant level
of pain is present, as determined by the assessment tool used. This item is used to calculate process
measures to capture the agency’s use of best practices following the completion of the comprehensive
assessment. The best practices stated in the item are not necessarily required in the Conditions of
Participation.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of Care.
Resumption of Care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

A standardized, validated tool is one that 1) has been scientifically tested on a population with
characteristics similar to that of the patient being assessed (for example, community-dwelling elderly,
noninstitutionalized adults with disabilities, etc.); and 2) includes a standard response scale (for example, a
scale where patients rate pain from 0-10). The standardized, validated tool must be appropriately
administered as indicated in the instructions and must be relevant for the patient's ability to respond. Severe
pain is defined according to the scoring parameters specified for the tool being used. CMS does not endorse
a specific tool.

•

If the standardized, validated tool does not define levels of "severe" pain, then the agency or care provider
should use the level(s) of pain identified in the tool that best reflect the concept of "severe."

•

Enter Response 0 if such a tool was not used to assess pain.

•

When a standardized, validated assessment has been conducted, enter Response 1 or Response 2 based
on the severity level that corresponds to the patient’s pain level, per the tool’s scoring instructions. Enter
Response 2 when the patient’s reported level of pain equates to a severe pain rating on the tool used.

•

In order to enter Response 1 or 2, the pain assessment must be conducted by the clinician responsible for
completing the comprehensive assessment during the allowed time frame (that is, within five days of SOC
and within two days of discharge from the inpatient facility at ROC).

DATA SOURCES / RESOURCES
•
•
•
•

Patient/caregiver interview.
Physical assessment.
Clinical record.
A variety of standardized pain assessment approaches have been tested and are available for provider use
in patient assessment. These approaches include visual analog scales, the Wong-Baker FACES Pain
Rating Scale, numerical scales, and the Memorial Pain Assessment Card. Links to these and other
assessment tools can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: E-4

Chapter 3

Section E – Sensory Status

OASIS ITEM
(M1242) Frequency of Pain Interfering with patient's activity or movement:
Enter Code

0
1
2
3
4

Patient has no pain
Patient has pain that does not interfere with activity or movement
Less often than daily
Daily, but not constantly
All of the time

ITEM INTENT
•

Identifies frequency with which pain interferes with patient’s activities, with treatments if prescribed.

TIME POINTS ITEM(S) COMPLETED
•
•
•
•

Start of care.
Resumption of care.
Follow-up.
Discharge from agency – not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Responses are arranged in order of least to most interference with activity or movement.

•

Pain interferes with activity when the pain results in the activity being performed less often than otherwise
desired, requires the patient to have additional assistance in performing the activity, or causes the activity to
take longer to complete. Include all activities (for example, sleeping, recreational activities, watching
television), not just ADLs.

•

When reviewing patient’s medications, the presence of medication for pain or joint disease provides an
opportunity to explore the presence of pain, when the pain is the most severe, activities with which the pain
interferes, and the frequency of this interference with activity or movement. Be careful not to overlook
seemingly unimportant activities (for example, the patient says she/he sits in the chair all day and puts off
going to the bathroom, because it hurts so much to get up from the chair or to walk). Evaluating the patient’s
ability to perform ADLs and IADLs can provide additional information about such pain. Assessing pain in a
nonverbal patient involves observation of facial expression (for example, frowning, gritting teeth), monitoring
heart rate, respiratory rate, perspiration, pallor, pupil size, irritability, or use of visual pain scales (for
example, FACES). The patient’s treatment for pain (whether pharmacologic or nonpharmacologic) must be
considered when evaluating whether pain interferes with activity or movement. Pain that is well controlled
with treatment may not interfere with activity or movement at all.

DATA SOURCES / RESOURCES
•
•
•
•
•

Patient/caregiver interview.
Observation of nonverbal indications of pain.
Physical assessment.
Referral information (for example, history and physical).
Standardized, validated pain assessment tools. Links to these tools can be found in Chapter 5 of this
manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: E-5

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?
Enter Code

No assessment conducted [Go to M1306 ]

ITEM INTENT
•

Identifies whether the home health agency care providers assessed the patient’s risk of developing pressure
ulcers. CMS does not require the use of standardized, validated tools, nor does it endorse one particular
tool.

•

This item is used to calculate process measures to capture the agency’s use of best practices following the
completion of the comprehensive assessment. The best practices stated in the item are not necessarily
required in the Conditions of Participation.

TIME POINTS ITEM(S) COMPLETED
•

Start of Care.

•

Resumption of Care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter Response 0, if the patient was not assessed for pressure ulcer risk.

•

In order to enter Response 1 or 2, the pressure ulcer risk assessment must be conducted by the clinician
responsible for completing the comprehensive assessment during the time frame specified by CMS for
completion of the assessment.

•

Enter Response 1, if the patient's risk for pressure ulcer development was clinically assessed, but no formal
pressure ulcer screening tool was used.

•

Enter Response 2, only if the patient was screened using a standardized, validated screening tool. This is
defined as a tool that 1) has been scientifically tested on a population with characteristics similar to that of
the patient being assessed (for example, community-dwelling elderly, noninstitutionalized adults with
disabilities); and 2) includes a standard response scale. The tool must be appropriately administered per the
tool’s instructions.

•

If both a standardized, validated screening tool and an evaluation of clinical factors are utilized, enter
Response 2.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Referral documentation.

•

Physician.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-1

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1302) Does this patient have a Risk of Developing Pressure Ulcers?
Enter Code
0
1

No
Yes

ITEM INTENT
•

Identifies if the patient is at risk for developing pressure ulcers. This item should be skipped if Response 0
was entered for M1300 (no pressure ulcer risk assessment).

TIME POINTS ITEM(S) COMPLETED
•

Start of Care.

•

Resumption of Care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

If pressure ulcer risk was assessed using a standardized, validated screening tool, use the scoring
parameters specified for the tool to identify if a patient is at risk for developing pressure ulcers. If the
evaluation was based on clinical factors (without a validated standardized screening tool), then the agency
or care provider may define what constitutes risk.

•

A validated standardized screening tool is a tool that 1) has been scientifically tested and evaluated with a
population with characteristics similar to the patient who is being evaluated and shown to be effective in
identifying people at risk for developing pressure ulcers; and 2) includes a standard response scale. The
standardized, validated tool must be appropriately administered per the tool’s instructions.

•

If both a standardized, validated screening tool and an evaluation of clinical factors are utilized, enter
Response 1 (Yes), if either assessment is positive for risk.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Referral documentation.

•

Physician.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-2

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as
Unstageable? (Excludes Stage 1 pressure ulcers and healed Stage 2 pressure ulcers)
Enter Code
0

No [Go to M1322 ]

Yes

ITEM INTENT
•

Identifies the presence or absence of Unhealed Stage 2 or higher or Unstageable pressure ulcers only.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Home health agencies may adopt the NPUAP guidelines in their clinical practice and documentation.
However, since CMS has adapted the NPUAP guidelines for OASIS purposes, the definitions do not
perfectly align with each stage as described by NPUAP. When discrepancies exist between the NPUAP
definitions and the OASIS scoring instructions provided in the OASIS Guidance Manual and CMS Q&As,
providers should rely on the CMS OASIS instructions.

•

Pressure ulcers are defined as localized injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or friction.

•

If pressure is not the primary cause of the lesion, do not report the wound as a pressure ulcer.

•

Terminology referring to “healed” vs. “unhealed” ulcers can refer to whether the ulcer is “closed” vs. “open”.
Recognize, however, that Stage 1 pressure ulcers and Suspected Deep Tissue Injury (sDTI), although
closed (intact skin), would not be considered healed. Unstageable pressure ulcers, whether covered with a
non-removable dressing or eschar or slough, would not be considered healed.

•

Enter Response 0 (No), if the only pressure ulcer(s) is/are Stage 1 OR healed pressure ulcers (of any
previous stage) AND the patient has no other pressure ulcers.

•

Enter Response 1 (Yes), if the patient has an unhealed Stage 2, Stage 3, OR Stage 4 pressure ulcer OR if
the patient has an Unstageable ulcer, defined as:
-

Pressure ulcers that are known to be present but that are unobservable due to a dressing/device, such
as a cast, that cannot be removed to assess the skin underneath. “Known” refers to when
documentation is available that states a pressure ulcer exists under the non-removable dressing/device.

Pressure ulcers that are present on clinical assessment, but that cannot be staged because no bone,
muscle, tendon, or joint capsule (Stage 4 structures) are visible, and some degree of necrotic tissue
(eschar or slough) is present that the clinician believes may be obscuring the visualization of Stage 4
structures.

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Chapter 3: F-3

Chapter 3

Section F – Integumentary

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1306)
-

Suspected deep tissue injury in evolution, which is defined as a purple or maroon localized area of
discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or
shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as
compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin
tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and
become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with
optimal treatment.

•

Stage 2 (partial thickness) pressure ulcers heal through the process of regeneration of the epidermis across
a wound surface, known as “re-epithelialization.”

•

Stage 3 and 4 (full thickness) pressure ulcers heal through a process of granulation (filling of the wound with
connective/scar tissue), contraction (wound margins contract and pull together), and re-epithelialization
(covers with epithelial tissue from within wound bed and/or from wound margins). Once the pressure ulcer
has fully granulated and the wound surface is completely covered with new epithelial tissue, the wound is
considered closed, and will continue to remodel and increase in tensile strength. For the purposes of scoring
the OASIS, the wound is considered healed at this point, and should no longer be reported as an unhealed
pressure ulcer.

•

Agencies should be aware that the patient is at higher risk of having the site of a closed pressure ulcer open
up due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile
strength of the skin overlying a closed full thickness pressure ulcer is only 80% of normal skin tensile
strength. Agencies should pay careful attention that preventative measures are put into place that will
mitigate the re-opening of a closed ulcer.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Referral documentation.

•

Physician.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-4

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1307) The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2 Pressure
Ulcers)
Enter Code

1
2

Was present at the most recent SOC/ROC assessment
Developed since the most recent SOC/ROC assessment. Record date pressure ulcer first
identified:
month
day
year
No Stage 2 pressure ulcers are present at discharge

ITEM INTENT
•

The intent of this item is to a) identify the oldest Stage 2 pressure ulcer that is present at the time of
discharge and is not fully epithelialized (healed), b) assess the length of time this ulcer remained unhealed
while the patient received care from the home health agency and c) identify patients who develop Stage 2
pressure ulcers while under the care of the agency.

TIME POINTS ITEM(S) COMPLETED
•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Do not reverse stage pressure ulcers as a way to document healing as it does not accurately characterize
what is physiologically occurring as the ulcer heals. For example, over time, even though a Stage 4 pressure
ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost
(muscle, fat, dermis) will never be replaced with the same type of tissue. Clinical standards require that this
ulcer continue to be documented as a Stage 4 pressure ulcer until it has healed.

•

Stage 2 (partial thickness) pressure ulcers heal through the process of regeneration of the epidermis across
a wound surface called, “re-epithelialization.”

•

Enter Response 1 only if the oldest Stage 2 pressure ulcer that is present at discharge was already present
as a Stage 2 pressure ulcer when first assessed at the SOC/ROC.

•

Enter Response 2 if the oldest Stage 2 pressure ulcer that is present at discharge was NOT a Stage 2
pressure ulcer at the most recent SOC/ROC.

•

If Response 2 is entered, specify the date the Stage 2 pressure ulcer was first identified. Use two digits to
indicate the month (for example, May is 05), single-digit dates should begin with 0, and use four digits to
indicate the year (for example, May 4, 2017 would be 05/04/2017).

•

If no pressure ulcer existed at the SOC, then a Stage 1 pressure ulcer developed, which progressed to a
Stage 2 by discharge, enter Response 2, and specify the date that the pressure ulcer was first identified as a
Stage 2 ulcer.

•

Enter “NA” if the patient has no Stage 2 pressure ulcers at the time of discharge, or all previous Stage 2
pressure ulcers have healed.

•

An ulcer that is suspected of being a Stage 2, but is Unstageable due to non-removable dressing/device at
the time of discharge, should not be identified as the “oldest Stage 2 pressure ulcer” (See M1311 for
definition of Unstageable due to non-removable dressing/device).

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: F-5

Chapter 3

Section F – Integumentary

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical assessment.

•

Clinical Record.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-6

Chapter 3

Section F – Integumentary

OASIS ITEM
Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound
bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
[If 0 at FU/DC Go to M1311B1]
A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or
muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Number of Stage 3 pressure ulcers
[If 0 at FU/DC Go to M1311C1]
B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar
may be present on some parts of the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers
[If 0 at FU/DC Go to M1311D1]
C2. Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
D1. Unstageable: Non-removable dressing: Known but not stageable due to non-removable
dressing/device
Number of unstageable pressure ulcers due to non-removable dressing/device
[If 0 at FU/DC Go to M1311E1]
D2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed
by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
[If 0 at FU/DC Go to M1311F1]
E2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
F1. Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution
Number of unstageable pressure ulcers with suspected deep tissue injury in evolution
[ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]
F2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

[Omit “A2, B2, C2, D2, E2 and F2” on SOC/ROC ]

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: F-7

Chapter 3

Section F – Integumentary

ITEM INTENT
•

Identifies the number of Stage 2 or higher pressure ulcers at each stage present at the time of assessment.
Stage 1 pressure ulcers and ulcers that have healed are not reported in this item.

TIME POINTS ITEMS COMPLETED
•

Start of Care.

•

Resumption of Care.

•

Follow-up.

•

Discharge from agency—not to inpatient facility.

RESPONSE SPECIFIC INSTRUCTIONS
•

Terminology referring to “healed” vs. “unhealed” ulcers refers to whether the ulcer is “closed” vs. “open”.
Recognize, however, that Stage 1 pressure ulcers and Suspected Deep Tissue Injury (sDTI), although
closed (intact skin), would not be considered healed. Unstageable pressure ulcers, whether covered with a
non-removable dressing or eschar or slough, would not be considered healed.

Determining “Present on Admission”
•

For the OASIS, “Present on Admission” and “Present at SOC/ROC” have equivalent meanings.

•

For each pressure ulcer, determine whether the pressure ulcer was present at the time of the most recent
SOC/ROC, and did not form during this home health quality episode.

•

If the pressure ulcer was unstageable at SOC/ROC, but becomes numerically stageable later, when
completing the Discharge assessment, its “Present on Admission” stage should be considered the stage at
which it first becomes numerically stageable. If it subsequently increases in numerical stage, do not report
the higher stage ulcer as being “present at SOC/ROC” when completing the Discharge assessment.

•

The general standard of practice for patients starting or resuming care is that patient assessments are
completed beginning as close to the actual time of the SOC/ROC as possible. If a pressure ulcer that is
identified on the SOC date increases in numerical stage (worsens) within the assessment time frame, the
initial stage of the pressure ulcer would be reported in M1311 at the SOC.

•

At SOC/ROC, enter a response for the following rows of this item: A1, B1, C1, D1, E1, F1.
-

•

Example: At SOC, in B1, enter the number of Stage 3 pressure ulcers that are currently present. Enter 0
if no Stage 3 pressure ulcers are present at the time of the assessment.

At Follow-Up and Discharge, enter a response for each row of this item: A1, A2, B1, B2, C1, C2, D1, D2, E1,
E2, F1, F2.
-

Example: At Discharge, in A1 enter the number of Stage 2 pressure ulcers that are currently present. If
no Stage 2 pressure ulcers are currently present, enter 0 in A1 and skip A2. If at least one Stage 2
pressure ulcer is reported in A1, enter in A2 the number of these Stage 2 pressure ulcers that were
present at the most recent SOC/ROC.

Stage 2 ulcers
•

Report the number of Stage 2 or higher pressure ulcers that are present on the current day of assessment.

•

Definition: Stage 2 pressure ulcers are characterized by partial thickness loss of dermis presenting as a
shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or
open/ruptured blister.

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Effective 1/1/2017
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Chapter 3: F-8

Chapter 3

Section F – Integumentary

Stage 3 and 4 ulcers
•

Definition: Stage 3 pressure ulcers are characterized by full thickness tissue loss. Subcutaneous fat may be
visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of
tissue loss. May include undermining or tunneling.

•

Definition: Stage 4 pressure ulcers are characterized by full thickness tissue loss with exposed bone, tendon
or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining
and tunneling.

•

If any bone, tendon or muscle or joint capsule (Stage 4 structures) is visible, the pressure ulcer should be
reported as a Stage 4 pressure ulcer, regardless of the presence or absence of slough and/or eschar in the
wound bed.

•

A previously closed Stage 3 or Stage 4 pressure ulcer that is currently open again should be reported at its
worst stage.

•

If the patient has been in an inpatient setting for some time, it is conceivable that the wound has already
started to granulate, thus making it challenging to know the stage of the wound at its worst. The clinician
should make every effort to contact previous providers (including patient’s physician) to determine the stage
of the wound at its worst. An ulcer's stage can worsen, and this item should be answered using the worst
stage if this occurs.

•

A muscle flap, skin advancement flap, or rotational flap (defined as full thickness skin and subcutaneous
tissue partially attached to the body by a narrow strip of tissue so that it retains its blood supply) performed
to surgically replace a pressure ulcer is a surgical wound. It should not be reported as a pressure ulcer on
M1311.

•

A pressure ulcer treated with a skin graft (defined as transplantation of skin to another site) should not be
reported as a pressure ulcer and until the graft edges completely heal, should be reported as a surgical
wound on M1340.

•

A pressure ulcer that has been surgically debrided remains a pressure ulcer and should not be reported as a
surgical wound on M1340.

Unstageable ulcers
•

Definition: Pressure ulcers covered with slough and/or eschar are unstageable. Rationale: The true
anatomic depth of soft tissue damage (and therefore stage) cannot be determined. The pressure ulcer stage
can be determined only when enough slough and/or eschar is removed to expose the anatomic depth of soft
tissue damage.

•

Pressure ulcers that are known to be present but that are Unstageable due to a dressing/device, such as a
cast that cannot be removed to assess the skin underneath, should be reported as D1 (Unstageable).
“Known” refers to when documentation is available that states a pressure ulcer exists under the nonremovable dressing/device. Examples of a non-removable dressing/device include a dressing that is not to
be removed per physician’s order (such as those used in negative-pressure wound therapy [NPWT], an
orthopedic device, or a cast.

•

Response F1 refers to a suspected deep tissue injury in evolution, which is defined as a purple or maroon
localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from
pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or
cooler as compared to adjacent tissue. The number of pressure ulcers meeting this definition should be
counted to determine the response to F1. Deep tissue injury may be difficult to detect in individuals with dark
skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and
become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with
optimal treatment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-9

Chapter 3

Section F – Integumentary

DATA SOURCES/RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Clinical record.

•

Referral documentation.

•

Physician.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-10

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1313) Worsening in Pressure Ulcer Status since SOC/ROC:
Instructions for a-c: Indicate the number of current pressure ulcers that were not present or were at a lesser
stage at the most recent SOC/ROC. If no current pressure ulcer at a given stage, enter 0.
Enter Number
a. Stage 2
b. Stage 3
c. Stage 4
Instructions for e: For pressure ulcers that are Unstageable due to slough/eschar, report the number that are new
or were at a Stage 1 or 2 at the most recent SOC/ROC.
Enter Number
d. Unstageable – Known or likely but Unstageable due to non-removable dressing.
e. Unstageable – Known or likely but Unstageable due to coverage of wound bed by
slough and/or eschar.
f.

Unstageable – Suspected deep tissue injury in evolution.

ITEM INTENT
•

This item documents the number of pressure ulcers present at Discharge that were not present (are new) or
have “worsened” (increased in numerical stage) since the most recent Start or Resumption of Care
assessment.

TIME POINTS ITEM(S) COMPLETED
•

Discharge.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Review the history of each current pressure ulcer. Specifically, compare the current stage at Discharge to
past stages to determine whether any pressure ulcer currently present is new or at an increased numerical
stage (worsened) when compared to the most recent SOC/ROC. Then, for each current stage, count the
number of current pressure ulcers that are new or have increased in numerical stage since the last
SOC/ROC was completed. This allows a more accurate assessment than simply comparing total counts at
Discharge and most recent SOC/ROC.

•

If a pressure ulcer increased in numerical stage from SOC (or ROC) to Discharge, it is considered worsened
and would be included in counts of worsened pressure ulcers on M1313 at Discharge.

•

For definitions of pressure ulcer stages, see M1311.

•

For pressure ulcers that are currently Stage 2, 3 or 4 (rows a, b and c):
-

Mark a response for each row of this item: a, b, and c. If at Discharge there are currently NO ulcers at a
given stage, enter “0” for that stage/row.

Report the number of current pressure ulcers at each stage that are new or have worsened since the
most recent SOC/ROC assessment.

•

For pressure ulcers that are currently Stage 2, 3 or 4, “worsening” refers to a pressure ulcer that has
progressed to a deeper level of tissue damage and is therefore staged at a higher number using a numerical
scale of 1-4 at the time of discharge in comparison to the most recent SOC/ROC assessment.

•

For row a: Stage 2. Enter the number of current pressure ulcers at Discharge, whose deepest anatomical
stage is Stage 2, that were not present or were a Stage 1 at most recent SOC/ROC. Enter “0” if there are no
current Stage 2 pressure ulcers or no Stage 2 pressure ulcers that are new or worsened since most recent
SOC/ROC.

OASIS-C1/ICD-10 Guidance Manual
October 2015
Centers for Medicare & Medicaid Services

Chapter 3: F-11

Chapter 3

Section F – Integumentary

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1313)
•

For row b: Stage 3. Enter the number of current pressure ulcers at Discharge whose deepest anatomical
stage is Stage 3, that were not present or were a Stage 1 or 2 at the most recent SOC/ROC. Enter “0” if
there are no current Stage 3 pressure ulcers or no Stage 3 pressure ulcers that are new or worsened since
most recent SOC/ROC.

•

For row c: Stage 4. Enter the number of current pressure ulcers at Discharge whose deepest anatomical
stage is Stage 4, that were not present or were at Stage 1, 2, or 3 at the most recent SOC/ROC. Enter “0” if
there are no current Stage 4 pressure ulcers or no Stage 4 pressure ulcers that are new or worsened since
most recent SOC/ROC.

•

For row d: Unstageable due to non-removable dressing. Enter the number of current pressure ulcers at
Discharge that are unstageable due to a non-removable dressing, that were not present at the most recent
SOC/ROC.

•

For row e: Unstageable due to slough and/or eschar. Enter the number of current pressure ulcers at
Discharge that are unstageable due to slough and/or eschar, that were not present or were a Stage 1 or 2 at
the most recent SOC/ROC. Pressure ulcers that are currently Unstageable due to presence of slough or
eschar and were Stage 3 or 4 at the most recent SOC/ROC are not considered worsened.

•

For row f: Unstageable–Suspected Deep Tissue Injury (sDTI). Enter the number of sDTIs present at
Discharge that were not present or were a Stage 1 or 2 pressure ulcer at the most recent SOC/ROC.

•

See the following page for a reporting algorithm.

•

Once the pressure ulcer has fully granulated and the wound surface is completely covered with new
epithelial tissue, the wound is considered healed, and should no longer be reported as an unhealed
pressure ulcer.

•

A previously closed Stage 3 or Stage 4 pressure ulcer that breaks down again should be staged at its worst
stage.

•

If the pressure ulcer was unstageable for any reason at the most recent SOC/ROC, do not consider it new or
worsened if at some point between SOC/ROC and Discharge it became stageable and remained at that
same stage at Discharge.

•

If the pressure ulcer was unstageable at SOC/ROC, then was stageable on a routine visit and/or Follow-Up
assessment, and by Discharge the pressure ulcer had increased in numerical stage since the routine visit
and/or Follow-Up assessment, is should be considered worsened at Discharge.

•

If a previously stageable pressure ulcer becomes unstageable, then was debrided sufficiently to be restaged
by Discharge, compare its stage before and after it was deemed unstageable. If the pressure ulcer’s stage
has increased in numerical staging, report this as worsened.

•

Pressure ulcers that are Unstageable at Discharge due to a dressing/device, such as a cast that cannot be
removed to assess the skin underneath cannot be reported as new or worsened unless no pressure ulcer
existed at that site at the most recent SOC/ROC.

•

A dash ( –) value is a valid response for this item. A dash (–) value indicates that no information is available,
and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred,
discharged or dies before assessment of the item could be completed. CMS expects dash use to be a rare
occurrence.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-12

Chapter 3

Section F – Integumentary

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Clinical record.

•

Referral documentation.

•

Physician.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-13

Chapter 3

Section F – Integumentary

OASIS ITEM
Reporting algorithm for M1313
CURRENT STAGE
at Discharge

Look back to
most recent
SOC/ROC

PRIOR STAGE
at most recent SOC/ROC



Not present
Stage 1
Covered with a non-removable
dressing/device, then documented
as a Stage 1 at any home visit or
Follow-Up assessment(s)
Stage 2




Stage 3
Stage 4



Covered with a non-removable
dressing/device and remains
Unstageable until assessed as a
Stage 2 at Discharge



Not present



Stage 1




Stage 2
Unstageable with documented
Stage 1 and/or 2 at any home visit
or Follow-Up assessment(s)



Stage 3



Stage 4

NA (Stage 4 could
not become a
Stage 3)



Unstageable until assessed as a
Stage 3 at Discharge



Not present



Stage 1



Stage 2




Stage 3
Unstageable with documented
Stage 1, 2, and/or 3 at any home
visit or Follow-Up assessment(s)



Stage 4



Unstageable until assessed as a
Stage 4 at Discharge



Not present







Stage 1
Stage 2
Stage 3
Stage 4
Unstageable





a. Stage 2
at Discharge

b. Stage 3
at Discharge

c. Stage 4
at Discharge

d. Unstageable
due to nonremovable
dressing
at Discharge

If same
pressure ulcer
at most
recent
SOC/ROC
was:

If same
pressure
ulcer at most
recent
SOC/ROC
was:

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

REPORT AS
NEW OR
WORSENED?

YES
NO
NA (Stage 3 or 4
could not become
a Stage 2)
NO

YES

YES
NO

Chapter 3: F-14

Chapter 3
CURRENT STAGE
at Discharge

e. Unstageable
due to slough
and/or eschar
at Discharge

f. Unstageable –
suspected deep
tissue injury
at Discharge

Section F – Integumentary
Look back to
most recent
SOC/ROC

If same
pressure ulcer
at most
recent
SOC/ROC
was:

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

PRIOR STAGE
at most recent SOC/ROC

REPORT AS
NEW OR
WORSENED?



Not present



Stage 1



Stage 2

YES




Stage 3
Stage 4



Unstageable



Not present



Stage 1






Stage 2
Stage 3
Stage 4
Unstageable due to slough and/or
eschar
Unstageable – Suspected DTI or due
to a non-removable dressing/device



YES
NA (Full thickness
pressure ulcer
could not become
a sDTI)
NO

Chapter 3: F-15

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1320) Status of Most Problematic Pressure Ulcer that is Observable: (Excludes pressure ulcer that cannot
be observed due to a non-removable dressing/device)
Enter Code

0
1
2
3
NA

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing
No observable pressure ulcer

ITEM INTENT
•

Identifies the degree of closure visible in the most problematic observable pressure ulcer, Stage 2 or higher.
Please note, Stage 1 pressure ulcers and ulcers that have healed are not considered for this item.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

•

Determine which pressure ulcer(s) are observable:

•

Includes all Stage 2 or higher pressure ulcers that are not covered with a non-removable dressing or
device, even if Unstageable

When determining the healing status of a pressure ulcer for answering M1320, the presence of necrotic
tissue does NOT make the pressure ulcer “NA – No observable pressure ulcer.”

Determine which observable pressure ulcer is most problematic:
-

“Most problematic” may be the largest, the most advanced stage, the most difficult to access for
treatment, the most difficult to relieve pressure, etc., depending on the specific situation.

If the patient has only one observable pressure ulcer, that ulcer is the most problematic.

Utilize the Wound Ostomy and Continence Nurses (WOCN) Society’s Guidance on OASIS to determine
status of the most problematic observable pressure ulcer:
-

Response 0 – Newly Epithelialized: wound bed completely covered with new epithelium, no exudate, no
avascular tissue (eschar and/or slough); no signs or symptoms of infection.

Response 1 – Fully Granulating: wound bed filled with granulation tissue to the level of the surrounding
skin or new epithelium; no dead space, no avascular tissue (eschar and/or slough); no signs or
symptoms of infection; wound edges are open

Response 2 – Early/Partial Granulation: wound with ≥25% of the wound bed covered with granulation
tissue; <25% of the wound bed covered with avascular tissue (eschar and/or slough); may have dead
space; no signs or symptoms of infection; wound edges open.

OASIS-C1/ICD-10 Guidance Manual
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Chapter 3: F-16

Chapter 3

Section F – Integumentary

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1320)
-

Response 3 – Not Healing: wound with ≥25% avascular tissue (eschar and/or slough) OR
signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound
edges OR persistent failure to improve despite appropriate comprehensive wound management.

•

Because Stage 2 ulcers do not granulate and newly epithelialized Stage 2 ulcers are not counted, the only
appropriate response for a Stage 2 ulcer is 3 – Not Healing.

•

Since a suspected Deep Tissue Injury in evolution does not granulate and would not be covered with new
epithelial tissue, the only appropriate response for a suspected Deep Tissue Injury is 3 – Not Healing.

•

A pressure ulcer with necrotic tissue (eschar/slough) obscuring the wound base cannot be staged, but its
healing status is either Response 2 – Early/Partial Granulation if necrotic or avascular tissue covers <25% of
the wound bed, or Response 3 - Not Healing, if the wound has ≥25% necrotic or avascular tissue.

DATA SOURCES / RESOURCES
•

Observation.

•

Physical Assessment.

•

Referral documentation.

•

Review of health history.

•

Physician.

•

See references/resources (including a link to the Wound Ostomy and Continence Nurses (WOCN) Society’s
Guidance on OASIS) in Chapter 5 of the OASIS Guidance Manual.

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Chapter 3: F-17

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1322) Current Number of Stage 1 Pressure Ulcers: Intact skin with non-blanchable redness of a localized
area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as
compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones
only it may appear with persistent blue or purple hues.
Enter Code

0
1
2
3
4 or more

ITEM INTENT
•

Identifies the presence and number of Stage 1 pressure ulcers.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

NPUAP defines a Stage 1 ulcer as follows: “Intact skin with non-blanchable redness of a localized area
usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ
from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent
tissue. Stage 1 ulcers may be difficult to detect in individuals with dark skin tones and may indicate "at risk"
persons (a heralding sign of risk).”

•

Recognize that although Stage 1 pressure ulcers are closed (intact skin), they would not be considered
healed.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

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Chapter 3: F-18

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1324) Stage of Most Problematic Unhealed Pressure Ulcer that is Stageable: (Excludes pressure ulcer
that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or
eschar, or suspected deep tissue injury.)
Enter Code

1
2
3
4
NA

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers or no stageable pressure ulcers

ITEM INTENT
•

Identifies the stage of the most problematic stageable pressure ulcer.

•

Please note; ulcers that have healed are not considered for this item.

TIME POINTS ITEM(S) COMPLETED
•

Start of Care.

•

Resumption of Care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

•

Determine which pressure ulcer(s) are stageable or Unstageable. A pressure ulcer is considered
Unstageable if:

•

it is covered with a non-removable dressing/device, such as a cast, that cannot be removed.

it is a suspected deep tissue injury in evolution, or

the wound bed is obscured by some degree of necrotic tissue AND no bone, muscle, tendon, or joint
capsule (Stage 4 structures) are visible. Note that if a Stage 4 structure is visible, the pressure ulcer is
reportable as a Stage 4 even if slough or eschar is present.

Determine which stageable pressure ulcer is the most problematic.
-

“Most problematic” may be the largest, the most advanced stage, the most difficult to access for
treatment, the most difficult to relieve pressure, etc., depending on the specific situation.

If the patient has only one stageable pressure ulcer, then that ulcer is the most problematic.

Enter the response that most accurately describes the stage of the most problematic stageable pressure
ulcer using the definitions of Stage in M1311 that were derived from the National Pressure Ulcer Advisory
Panel (NPUAP) staging system.
-

Enter “NA” if the patient has NO pressure ulcers or only has pressure ulcers that are Unstageable as
defined above.

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Chapter 3: F-19

Chapter 3

Section F – Integumentary

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1324)
-

Do not reverse stage pressure ulcers as a way to document healing as it does not accurately
characterize what is physiologically occurring as the ulcer heals. For example, over time, even though a
Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the
tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Clinical
standards require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has
healed.

If a pressure ulcer is Stage 4 at SOC and is granulating at the Follow-up Assessment, the ulcer remains
a Stage 4 ulcer.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical assessment.

•

Referral documentation.

•

Review of health history.

•

Physician.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: F-20

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1330) Does this patient have a Stasis Ulcer?
Enter Code

No [Go to M1340 ]

1
2

Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY

Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to nonremovable dressing/device) [Go to M1340 ]

ITEM INTENT
•

Identifies patients with ulcers caused by inadequate venous circulation in the area affected (usually lower
legs). This lesion is often associated with stasis dermatitis.

•

Stasis ulcers DO NOT include arterial lesions or arterial ulcers.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

A response of “Yes” identifies the presence of an ulcer caused by inadequate venous circulation in the area
affected (usually lower legs).

•

It is important to differentiate stasis ulcers from other types of skin lesions, and only report stasis ulcers in
this item.

•

Once a stasis ulcer has completely epithelialized, it is considered healed and should not be reported as a
current stasis ulcer.

•

Enter Response 1 if the patient has both an observable stasis ulcer AND a reported stasis ulcer that cannot
be observed because of a dressing or device, such as a cast or Unna boot) that cannot be removed.
Information may be obtained from the physician or patient/caregiver regarding the presence of a stasis ulcer
underneath the cast or dressing.

•

Enter Response 3 ONLY if the patient has a reported stasis ulcer that cannot be observed because of a
dressing or device, such as a cast or Unna boot that cannot be removed, and has no observable stasis
ulcers. Information may be obtained from the physician or patient/caregiver regarding the presence of a
stasis ulcer underneath the cast or dressing.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Physician.

•

Physician’s orders.

•

Referral information.

•

Review of health history.

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Chapter 3: F-21

Chapter 3

Section F – Integumentary

DATA SOURCES / RESOURCES (cont’d for OASIS ITEM M1324)
•

Observation.

•

Physical assessment.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

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Effective 1/1/2017
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Chapter 3: F-22

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1332) Current Number of Stasis Ulcer(s) that are Observable:
Enter Code

1
2
3
4

One
Two
Three
Four or more

ITEM INTENT
•

Identifies the number of visible (observable) stasis ulcers.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

All stasis ulcers except those that are covered by a non-removable dressing/device, such as a cast or Unna
boot, are considered observable.

DATA SOURCES / RESOURCES
•

Observation.

•

Physical Assessment.

•

Review of health history.

•

Physician.

•

Referral information.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

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Effective 1/1/2017
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Chapter 3: F-23

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1334) Status of Most Problematic Stasis Ulcer that is Observable:
Enter Code

1
2
3

Fully granulating
Early/partial granulation
Not healing

ITEM INTENT
•

Identifies the degree of healing present in the most problematic, observable stasis ulcer. The “most
problematic” ulcer may be the largest, the most resistant to treatment, an ulcer that is infected, etc.,
depending on the specific situation.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Determine which stasis ulcers are observable. Includes all stasis ulcers that are not covered with a nonremovable dressing/device, such as a cast or Unna boot.

•

Determine which observable stasis ulcer is the most problematic.

•

“Most problematic” may be based on healing status, size, difficulty in accessing for treatment, etc.,
depending on clinical judgment and the specific situation.

If the patient has only one observable stasis ulcer, that ulcer is the most problematic.

Utilize the Wound Ostomy and Continence Nurses (WOCN) Society’s Guidance on OASIS to determine
status of the most problematic observable stasis ulcer:
-

Response 1 – Fully Granulating: Enter Response 1 when a stasis ulcer has a wound bed filled with
granulation tissue to the level of the surrounding skin or new epithelium; no dead space, no avascular
tissue; no signs or symptoms of infection; wound edges are open.

Response 2 – Early/Partial Granulation: Enter Response 2 when ≥ 25% of the wound bed is covered
with granulation tissue; there is minimal avascular tissue (that is, <25% of the wound bed is covered
with avascular tissue); may have dead space; no signs or symptoms of infection; wound edges open.

Response 3 – Not Healing: Enter Response 3 when wound has ≥25% avascular tissue OR
signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound
edges OR persistent failure to improve despite appropriate comprehensive wound management.

Once a stasis ulcer has completely epithelialized and is without signs/symptoms of infection, it is considered
healed and should not be reported as a current stasis ulcer.

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Chapter 3: F-24

Chapter 3

Section F – Integumentary

DATA SOURCES / RESOURCES
•

Observation.

•

Physical Assessment.

•

Review of health history.

•

See references/resources (including a link to the Wound Ostomy and Continence Nurses (WOCN) Society’s
Guidance on OASIS) in Chapter 5 of the OASIS Guidance Manual.

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Effective 1/1/2017
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Chapter 3: F-25

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1340) Does this patient have a Surgical Wound?
Enter Code

No [At SOC/ROC, go to M1350 ; At FU//DC, go to M1400 ]

1
2

Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device
[At SOC/ROC, go to M1350 ; At FU/DC, go to M1400 ]

ITEM INTENT
•

Identifies the presence of a wound resulting from a surgical procedure.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Old surgical wounds that have resulted in scar or keloid formation are not considered current surgical
wounds and should not be included in this item.

•

If the patient has both an observable and an unobservable wound, the best response is 1 – Yes, patient has
at least one observable surgical wound.

•

Enter Response 2 if the only surgical wound(s) is/are not observable. A wound is considered not observable
if it is covered by a dressing/device, such as a cast, which is not to be removed per physician order.

•

For the purpose of this OASIS item, a surgical site closed primarily (with sutures, staples, or a chemical
bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has
been present for approximately 30 days, unless it dehisces or presents signs of infection. After 30 days, it is
generally described as a scar and should not be included in this item. The incision line would be considered
the surgical wound. The staple or suture sites are not considered as surgical wounds for M1340.

•

If a pressure ulcer is surgically closed with a flap or graft it is no longer reported as a pressure ulcer. It
should be reported as a surgical wound until healed. If the flap or graft fails, it should continue to be
considered a surgical wound until healed.

•

A bowel ostomy is excluded as a surgical wound, unless a "take-down" procedure of a previous bowel
ostomy is performed, in which case the surgical take-down produces a surgical wound. A bowel ostomy
being allowed to close on its own is excluded as a surgical wound.

•

All other ostomies are excluded from consideration under this item and should not be counted as surgical
wounds. There are many types of "ostomies," all of which involve a surgically formed opening from outside
the body to an internal organ or cavity. Examples include cystostomy, urostomy, thoracotomy, tracheostomy,
gastrostomy, etc. These may be reported in M1350 if the home health agency is providing intervention
specific to the ostomy.

•

Orthopedic pin sites, central line sites (centrally-inserted venous catheters), stapled or sutured incisions, and
wounds with drains are all considered surgical wounds. Medi-port sites and other implanted infusion devices
or venous access devices are considered surgical wounds.

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Chapter 3: F-26

Chapter 3

Section F – Integumentary

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1340)
•

A PICC line (peripherally-inserted venous catheter), either tunneled or non-tunneled, is NOT a surgical
wound, when it is peripherally inserted.

•

Cataract surgery of the eye, surgery to the mucosal membranes, or a gynecological surgical procedure via a
vaginal approach does not create a surgical wound for the purpose of this item.

•

For additional guidance on questions related to surgical wounds, please see Q & As for M1340.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Referral documentation.

•

Review of health history.

•

Physician.

•

CMS OASIS Q & As can be accessed through the CMS OASIS web page.

•

See references/resources in Chapter 5 of the OASIS Guidance Manual.

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Chapter 3: F-27

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1342) Status of Most Problematic Surgical Wound that is Observable
Enter Code

0
1
2
3

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

ITEM INTENT
•

Identifies the degree of healing present in the most problematic, observable surgical wound.

TIME POINTS ITEM(S) COMPLETED
•

Start of Care.

•

Resumption of Care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

•

Determine which surgical wounds are observable.
-

Includes all surgical wounds (as defined in M1340 guidance) that are not covered with a non-removable
dressing/device, such as a cast.

For the purpose of this OASIS item, a surgical site closed primarily (with sutures, staples, or a chemical
bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has
been present for approximately 30 days, unless it dehisces or presents signs of infection. After 30 days,
it is generally described as a scar and no longer a surgical wound.

Openings in the skin adjacent to the incision line caused by the removal of staples or sutures are not to
be considered as part of the surgical wound for M1342.

Identify the most problematic observable surgical wound.
-

The “most problematic” surgical wound may be the largest, the most resistant to treatment, an infected
surgical wound, etc., depending on clinical judgment and the specific situation.

If the patient has only one observable surgical wound, that wound is the most problematic.

Determine status of the most problematic surgical wound using Wound Ostomy and Continence Nurses
(WOCN) Society’s Guidance on OASIS guidance:
-

The clinician must first assess if the wound is healing entirely by primary intention (well-approximated
with no dehiscence), or if there is a portion healing by secondary intention, (due to dehiscence,
interruption of the incision, or intentional secondary healing).

Surgical wounds healing by primary intention (approximated incisions) do not granulate, therefore the
only appropriate responses would be Response 0 – “Newly epithelialized” or Response 3 – “Not
healing”. If the wound is healing solely by primary intention, observe if the incision line has reepithelialized. Epithelialization is regeneration of the epidermis across a wound surface. (If there is no
interruption in the healing process, this generally takes within a matter of hours to three days postoperatively.) If there is not full epithelial resurfacing such as in the case of a scab adhering to
underlying tissue, the correct response would be "Not healing" for the wound healing exclusively by

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Chapter 3: F-28

Chapter 3

Section F – Integumentary

primary intention. A surgical incision would not automatically be considered 3 – Not healing solely due
to the presence of staples.

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1340)
-

Secondary Intention: If it is determined that there is incisional separation, healing will be by secondary
intention. Surgical incisions healing by secondary intention do granulate, therefore may be reported as
"Not healing," "Early/partial granulation," "Fully granulating," and eventually "Newly epithelialized.”

Response “0 – Newly epithelialized”: Enter Response 0 when the wound bed has completely covered
with new epithelium; no exudate; no avascular tissue (eschar and/or slough); no signs or symptoms or
infection. Epithelialization is characterized by "Epidermal resurfacing" and means the opening created
during the surgery is covered by epithelial cells. If epidermal resurfacing has occurred completely, the
correct response in the OASIS would be "Newly epithelialized" until approximately 30 days of complete
epidermal resurfacing have passed without complication, at which time it is no longer a reportable
surgical wound.

Enter Response 0 – Newly epithelialized for implanted venous access devices and infusion devices
when the insertion site is healed and without signs and symptoms of infection.

Response 1 – Fully granulating: Enter Response 1 when a surgical wound has a wound bed filled with
granulation tissue to the level of the surrounding skin; no dead space, no avascular tissue; no signs or
symptoms of infection; wound edges are open.

Response 2 – Early/partial granulation: Enter Response 2 when ≥25% of the wound bed is covered with
granulation tissue; there is minimal avascular tissue (that is, <25% of the wound bed is covered with
avascular tissue); no signs or symptoms of infection; wound edges open.

Response 3 – Not healing: Enter Response 3 when wound has ≥25% avascular tissue OR
signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound
edges OR persistent failure to improve despite appropriate comprehensive wound management.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Referral documentation.

•

Review of health history.

•

Physician.

•

CMS OASIS Q & As can be accessed through the CMS OASIS web page.

•

See references/resources (including a link to the Wound Ostomy and Continence Nurses (WOCN) Society’s
Guidance on OASIS) in Chapter 5 of the OASIS Guidance Manual.

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Chapter 3: F-29

Chapter 3

Section F – Integumentary

OASIS ITEM
(M1350) Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those
described above, that is receiving intervention by the home health agency?
Enter Code
0
1

No
Yes

ITEM INTENT
•

Identifies the presence of a skin lesion or open wound NOT ALREADY ADDRESSED IN PREVIOUS ITEMS
that is receiving clinical assessment or intervention from the home health agency.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

A lesion is a broad term used to describe an area of pathologically altered tissue. All alterations in skin
integrity are considered to be lesions. Examples of lesions include but are not limited to sores, skin tears,
burns, ulcers, rashes, edema, and persistent redness without a break in the skin.

•

Certain open wounds/lesions are not included in this item. These include:
o

bowel ostomies (which are reported in OASIS item M1630);

wounds resulting from cataract surgery, surgery to mucosal membranes, or gynecological surgical
procedures by a vaginal approach;

tattoos, piercings, and other skin alterations unless ongoing assessment and/or clinical intervention
by the home health agency is a part of the planned/provided care;

any other skin lesions or open wounds that are not receiving clinical intervention from the home
health agency.

•

“Receiving clinical assessment or intervention from the home health agency” means the lesion is being
clinically assessed on an ongoing basis as indicated on the home health agency’s Plan of Care (for
example, wound measurements for a traumatic laceration).

•

Response 0 – “No” should be entered if:

•

the patient does not have any open wounds/skin lesions (as defined above), or;

all of the patient’s open wounds/skin lesions are pressure ulcers, stasis ulcers, and/or surgical wounds,
which are addressed in other OASIS integumentary items;

the patient’s open wounds/skin lesions are not receiving clinical intervention from the home health
agency (as defined above).

Response 1 – “Yes” should be entered for all types of other open wounds/skin lesions that are part of the
agency’s planned/provided care but are NOT addressed in other OASIS Integumentary Items. Examples
include but are not limited to:
-

burns, diabetic ulcers, cellulitis, abscesses, edema, wounds caused by trauma of various kinds;

PICC line and peripheral IV sites;

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Chapter 3

Section F – Integumentary

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1350)
-

non-bowel ostomies (for example, tracheostomies, thoracotomies, urostomies, jejunostomies,
gastrostomies) if clinical interventions (for example, cleansing, dressing changes, assessment) are
being provided by the home health agency during the care episode.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physical Assessment.

•

Referral documentation.

•

Review of health history.

•

Physician.

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Chapter 3: F-31

Chapter 3

Section G – Respiratory Status

OASIS ITEM
(M1400) When is the patient dyspneic or noticeably Short of Breath?

Enter Code

0
1
2
3
4

ITEM INTENT
•

Identifies the level of exertion/activity that results in a patient’s dyspnea or shortness of breath.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency – not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

If the patient uses oxygen continuously, enter the response based on assessment of the patient’s shortness
of breath while using oxygen. If the patient uses oxygen intermittently, enter the response based on the
patient’s shortness of breath WITHOUT the use of oxygen.
Responses are based on the patient’s actual use of oxygen in the home, not on the physician’s oxygen order.

•

The responses represent increasing severity of shortness of breath.

•

For a chairfast or bedbound patient, evaluate the level of exertion required to produce shortness of breath.
The chairfast patient can be assessed for level of dyspnea while performing ADLs or at rest. Response 0
would apply if the patient has not been short of breath during the day of assessment. Response 1 would be
appropriate if demanding bed-mobility activities produce dyspnea in the bedbound patient (or physically
demanding transfer activities produce dyspnea in the chairfast patient). See Responses 2, 3, and 4 for
assessment examples for these patients as well as ambulatory patients.

DATA SOURCES / RESOURCES
•

Observation.

•

Physical assessment.

•

Patient/caregiver interview.

•

Review of health history.

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Chapter 3: G-1

Chapter 3

Section G – Respiratory Status

OASIS ITEM
(M1410) Respiratory Treatments utilized at home: (Mark all that apply.)

⃞1

Oxygen (intermittent or continuous)

⃞2

Ventilator (continually or at night)

⃞3

Continuous / Bi-level positive airway pressure

⃞4

None of the above

ITEM INTENT
•

Identifies any of the listed respiratory treatments being used by this patient in the home.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Excludes any respiratory treatments that are not listed in the item (for example, does not include nebulizers,
inhalers).

•

Response 3 reflects both CPAP and BiPAP.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Observation.

•

Physician’s orders.

•

Referral information.

•

Review of health history.

OASIS-C2 Guidance Manual
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Chapter 3: G-2

Chapter 3

Section H – Cardiac Status

OASIS ITEM
(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient
exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or
weight gain) at the time of or at any time since the most recent SOC/ROC assessment?
Enter Code

No [Go to M2005 at TRN; Go to M1600 at DC ]

Yes

Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]

Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC ]

ITEM INTENT
•

Identifies whether a patient with a diagnosis of heart failure experienced one or more symptoms of heart
failure at the time of or at any time since the most recent SOC/ROC assessment.

•

This item is used to calculate process measures to capture the agency’s use of best practices following the
completion of the comprehensive assessment. The best practices/assessments stated in the item are not
necessarily required in the Conditions of Participation.

TIME POINTS ITEM(S) COMPLETED
•
•

Transfer to inpatient facility.
Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Enter Response 0, 1 or 2 if the patient has a diagnosis of heart failure, regardless of whether the diagnosis
is documented elsewhere in the OASIS assessment.

•

Enter “NA” if the patient does not have a diagnosis of heart failure.

•

If the patient has a diagnosis of heart failure, enter Response 1 – Yes, to report symptoms associated with
heart failure even if there are other co-morbidities that also could produce the symptom (for example,
dyspnea in a patient with pneumonia and heart failure).

•

Consider any new or ongoing heart failure symptoms (reported or observed) that occurred at the time of or
at any time since the most recent SOC/ROC.

DATA SOURCES / RESOURCES
•

Review of clinical record including physical assessment data, weight trends, and clinical notes using HHA
systems put into place to accomplish such a review (for example, flow sheets, reports from electronic health
record data) at the time of, or at any time since, the most recent SOC/ROC assessment.

•

A complete list of symptoms of heart failure can be found in clinical heart failure guidelines in Chapter 5 of
this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: H-1

Chapter 3

Section H – Cardiac Status

OASIS ITEM
(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms
indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment,
what action(s) has (have) been taken to respond? (Mark all that apply.)

⃞0

No action taken

⃞1

Patient’s physician (or other primary care practitioner) contacted the same day

⃞2

Patient advised to get emergency treatment (for example, call 911 or go to emergency room)

⃞3

Implemented physician-ordered patient-specific established parameters for treatment

⃞4

Patient education or other clinical interventions

⃞5

Obtained change in care plan orders (for example, increased monitoring by agency, change in
visit frequency, telehealth)

ITEM INTENT
•

Identifies actions the home health care providers took in response to symptoms of heart failure that occurred
at the time of or at any time since the most recent SOC/ROC assessment. This item is used to calculate
process measures to capture the agency’s use of best practices following the completion of the
comprehensive assessment. The best practices stated in the item are not necessarily required in the
Conditions of Participation.

TIME POINTS ITEM(S) COMPLETED
•
•

Transfer to an inpatient facility.
Discharge from agency - not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Include any actions that were taken in response to HF symptoms at least one time at the time of or at any
time since the most recent SOC/ROC assessment. If the interventions are not completed as outlined in this
item, select Response 0 – No action taken. However, in this case, the care provider should document
rationale in the clinical record.

•

If Response 0 is selected, none of the other responses should be selected.

•

Response 1 includes communication to the physician or primary care practitioner made by telephone,
voicemail, electronic means, fax, or any other means that appropriately conveys the message of patient
status. Response 1 is appropriate only if a physician responds to the agency communication with
acknowledgment of receipt of information and/or further advice or instructions on the same day. Same day
means by the end of this calendar day. In many situations, other responses also will be marked that indicate
the action taken as a result of the contact (that is, any of Responses 2-5).

•

Response 2 should be selected when the patient exhibits symptoms of heart failure that require immediate
attention in an emergency room and is advised to do so by agency staff. It is not selected when a patient is
educated to go to the ER or call 911 based on pre-established parameters.

•

Response 3 would be best for a situation in which either the home care clinician reminds the patient to
implement or is aware that the patient is following physician-established parameters for treatment.

•

Response 4 includes “Patient education,” referring to the effective sharing of pertinent heart failure-related
information to increase patient knowledge, skill, and responsibility. Simply providing a patient with printed
materials regarding heart failure without assessment of their understanding of the content should not be
considered patient education.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: H-2

Chapter 3

Section H – Cardiac Status

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1511)
•

Interventions provided via the telephone or other telehealth methods utilized to address heart failure
symptoms can be reported.

DATA SOURCES / RESOURCES
•
•
•

Review of clinical record at the time of or at any time since the previous OASIS assessment.
Physician-ordered home health Plan of Care.
Examples of standard clinical guidelines can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: H-3

Chapter 3

Section I – Elimination

OASIS ITEM
(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0
1
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown [Omit “UK” option on DC ]

ITEM INTENT
●

Identifies treatment of urinary tract infection during the past 14 days.

TIME POINTS ITEM(S) COMPLETED
●
●
●

Start of care.
Resumption of care.
Discharge from agency – not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

The term “past 14 days” is the two-week period immediately preceding the Start/Resumption of Care date
(or for Discharge, the M0090 Date Assessment Completed). This means that for purposes of counting the
14-day period, the Start of Care date is day 0 and the day immediately prior to the Start of Care date is day
1. For example, if the patient’s SOC date is August 20, any treatment for a UTI occurring on or after August
6 would be considered.

●

Unknown is not an option at Discharge from Agency.

●

Enter Response 0 – No, if patient has not been treated for a UTI within the past two weeks, including if the
patient had symptoms of a UTI or a positive culture for which the physician did not prescribe treatment, or
the treatment ended more than 14 days ago.

●

Enter Response 1 – Yes, when the patient has been prescribed an antibiotic within the past 14 days
specifically for a confirmed or suspected UTI.

●

Enter Response 1 – Yes, if the patient is on prophylactic treatment and develops a UTI.

●

Enter “NA” – if the patient is on prophylactic treatment to prevent UTIs.

DATA SOURCES / RESOURCES
●
●
●
●
●
●

Patient/caregiver interview.
Physician orders.
Review of health history.
Referral information.
Physician.
Medication list.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: I-1

Chapter 3

Section I – Elimination

OASIS ITEM
(M1610) Urinary Incontinence or Urinary Catheter Presence:
Enter Code

No incontinence or catheter (includes anuria or ostomy for urinary drainage)

[Go to M1620 ]
1
2

Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic) [Go to M1620 ]

ITEM INTENT
●

Identifies presence of urinary incontinence or condition that requires urinary catheterization of any type,
including intermittent or indwelling. The etiology (cause) of incontinence is not addressed in this item.

TIME POINTS ITEM(S) COMPLETED
●
●
●
●

Start of care.
Resumption of care.
Follow-up.
Discharge from agency - not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Enter Response 0 if the patient has anuria or an ostomy for urinary drainage (for example: an ileal conduit),
or if the patient has a urinary diversion that is pouched (ileal conduit, urostomy, ureterostomy, nephrostomy),
with or without a stoma.

●

Enter Response 1 if the patient is incontinent at any time (including “occasionally,” “only when I sneeze,”
“sometimes I leak a little bit,” etc.).

●

Enter Response 1 if the patient is incontinent or is dependent on a timed-voiding program. Timed voiding is
defined as scheduled toileting assistance or prompted voiding to manage incontinence based on identified
patterns. Time voiding is a compensatory strategy; it does not cure incontinence.

●

Enter Response 2 if a catheter or tube is utilized for drainage (even if catheterizations are intermittent).

●

Enter Response 2 if the patient requires the use of a catheter for urinary drainage for any reason (for
example: retention, post-surgery, incontinence). Enter Response 2 and follow the skip pattern if the patient
is both incontinent and requires a urinary catheter.

●

Enter Response 2 if a catheter was inserted during the comprehensive assessment.

●

A leaking urinary drainage appliance is not incontinence.

●

A catheter solely utilized for irrigation of the bladder or installation with an antibiotic is not reported in this
item.

●

If a catheter was discontinued during the comprehensive assessment or if a catheter is both inserted and
discontinued during the comprehensive assessment, Response 0 or 1 would be appropriate, depending on
whether or not the patient is continent.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: I-2

Chapter 3

Section I – Elimination

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1610)
●

Assessment strategies: Review the urinary elimination pattern as you take the health history. Does the
patient admit having difficulty controlling the urine, or is he/she embarrassed about needing to wear a pad so
as not to wet on clothing? Do you have orders to change a catheter? Is your stroke patient using an
external catheter? Be alert for an odor of urine, which might indicate there is a problem with bladder
sphincter control. If the patient receives aide services for bathing and/or dressing, ask for input from the aide
(at follow-up assessment). This information can then be discussed with the patient. Urinary incontinence
may result from multiple causes, including physiologic reasons, cognitive impairments, or mobility problems.

DATA SOURCES / RESOURCES
●
●
●
●
●
●

Patient/caregiver interview.
Observation.
Physical assessment.
Physician orders.
Review of health history.
Referral information.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: I-3

Chapter 3

Section I – Elimination

OASIS ITEM
(M1615) When does Urinary Incontinence occur?
Enter Code

0
1
2
3
4

Timed-voiding defers incontinence
Occasional stress incontinence
During the night only
During the day only
During the day and night

ITEM INTENT
●

Identifies when the urinary incontinence occurs.

TIME POINTS ITEM(S) COMPLETED
●
●
●

Start of care.
Resumption of care.
Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Enter Response 0 if timed-voiding defers incontinence. Timed voiding determines the patient’s pattern for
voiding and schedules toileting to prevent episodes of leaking. The patient can self-schedule toileting or the
caregiver can prompt or bring the patient to the toilet. Timed voiding is a compensatory strategy; it does not
cure incontinence. If timed voiding does not defer incontinence, do not enter Response 0.

●

Enter Response 1 – Occasional stress incontinence—when the patient is unable to prevent escape of
relatively small amounts of urine when coughing, sneezing, laughing, lifting, moving from sitting to standing
position, or other activities (stress), which increase abdominal pressure.

●

If urinary incontinence happens with regularity or in other circumstances than those described in the
definition of stress incontinence, determine when the incontinence usually occurs and enter Response 2, 3,
or 4 as appropriate.

●

Enter Response 2 – During the night only – when the patient’s incontinence occurs while the patient is
sleeping at night.

●

Enter Response 3 – During the day only—when the patient’s incontinence occurs while the patient is
up/awake during the day. Includes incontinence during daytime naps.

●

Enter Response 4 – During the day and night—when the patient is incontinent when sleeping at night and
up/awake during the day.

DATA SOURCES / RESOURCES
●
●
●
●
●

Patient/caregiver interview.
Observation.
Physical assessment.
Review of health history.
Referral information.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: I-4

Chapter 3

Section I – Elimination

OASIS ITEM
(M1620) Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

ITEM INTENT
●

Identifies how often the patient experiences bowel incontinence. Refers to the frequency of a symptom
(bowel incontinence), not to the etiology (cause) of that symptom. This item does not address treatment of
incontinence or constipation (for example: a bowel program).

TIME POINTS ITEM(S) COMPLETED
●
●
●
●

Start of care.
Resumption of care.
Follow-up.
Discharge from agency - not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Responses are arranged in order of least to most frequency of bowel incontinence.

●

Response 4 – On a daily basis—indicates that the patient experiences bowel incontinence once per day.

●

Enter “NA” if patient has an ostomy for bowel elimination.

●

Unknown is not an option at follow-up or discharge.

●

Assessment strategies: Review the bowel elimination pattern as you take the health history. Observe the
cleanliness around the toilet when you are in the bathroom. Note any visible evidence of soiled clothing. Ask
the patient if she/he has difficulty controlling stools, has problems with soiling clothing, uncontrollable
diarrhea, etc. The patient’s responses to these items may make you aware of an as yet unidentified problem
that needs further investigation. If the patient is receiving aide services, question the aide about evidence of
bowel incontinence at follow-up time points. This information can then be discussed with the patient.
Incontinence may result from multiple causes, including physiologic reasons, mobility problems, or cognitive
impairments.

DATA SOURCES / RESOURCES
●
●
●
●
●

Patient/caregiver interview.
Observation.
Physical assessment.
Review of health history.
Referral information.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: I-5

Chapter 3

Section I – Elimination

OASIS ITEM
(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the
last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or
treatment regimen?
Enter Code

Patient does not have an ostomy for bowel elimination.

ITEM INTENT
●

Identifies whether the patient has an ostomy for bowel elimination and, if so, whether the ostomy was related
to a recent inpatient stay or caused a change in medical treatment plan.

TIME POINTS ITEM(S) COMPLETED
●
●
●

Start of care.
Resumption of care.
Follow-up.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Applies to any type of ostomy for bowel elimination (for example: colostomy, ileostomy). This item only
addresses bowel ostomies, not other types of ostomies (for example: urinary ostomies, tracheostomies).

●

If an ostomy has been reversed, then the patient does not have an ostomy at the time of assessment.

●

If patient does not have an ostomy for bowel elimination, enter Response 0 – Patient does not have an
ostomy for bowel elimination.

●

If the patient does have an ostomy for bowel elimination, determine whether the ostomy was related to an
inpatient stay or necessitated a change in the medical or treatment regimen within the last 14 days.

●

The term “past fourteen days” is the two-week period immediately preceding the Start/Resumption of Care
or Follow-Up assessment. This means that for purposes of counting the 14-day period, the Start of Care
date is day 0 and the day immediately prior to the Start of Care date is day 1. For example, if the patient’s
SOC date is August 20, any ostomy related to an inpatient stay or requiring medical or treatment regimen
change that occurred on or after August 6 would be considered.

DATA SOURCES / RESOURCES
●
●
●
●
●
●

Patient/caregiver interview.
Physician orders.
Review of health history.
Referral information.
Physician.
Supplies list.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: I-6

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
Enter Code

1
2

3
4

ITEM INTENT
•

Identifies the patient’s current (at the time of the assessment and in the preceding 24 hours) level of
cognitive functioning, including alertness, orientation, comprehension, concentration, and immediate
memory for simple commands.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Responses progress from no impairment to severely impaired. Consider the degree of impairment.

•

Consider the patient’s signs/symptoms of cognitive dysfunction that have occurred over the past 24 hours.

•

Consider the amount of supervision and care the patient has required due to cognitive deficits.

•

Patients with diagnoses such as dementia, delirium, development delay disorders, mental retardation, etc.,
will have various degrees of cognitive dysfunction.

•

Patients with neurological deficits related to stroke, mood/anxiety disorders, or who receive opioid therapy
may have cognitive deficits.

DATA SOURCES / RESOURCES
•
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Links to cognitive assessment tools can be found in Chapter 5 of this manual.
Review of past health history.
Physician.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-1

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1710) When Confused (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
4
NA

Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not constantly
Constantly
Patient nonresponsive

ITEM INTENT
•

Identifies the time of day or situations when the patient experienced confusion, if at all.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Discharge from agency—not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

This item may not relate directly to Item M1700. Assess specifically for confusion in the past 14 days.

•

The term “past 14 days” is the two-week period immediately preceding the Start/Resumption of Care date
(or for Discharge, the M0090 Date Assessment Completed). This means that for purposes of counting the
14-day period, the Start of Care date is day 0 and the day immediately prior to the Start of Care date is day
1. For example, if the patient’s SOC date is August 20, any confusion occurring on or after August 6 would
be considered.

•

Enter Response 0 if the patient had no confusion in the last 14 days. Enter Response 1, 2, 3, or 4 if the
patient has experienced confusion and each response represents a worsening of confusion frequency.
Response 1 is entered when the patient's confusion is isolated to a new or a complex situation; for example,
the patient became confused when a new caregiver was introduced or when a procedure was performed the
first time. Response 2, 3, or 4 is entered when confusion occurs without the stimulus of a new or complex
situation, or when confusion that initially presented with a new or complex situation persists days after the
new or complex situation becomes more routine. Responses 2, 3 and 4 differ from each other based on the
time when the confusion occurred. Enter Response 2 if the confusion only occurred when the patient was
awakening from a sleep or during the night. Enter Response 3 if the confusion occurs during the day and
evening, but is not constant. If confusion was not constant, but occurred more often than just upon
awakening or at night, enter Response 3.

•

“Nonresponsive” means that the patient is unable to respond or the patient responds in a way that you
cannot make a clinical judgment about the patient’s level of orientation. If the patient is nonresponsive at the
time of assessment, report whether the patient experienced any confusion during the past 14 days if this
information can be elicited from the caregiver or other source. If the patient is nonresponsive at the time of
assessment and the information cannot be elicited from the caregiver or other source, enter “NA – Patient
nonresponsive.”

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-2

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

DATA SOURCES / RESOURCES
•
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Review of recent (past 14 days) health history.
Physician.
Links to a resource for patients with Alzheimer’s disease or dementia can be found in Chapter 5 of this
manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-3

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1720) When Anxious (Reported or Observed Within the Last 14 Days):
Enter Code

0
1
2
3
NA

None of the time
Less often than daily
Daily, but not constantly
All of the time
Patient nonresponsive

ITEM INTENT
•

Identifies the frequency with which the patient has felt anxious within the past 14 days.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Discharge from agency - not to inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Anxiety includes:
-

Worry that interferes with learning and normal activities,

Feelings of being overwhelmed and having difficulty coping, or

Symptoms of anxiety disorders.

•

Responses appear in order of increasing frequency of anxiety.

•

“Nonresponsive” means that the patient is unable to respond or the patient responds in a way that you can’t
make a clinical judgment about the patient’s level of anxiety. If the patient is nonresponsive at the time of
assessment, report whether the patient experienced any anxiety during the past 14 days if this information
can be elicited from the caregiver or other source. If the patient is nonresponsive at the time of assessment
and the information cannot be elicited from the caregiver or other source, enter “NA – Patient
nonresponsive.”

•

The term “past 14 days” is the two-week period immediately preceding the Start/Resumption of Care date
(or for Discharge, the M0090 Date Assessment Completed). This means that for purposes of counting the
14-day period, the Start of Care date is day 0 and the day immediately prior to the Start of Care date is day
1. For example, if the patient’s SOC date is August 20, any anxiety occurring on or after August 6 would be
considered. If nonresponsive on the day of assessment, report whether patient experienced anxiety during
the past 14 days.

DATA SOURCES / RESOURCES
•
•
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information.
Review of recent (past 14 days) health history.
Physician.
Links to standardized anxiety screening tools can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-4

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1730) Depression Screening: Has the patient been screened for depression, using a standardized, validated
depression screening tool?

Enter Code

0
1

PHQ-2©*

2
3

Not at all
0–1 day

Several
days
2– 6 days

Nearly
More than half every day
NA
of the days
12–14 Unable to
7–11 days
days
respond

Little interest or pleasure
in doing things

⃞0

⃞1

⃞2

⃞3

⃞NA

Feeling down,
depressed, or hopeless?

⃞0

⃞1

⃞2

⃞3

⃞NA

ITEM INTENT
•

Identifies if the home health agency screened the patient for depression using a standardized, validated
depression-screening tool.

•

CMS does not mandate that clinicians conduct depression screening for all patients, nor is there a mandate
for the use of the PHQ-2© or any other particular standardized, validated tool. This item is used to calculate
process measures to capture the agency’s use of best practices following the completion of the
comprehensive assessment. The best practices stated in the item are not necessarily required in the
Conditions of Participation.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Depressive feelings, symptoms, and/or behaviors may be observed by the clinician or reported by the
patient, family, or others as allowed by the standardized, validated tool’s administration instructions.

•

To meet the definition of “standardized, validated,” the depression screening tool must 1) have been
scientifically tested on a population with characteristics similar to that of the patient being assessed (for
example, community-dwelling elderly, noninstitutionalized adults with disabilities, etc.) and 2) include a
standard response scale.

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: J-5

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1730)

•

The standardized, validated tool must be both appropriate for the patient based on their cognitive and
communication deficits and appropriately administered per the tool’s instructions.

If a standardized, validated depression-screening tool is used, use the scoring parameters specified for
the tool to identify if a patient meets criteria for further evaluation of depression.

In order to enter Response 1, 2 or 3, the standardized, validated depression screening must be
conducted by the clinician responsible for completing the comprehensive assessment during the time
frame specified by CMS for completion of the assessment (specifically, within five days of SOC or within
two days of discharge from the inpatient facility at ROC).

Enter Response 0 if a standardized, validated depression screening was not conducted.
-

•

If the clinician chooses not to assess the patient (because there is no appropriate depression screening
tool available or for any other reason), Response 0 – No should be entered.

Enter Response 1 if the PHQ-2© is completed, and select the appropriate responses in rows a and b.
Please note that the PHQ-2© instructions indicate that the patient is interviewed, not family or others. If the
patient scores three points or more on the PHQ-2©, then further depression screening is indicated.
-

If the PHQ-2© is not used to assess the patient, you may choose to administer a different standardized,
validated depression screening tool with instructions that may allow for information to be gathered by
observation and caregiver interview as well as self-report. In this case, the clinician would enter
Response 2 or 3 for M1730, depending on the outcome of the assessment.

•

Enter Response 2 if the patient is screened with a different standardized, validated assessment AND the
tool indicated the need for further evaluation.

•

Enter Response 3 if the patient is screened with a different standardized, validated assessment BUT the tool
indicates no need for further evaluation.

DATA SOURCES / RESOURCES
•
•
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information.
Physician.
A link with more information on the PHQ–2© can be found in Chapter 5 of this manual.
There are many depression screening tools available. Links to several tools can be found in Chapter 5 of
this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-6

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week
(Reported or Observed): (Mark all that apply.)

⃞1

Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24
hours, significant memory loss so that supervision is required

⃞2

Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop
activities, jeopardizes safety through actions

⃞3

Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.

⃞4

Physical aggression: aggressive or combative to self and others (for example, hits self, throws
objects, punches, dangerous maneuvers with wheelchair or other objects)

⃞5

Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)

⃞6

Delusional, hallucinatory, or paranoid behavior

⃞7

None of the above behaviors demonstrated

ITEM INTENT
•

Identifies specific behaviors associated with significant neurological, developmental, behavioral, or
psychiatric disorders.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Behaviors may be observed by the clinician or reported by the patient, family, or others.

•

Behaviors reported could be identified by a formal diagnosis and/or determined by the assessing clinician to
be associated with a significant neurological, developmental, behavioral and/or psychiatric disorder.

•

Include behaviors which are severe enough to:

•

make the patient unsafe to self or others,

cause considerable stress to the caregivers, or

require supervision or intervention.

If Response 7 is selected, none of the other responses should be selected.

DATA SOURCES / RESOURCES
•
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information.
Physician.
Links to standardized cognitive screening tools can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-7

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed): Any physical, verbal, or
other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.
Enter Code

0
1
2
3
4
5

Never
Less than once a month
Once a month
Several times each month
Several times a week
At least daily

ITEM INTENT
•

Identifies frequency of any behaviors that are disruptive or dangerous to the patient or the caregivers.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Consider if the patient has any problematic behaviors—not just the behaviors listed in M1740—which
jeopardize or could jeopardize the safety and well-being of the patient or caregiver. Then consider how
frequently these behaviors occur.

•

Include behaviors considered symptomatic of neurological, cognitive, behavioral, developmental, or
psychiatric disorders, identified either by diagnosis and/or based on the assessing clinician’s clinical
judgment.

•

Use clinical judgment to determine if the degree of the behavior is disruptive or dangerous to the patient or
caregiver.

•

Behaviors can be observed by the clinician or reported by the patient, family, or others.

•

Examples of disruptive/dangerous behaviors include sleeplessness, “sun-downing,” agitation, wandering,
aggression, combativeness, getting lost in familiar places, etc.

DATA SOURCES / RESOURCES
•
•
•
•
•
•
•

Patient/caregiver interview.
Observation.
Physical assessment.
Referral information.
Review of past health history.
Physician.
Links to additional information sources can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-8

Chapter 3

Section J – Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric
nurse?
Enter Code

0
1

No
Yes

ITEM INTENT
•

Identifies whether the patient is receiving psychiatric nursing services at home as provided by a qualified
psychiatric nurse. “Psychiatric nursing services” address mental/emotional needs; a “qualified psychiatric
nurse” is so qualified through educational preparation, certification, or experience.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS

DATA SOURCES / RESOURCES
•
•
•
•
•
•

Patient/caregiver interview.
Observation.
Referral information.
Physician orders/Plan of Care.
Clinical record.
HHAs may elect to reference Section 40.1.2.15 of Chapter 7 in the Medicare Benefit Policy Manual for
additional information.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: J-9

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1800) Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and
hands, hair care, shaving or make up, teeth or denture care, or fingernail care).
Enter Code

0
1
2
3

Able to groom self unaided, with or without the use of assistive devices or adapted methods.
Grooming utensils must be placed within reach before able to complete grooming activities.
Someone must assist the patient to groom self.
Patient depends entirely upon someone else for grooming needs.

ITEM INTENT
•

Identifies the patient’s ability to tend to personal hygiene needs, excluding bathing, shampooing hair, and
toileting hygiene.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely perform
grooming, given the current physical and mental/emotional/cognitive status, activities permitted, and
environment. The patient must be viewed from a holistic perspective in assessing ability to perform ADLs.
Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments, (for example, impaired vision or pain)

environmental barriers (for example, accessing grooming aids, mirror and sink).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, choose the response describing the patient’s
ability more than 50% of the time period under consideration.

The grooming scale presents the most independent level first, then proceeds to the most
dependent. Read each response carefully to determine which one best describes what the patient
is currently able to do.

Grooming includes several activities. The frequency with which selected activities are performed
(such as washing face and hands vs. fingernail care) must be considered in responding. Patients
able to do more frequently performed activities (for example, washing hands and face) but unable
to do less frequently performed activities (trimming fingernails) should be considered to have more
ability in grooming.

In cases where a patient’s ability is different for various grooming tasks, enter the response that
best describes the patient’s level of ability to perform the majority of grooming tasks.

Response 2 includes standby assistance or verbal cueing.

OASIS-C2 Guidance Manual
Effective 1/1/2017Chapter 3: K-1
Centers for Medicare & Medicaid Services

Chapter 3

Section K – ADLs / IADLs

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-2

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments,
pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
Enter Code

Able to get clothes out of closets and drawers, put them on and remove them from the upper
body without assistance.

Able to dress upper body without assistance if clothing is laid out or handed to the patient.

Someone must help the patient put on upper body clothing.

Patient depends entirely upon another person to dress the upper body.

ITEM INTENT
•

Identifies the patient’s ability to dress upper body, including the ability to obtain, put on, and remove upper
body clothing. Assess ability to put on whatever clothing is routinely worn. This specifically includes the
ability to manage zippers, buttons, and snaps if these are routinely worn.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely dress
the upper body, given the current physical and mental/emotional/cognitive status, activities permitted, and
environment. The patient must be viewed from a holistic perspective in assessing ability to perform ADLs.
Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or pain)

environmental barriers (for example, stairs, narrow doorways, location where dressing items are
stored).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Prosthetic, orthotic, or other support devices applied to the upper body (for example, upper extremity
prosthesis, cervical collar, or arm sling) should be considered as upper body dressing items.

•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability
more than 50% of the time period under consideration.

•

The ability to dress upper body scale presents the most independent level first then proceeds to the most
dependent. Read each response carefully to determine which one best describes what the patient is able to
do.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-3

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1810)
•

In cases where a patient’s ability is different for various upper body dressing tasks, enter the response that
best describes the patient’s level of ability to perform the majority of upper body dressing tasks.If the patient
requires standby assistance (a "spotter") to dress safely or requires verbal cueing/reminders, enter
Response 2.

•

If a patient modifies the clothing they wear due to a physical impairment, the modified clothing selection will
be considered routine if there is no reasonable expectation that the patient could return to their previous
style of dressing. There is no specified timeframe at which the modified clothing style will become the routine
clothing.

•

The clinician will need to determine which clothes should be considered routine. It will be considered
routine because the clothing is what the patient usually wears and will continue to wear, or because the
patient is making a change in clothing options to styles that are expected to become the patient's new
routine clothing.

•

Assessment strategies: A combined observation/interview approach with the patient or caregiver is helpful in
determining the most accurate response for this item. Ask the patient if he/she has difficulty dressing upper
body. Observe the patient’s general appearance and clothing and ask questions to determine if the patient
has been able to dress independently and safely. Opening and removing upper body garments during the
physical assessment of the heart and lung provides an excellent opportunity to evaluate the upper extremity
range of motion, coordination, and manual dexterity needed for dressing. The patient also can be asked to
demonstrate the body motions involved in dressing. Assess ability to put on whatever clothing is routinely
worn.

DATA SOURCES / RESOURCES
•

Observation.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-4

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments,
slacks, socks or nylons, shoes:
Enter Code

Able to obtain, put on, and remove clothing and shoes without assistance.

Able to dress lower body without assistance if clothing and shoes are laid out or handed to
the patient.

Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.

Patient depends entirely upon another person to dress lower body.

ITEM INTENT
•

Identifies the patient’s ability to dress lower body, including the ability to obtain, put on, and remove lower
body clothing. Assess ability to put on whatever clothing is routinely worn.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely dress
the lower body, given the current physical and mental/emotional/cognitive status, activities permitted, and
environment. The patient must be viewed from a holistic perspective in assessing ability to perform ADLs.
Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or pain)

environmental barriers (for example, stairs, narrow doorways, location where dressing items are
stored).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Prosthetic, orthotic, or other support devices applied to the lower body (for example, lower extremity
prosthesis, ankle-foot orthosis [AFO], or anti-embolism stockings) should be considered as lower body
dressing items/tasks.

•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability
more than 50% of the time period under consideration.

•

The ability to dress lower body scale presents the most independent level first, then proceeds to the most
dependent. Read each response carefully to determine which one best describes what the patient is able to
do.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-5

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1820)
•

In cases where a patient’s ability is different for various dressing lower body tasks, enter the response that
best describes the patient’s level of ability to perform the majority of dressing lower body tasks.

•

If the patient requires standby assistance (a "spotter") to dress safely or verbal cueing/reminders, enter
Response 2.

•

Assessment strategies: A combined observation/interview approach with the patient or caregiver is helpful in
determining the most accurate response for this item. The patient can report the lower body dressing
procedure. Observe spinal flexion, joint range of motion, shoulder and upper arm strength, and manual
dexterity during the assessment. Ask the patient to demonstrate the body motions involved in dressing.
Assess ability to put on whatever clothing is routinely worn.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-6

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1830)

Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing
hands, and shampooing hair).

Enter Code

Able to bathe self in shower or tub independently, including getting in and out of tub/shower.

With the use of devices, is able to bathe self in shower or tub independently, including
getting in and out of the tub/shower.

Able to bathe in shower or tub with the intermittent assistance of another person:
(a)

for intermittent supervision or encouragement or reminders, OR

(b)

to get in and out of the shower or tub, OR

(c)

for washing difficult to reach areas.

Able to participate in bathing self in shower or tub, but requires presence of another person
throughout the bath for assistance or supervision.

Unable to use the shower or tub, but able to bathe self independently with or without the use
of devices at the sink, in chair, or on commode.

Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in
bedside chair, or on commode, with the assistance or supervision of another person.

Unable to participate effectively in bathing and is bathed totally by another person.

ITEM INTENT
•

Identifies the patient’s ability to bathe entire body and the assistance that may be required to safely bathe,
including transferring in/out of the tub/shower. The intent of the item is to identify the patient’s ABILITY, not
necessarily actual performance. "Willingness" and "adherence" are not the focus of these items. These
items address the patient's ability to safely bathe, given the current physical and mental/emotional/cognitive
status, activities permitted, and environment. The patient must be viewed from a holistic perspective in
assessing ability to perform ADLs. Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or pain)

environmental barriers (for example, stairs, narrow doorways, location of tub/shower, wash
basin/sink).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-7

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS
•

Specifically excludes washing face and hands, and shampooing hair.

•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability
more than 50% of the time period under consideration.

•

The bathing scale presents the most independent level first, then proceeds to the most dependent. Read
each response carefully to determine which one best describes what the patient is able to do.

•

If the patient requires standby assistance to bathe safely in the tub or shower or requires verbal
cueing/reminders, then enter Response 2 or Response 3, depending on whether the assistance needed is
intermittent (“2”) or continuous (“3”).

•

If the patient's ability to transfer into/out of the tub or shower is the only bathing task requiring human
assistance, enter Response 2. If a patient requires one, two, or all three of the types of assistance listed in
Response 2 of M1830 but not the continuous presence of another person as noted in Response 3, then
Response 2 is the best response.

•

The patient’s status should not be based on an assumption of a patient’s ability to perform a task with
equipment they do not currently have, preventing assessment.

•

If a patient is medically restricted from stair climbing, and the only tub/shower requires climbing stairs, the
patient is temporarily unable to bathe in the tub or shower due to combined medical restrictions and
environmental barriers. Responses 4, 5, or 6 would apply, depending on the patient's ability to participate in
bathing activities.

•

If the patient does not have a tub or shower in the home, or if the tub/shower is nonfunctioning or not safe
for patient use, the patient should be considered unable to bathe in the tub or shower. Responses 4, 5, or 6
would apply, depending on the patient's ability to participate in bathing activities.

•

For Response 4, the patient must be able to safely and independently bathe outside the tub/shower,
including independently accessing water at the sink, or setting up a basin at the bedside, etc.
Enter Response 5 if the patient is unable to bathe in the tub/shower and needs intermittent or continuous
assistance to wash their entire body safely at a sink, in a chair, or on a commode.
Enter Response 6 if the patient is totally unable to participate in bathing and is totally bathed by another
person, regardless of where bathing occurs or if patient has a functioning tub or shower.

•

Assessment strategies: A combined observation/interview approach with the patient or caregiver is helpful in
determining the most accurate response for this item. Ask the patient what type of assistance is needed to
wash entire body in tub or shower. Observe the patient’s general appearance in determining if the patient
has been able to bathe self independently and safely. Observe patient actually stepping into shower or tub
to determine how much assistance the patient needs to perform the activity safely. The patient who only
performs a sponge bath may be able to bathe in the tub or shower with assistance and/or a device. Evaluate
the amount of assistance needed for the patient to be able to safely bathe in tub or shower.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-8

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer
on and off toilet/commode.
Enter Code

Able to get to and from the toilet and transfer independently with or without a device.

When reminded, assisted, or supervised by another person, able to get to and from the toilet
and transfer.

Unable to get to and from the toilet but is able to use a bedside commode (with or without
assistance).

Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal
independently.

Is totally dependent in toileting.

ITEM INTENT
•

Identifies the patient’s ability to safely get to and from and transfer on and off the toilet or bedside commode.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely perform
toilet transferring, given the current physical and mental/emotional/cognitive status, activities permitted, and
environment. The patient must be viewed from a holistic perspective in assessing ability to perform ADLs.
Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or pain)

environmental barriers (for example, stairs, narrow doorways, location of toilet or bedside
commode).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Excludes personal hygiene and management of clothing when toileting.

•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability
more than 50% of the time period under consideration.

•

The toilet transferring scale presents the most optimal level first, then proceeds to less optimal toileting
methods. Read each response carefully to determine which one best describes what the patient is able to
do.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-9

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1840)
•

If the patient can get to and from the toilet during the day independently, but uses the commode at night for
convenience, enter Response 0.

•

If the patient requires standby assistance to get to and from the toilet safely or requires verbal
cueing/reminders, enter Response 1.

•

If the patient needs assistance getting to/from the toilet or with toileting transfer or both, then Response 1 is
the best option.

•

If the patient can independently get to the toilet, but requires assistance to get on and off the toilet, enter
Response 1.

•

A patient who is unable to get to/from the toilet or bedside commode, but is able to place and remove a
bedpan/urinal independently, enter Response 3. This is the best response whether or not a patient requires
assistance to empty the bedpan/urinal.

•

In the absence of a toilet in the home, the assessing clinician would need to determine if the patient is able
to use a bedside commode (Response 2), or if unable to use a bedside commode, if he is able to use a
bedpan/urinal independently (Response 3). If the patient is not able to use the bedside commode or
bedpan/urinal as defined in the responses, or if such equipment is not present in the home to allow
assessment, then Response 4 – totally dependent in toileting would be appropriate.

Assessment Strategies: A combined observation/interview approach with the patient or caregiver is
helpful in determining the most accurate response for this item. Ask the patient if he/she has any
difficulty getting to and from the toilet or bedside commode. Observe the patient during transfer and
ambulation to determine if the patient has difficulty with balance, strength, dexterity, pain, etc.
Determine the level of assistance needed by the patient to safely get on and off the toilet or
commode. Tasks related to personal hygiene and management of clothing are not considered
when responding to this item.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-10

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or
incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes
cleaning area around stoma, but not managing equipment.
0

Able to manage toileting hygiene and clothing management without assistance.

Able to manage toileting hygiene and clothing management without assistance if
supplies/implements are laid out for the patient.

Someone must help the patient to maintain toileting hygiene and/or adjust clothing.

Patient depends entirely upon another person to maintain toileting hygiene.

Enter Code

ITEM INTENT
•

Identifies the patient’s ability to manage personal hygiene and clothing when toileting.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely perform
toileting hygiene, given the current physical and mental/emotional/cognitive status, activities permitted, and
environment. The patient must be viewed from a holistic perspective in assessing ability to perform ADLs.
Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or pain)

environmental barriers (for example, stairs, narrow doorways, location of hygiene/clothing
management supplies/implements).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Toileting hygiene includes several activities, including pulling clothes up or down and adequately cleaning
(wiping) the perineal area.

•

Toileting hygiene includes the patient’s ability to maintain hygiene related to catheter care and the ability to
cleanse around all stomas that are used for urinary or bowel elimination (for example, urostomies,
colostomies, ileostomies).

•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability
more than 50% of the time period under consideration.

•

The toileting hygiene scale presents the most independent level first, then proceeds to the most dependent.
Read each response carefully to determine which one best describes what the patient is able to do.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-11

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1845)
•

This item refers the patient’s ability to manage personal hygiene and clothing with or without assistive
devices. The word “assistance” in this question refers to assistance from another person by verbal
cueing/reminders, supervision, and/or stand-by or hands-on assistance.

•

Enter Response 0 if the patient is independent in managing toileting hygiene and managing clothing.

•

Enter Response 1 if the patient is able to manage toileting hygiene and manage clothing IF supplies are laid
out for the patient.

•

If the patient can participate in hygiene and/or clothing management but needs some assistance with either
or both activities, enter Response 2.

•

Response 2 includes standby assistance or verbal cueing.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-12

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if
patient is bedfast.
Enter Code

Able to independently transfer.

Able to transfer with minimal human assistance or with use of an assistive device.

Able to bear weight and pivot during the transfer process but unable to transfer self.

Unable to transfer self and is unable to bear weight or pivot when transferred by another
person.

Bedfast, unable to transfer but is able to turn and position self in bed.

Bedfast, unable to transfer and is unable to turn and position self.

ITEM INTENT
•

Identifies the patient’s ability to safely transfer from bed to chair (and chair to bed), or position self in bed if
bedfast.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely transfer,
given the current physical and mental/emotional/cognitive status, activities permitted, and environment. The
patient must be viewed from a holistic perspective in assessing ability to perform ADLs. Ability can be
temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or pain)

environmental barriers environmental barriers (for example, stairs, narrow doorways, location of
current sleeping surface and a sitting surface).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

For most patients, the transfer between bed and chair will include transferring from a supine position in bed
to a sitting position at the bedside, then some type of standing, stand-pivot, or sliding board transfer to a
chair, and back into bed from the chair or sitting surface.

•

If there is no chair in the patient’s bedroom or the patient does not routinely transfer from the bed directly
into a chair in the bedroom, report the patient’s ability to move from a supine position in bed to a sitting
position at the side of the bed, and then the ability to stand and then sit on whatever surface is applicable to
the patient’s environment and need, (for example, a chair in another room, a bedside commode, the toilet, a
bench, etc.). Include the ability to return back into bed from the sitting surface.

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Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1850)
•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability
more than 50% of the time period under consideration.

•

The transferring scale presents the most optimal level first, then proceeds to less optimal levels of
transferring. Read each response carefully to determine which one best describes what the patient is able to
do.

•

Able to bear weight refers to the patient's ability to support the majority of his/her body weight through any
combination of weight-bearing extremities (for example, a patient with a weight-bearing restriction of one
lower extremity may be able to support his/her entire weight through the other lower extremity and upper
extremities). If the patient is able to transfer self from bed to chair, but requires standby assistance to
transfer safely, or requires verbal cueing/reminders, enter Response 1.

•

For Response 1, “minimal human assistance” could include any combination of verbal cueing, environmental
set-up, and/or actual hands-on assistance.
In order for the assistance to be considered minimal, it would mean the individual assisting the patient is
contributing less than 25% of the total effort required to perform the transfer.

•

If the patient transfers either with minimal human assistance (but not device), or with the use of a device (but
no human assistance), enter Response 1. If the patient requires both minimal human assistance and an
assistive device to transfer safely, enter Response 2.

•

If the patient can bear weight and pivot, but requires more than minimal human assist, enter Response 2.

•

The patient must be able to both bear weight and pivot for Response 2 to apply. If the patient is unable to do
one or the other and is not bedfast, enter Response 3.

•

If the patient is bedfast, enter Response 4 or 5, depending on the patient’s ability to turn and position self in
bed. Bedfast refers to being confined to the bed, either per physician restriction or due to a patient’s inability
to tolerate being out of the bed.

•

Assessment strategies: A combined observation/interview approach with the patient or caregiver is helpful in
determining the most accurate response for this item. Ask the patient about transferring ability. Observe the
patient during transfers and determine the amount of assistance required for safe transfer from bed to chair.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

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Chapter 3: K-14

Chapter 3

Section K – ADLs / IADLs

Section GG: FUNCTIONAL ABILITIES and GOALS
(GG0170C) Mobility
Code the patient’s usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at
SOC/ROC, code the reason. Code the patient’s discharge goal using the 6-point scale. Do not use codes 07,
09, or 88 to code discharge goal.
Coding:
Safety and Quality of Performance – If helper assistance
is required because patient’s performance is unsafe or of
poor quality, score according to amount of assistance
provided.
Activity may be completed with or without assistive devices.
06 Independent – Patient completes the activity by
him/herself with no assistance from a helper.
05 Setup or clean-up assistance – Helper SETS UP or
CLEANS UP; patient completes activity. Helper assists
only prior to or following the activity.
04 Supervision or touching assistance – Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance
as patient completes activity. Assistance may be
provided throughout the activity or intermittently.

1.
SOC/ROC
Performance

2.
Discharge
Goal

Enter Response in Boxes

Lying to Sitting
on Side of Bed:
The ability to
safely move
from lying on
the back to
sitting on the
side of the bed
with feet flat on
the floor, and
with no back
support.

03 Partial/moderate assistance – Helper does LESS
THAN HALF the effort. Helper lifts, holds or supports
trunk or limbs, but provides less than half the effort.
02 Substantial/maximal assistance – Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01 Dependent – Helper does ALL of the effort. Patient does
none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient
to complete the activity.
If activity was not attempted, code reason:
07 Patient refused
09 Not applicable
88 Not attempted due to medical condition or safety
concerns

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Chapter 3: K-15

Chapter 3

Section K – ADLs / IADLs

ITEM INTENT
•

Identifies the patient’s need for assistance with the mobility task of moving from lying on the back to sitting
on the side of the bed with feet flat on the floor, and with no back support.

ITEM RATIONALE
•

Mobility limitations can adversely affect wound healing and increase risk for the development of pressure
ulcers.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

STEPS FOR ASSESSMENT
1.

Assess the patient’s functional status based on direct observation and/or on report by the patient,
caregiver/family.

Patients should be allowed to perform activities as independently as possible, as long as they are safe.

If caregiver assistance is required because patient's performance is unsafe or of poor quality, enter the
response according to amount of assistance required to be safe.

Activities may be completed with or without assistive device(s). Use of assistive device(s) to complete an
activity should not affect the scoring of the activity.

If the patient’s self-care performance varies during the assessment time frame, report the patient’s usual
status, not the patient’s most independent status and not the patient’s most dependent status.

INSTRUCTIONS
•

For GG0170C1 – SOC/ROC Performance, report the patient’s usual status at SOC/ROC using the 6-point
scale or, using one of the three “activity was not attempted” codes, report the reason the activity was not
attempted.
-

Enter 06 – Independent, if the patient completes the activity by him/herself with no human
assistance

Enter 05 – Setup or clean-up assistance, if the caregiver SETS UP or CLEANS UP; patient
completes activity. Caregiver assists only prior to or following the activity, but not during the activity.
For example, the patient requires assistance putting on a shoulder sling prior to the transfer, or
requires assistance removing the bedding from off his/her lower body to get out of bed.

Enter 04 – Supervision or touching assistance, if the caregiver must provide VERBAL CUES or
TOUCHING/ STEADYING assistance as patient completes activity. Assistance may be required
throughout the activity or intermittently. For example, the patient requires verbal cueing, coaxing, or
general supervision for safety to complete activity; or patient may require only incidental help such
as contact guard or steadying assist during the activity.

Enter 03 – Partial/moderate assistance, if the caregiver must provide LESS THAN HALF the
effort. Caregiver lifts, holds, or supports trunk or limbs, but provides less than half the effort.

Enter 02 – Substantial/maximal assistance, if the caregiver must provide MORE THAN HALF
the effort. Caregiver lifts or holds trunk or limbs and provides more than half the effort.

Enter 01 – Dependent, if the caregiver must provide ALL of the effort. Patient is unable to
contribute any of the effort to complete the activity; or the assistance of two or more caregivers is
required for the patient to complete the activity.

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Chapter 3

•

Section K – ADLs / IADLs

If the patient does not attempt the activity and a caregiver does not complete the activity for
the patient, report the reason the activity was not attempted.

Enter 07 – Patient refused, if the patient refused to complete the activity.

Enter 09 – Not Applicable, if the patient did not perform this activity prior to the current illness,
exacerbation, or injury.

Code 88 – Not attempted due to medical condition or safety concerns, if the activity was not
attempted due to medical condition or safety concerns.

If no information is available or assessment is not possible for reason other than above,
enter a dash (“–“) for 1-SOC/ROC Performance.

A dash ( –) value is a valid response for this item. A dash (–) value indicates that no information is
available, and/or an item could not be assessed. This most often occurs when the patient is
unexpectedly transferred, discharged or dies before assessment of the item could be completed.
CMS expects dash use to be a rare occurrence.

For GG0170C2 – Discharge Goal, report the discharge goal using the 6-point scale. Do not enter 07, 09, or
88 to report the discharge goal. The assessing clinician, in conjunction with patient and family input, can
establish the discharge goal.
-

If the clinician, in collaboration with the patient and caregiver(s), determines that the patient is
expected to make functional progress by discharge, the response reported for Discharge Goal will
be higher (more independent) than the SOC/ROC Performance response.

If the clinician, patient, and family determine that the medically complex patient is not expected to
make progress during the home health episode, but it is expected that the patient would be able to
maintain his/her SOC functional level, the Discharge Goal response will be the same as the
patient’s SOC Performance response.

If the clinician, in collaboration with the patient and/or caregiver(s) determine that a patient with a
progressive neurological condition is expected to rapidly decline, and that skilled therapy services
may slow the decline of function, the Discharge Goal would be lower (more dependent) than the
SOC/ROC Performance response.

If the assessing clinician does not establish a Discharge Goal for the patient’s bed mobility task,
enter a dash (“–“) for 2-Discharge Goal.

A dash ( –) value is a valid response for this item. A dash (–) value indicates that no information is
available, and/or an item could not be assessed. This most often occurs when the patient is
unexpectedly transferred, discharged or dies before assessment of the item could be completed.
CMS expects dash use to be a rare occurrence.

Scoring Examples
1)

The patient pushes up from the bed to get himself from a lying to a seated position. The caregiver must
provide steadying (touching) as the patient scoots himself to the edge of the bed and lowers his feet onto the
floor.

•

GG0170C1 – SOC/ROC Performance: ENTER 04 – Supervision or touching assistance

•

Rationale: The patient required steadying/touching assistance in order to safely complete the task of
lying on his back to sitting on the side of the bed.

The patient pushes up on the bed to attempt to get himself from a lying to a seated position as the OT
provides much of the lifting assistance necessary for him to sit upright. The OT provides assistance as the
patient scoots himself to the edge of the bed and lowers his feet to the floor. Overall, the OT must provide
more than half of the effort to complete the task.

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Chapter 3

Section K – ADLs / IADLs

•

GG0170C1 - SOC/ROC Performance: ENTER 02 – Substantial/maximal assistance

•

Rationale: The patient required the caregiver to provide lifting and assistance that represents more
than half of the effort required to complete the task of lying on his back to sitting on the side of the bed.

The patient is obese and recovering from surgery for spinal stenosis with lower extremity weakness. The
caregiver partially lifts the patient’s trunk to a fully upright sitting position on the bed and minimally lifts each
leg toward the edge of the bed. The patient then scoots toward the edge of the bed, placing both feet flat
onto the floor. The patient completes most of the activity himself.

•

GG0170C1 - SOC/ROC Performance: ENTER 03 – Partial/moderate assistance

•

Rationale: The patient required the caregiver to provide limited assistance that represents more than
just verbal cues/touching/steadying, but less than half of the effort required to complete the task of lying
on his back to sitting on the side of the bed.

The patient states he wishes he could get out of bed himself rather than depending on his wife to help. At
the SOC the patient requires his wife to do most of the effort. Based on the patient’s prior functional status,
his current diagnoses, the expected length of stay, and his motivation to improve, the clinician expects that
by discharge, the patient would likely only require assistance helping his legs off the bed to complete the
supine to sitting task.

•

GG0170C1 - SOC/ROC Performance: ENTER 02 – Substantial/maximal assistance

•

GG0170C2 - Discharge Goal: Enter 03 – Partial/moderate assistance

•

Rationale: At the SOC, the patient required the caregiver to provide more than half of the effort
required to complete the task. The assessing clinician and patient expect functional improvement so
that by discharge the patient needs a caregiver to assistant, providing less than half of the effort.

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Chapter 3: K-18

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a
wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

Able to independently walk on even and uneven surfaces and negotiate stairs with or without
railings (specifically: needs no human assistance or assistive device).

With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to
independently walk on even and uneven surfaces and negotiate stairs with or without railings.

Requires use of a two-handed device (for example, walker or crutches) to walk alone on a
level surface and/or requires human supervision or assistance to negotiate stairs or steps or
uneven surfaces.

Able to walk only with the supervision or assistance of another person at all times.

Chairfast, unable to ambulate but is able to wheel self independently.

Chairfast, unable to ambulate and is unable to wheel self.

Bedfast, unable to ambulate or be up in a chair.

ITEM INTENT
•

Identifies the patient’s ability and the type of assistance required to safely ambulate or propel self in a
wheelchair over a variety of surfaces. The intent of the item is to identify the patient’s ABILITY, not
necessarily actual performance. "Willingness" and "adherence" are not the focus of these items. These
items address the patient's ability to safely ambulate or use a wheelchair, given the current physical and
mental/emotional/cognitive status, activities permitted, and environment. The patient must be viewed from a
holistic perspective in assessing ability to perform ADLs. Ability can be temporarily or permanently limited
by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or pain)

environmental barriers (for example, stairs, narrow doorways, unsafe flooring).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Follow-up.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Variety of surfaces refers to typical surfaces that the patient would routinely encounter in his/her
environment, and may vary based on the individual residence.

•

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Chapter 3: K-19

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1860)
•

The ambulation/locomotion scale presents the most optimal level first, then proceeds to less optimal mobility
abilities. Read each response carefully to determine which one best describes what the patient is able to do.

•

Regardless of the need for an assistive device, if the patient requires human assistance (hands on,
supervision and/or verbal cueing) to safely ambulate, enter Response 2 or Response 3, depending on
whether the assistance required is intermittent (“2”) or continuous (“3”).

If the patient is safely able to ambulate without a device on a level surface, but requires minimal
assistance on stairs, steps, and uneven surfaces, enter Response 2 (requires human supervision
or assistance to negotiate stairs or steps or uneven surfaces).

If a patient does not require human assistance, but safely ambulates with a walker in some areas of
the home, and a cane in other areas (due to space limitations, distances, etc.), enter the response
that reflects the device that best supports safe ambulation on all surfaces the patient routinely
encounters (for example, Response 2 is appropriate if a walker is required for safe ambulation in
the hallway and living room, even if there are some situations in the home where a cane provides
adequate support.)

If a patient does not have a walking device but is clearly not safe walking alone, enter Response 3,
able to walk only with the supervision or assistance should be reported, unless the patient is
chairfast.

Responses 4 and 5 refer to a patient who is unable to ambulate, even with the use of assistive
devices and/or continuous assistance. For a patient who demonstrates or reports ability to take one
or two steps to complete a transfer, but is otherwise unable to ambulate should be considered
chairfast, enter Response 4 or 5, based on ability to wheel self.

Assessment strategies: A combined observation/interview approach with the patient or caregiver is
helpful in determining the most accurate response for this item. Ask the patient about ambulation
ability. Observe the patient ambulating across the room or to the bathroom and the type of
assistance required. Note if the patient uses furniture or walls for support, or demonstrates loss of
balance or other actions that suggest a need for additional support for safe ambulation. Observe
patient’s ability and safety on stairs. If chairfast, assess ability to safely propel wheelchair
independently, whether the wheelchair is a powered or manual version.

DATA SOURCES / RESOURCES
•

Observation.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

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Chapter 3: K-20

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1870) Feeding or Eating: Current ability to feed self meals and snacks safely. Note: This refers only to the
process of eating, chewing, and swallowing, not preparing the food to be eaten.
Enter Code

0
1

2
3
4
5

Able to independently feed self.
Able to feed self independently but requires:
(a)
meal set-up; OR
(b)
intermittent assistance or supervision from another person; OR
(c)
a liquid, pureed or ground meat diet.
Unable to feed self and must be assisted or supervised throughout the meal/snack.
Able to take in nutrients orally and receives supplemental nutrients through a nasogastric
tube or gastrostomy.
Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or
gastrostomy.
Unable to take in nutrients orally or by tube feeding.

ITEM INTENT
•

Identifies the patient’s ability to feed him/herself, including the process of eating, chewing, and swallowing
food.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely selffeed, given the current physical and mental/emotional/cognitive status, activities permitted, and environment.
The patient must be viewed from a holistic perspective in assessing ability to perform ADLs. Ability can be
temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or hearing, pain).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

This item excludes evaluation of the preparation of food items, and transport to the table. Respond to this
item based on the assistance needed by the patient to feed himself once the food is placed in front of him.
Assistance means human assistance by verbal cueing/reminders, supervision, and/or stand-by or hands-on
assistance.

•

The patient’s ability may change as the patient’s condition improves or declines, or as medical restrictions
are imposed or lifted. The clinician must consider what the patient is able to do on the day of the
assessment. If ability varies over time, enter the response describing the patient’s ability more than 50% of
the time period under consideration.

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Chapter 3: K-21

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1870)
•

The feeding/eating scale presents the most optimal level first, then proceeds to less optimal feeding/eating
abilities. Read each response carefully to determine which one best describes what the patient is able to do.

●

Meal "set-up" (Response 1) includes activities such as mashing a potato, cutting up meat/vegetables when
served, pouring milk on cereal, opening a milk carton, adding sugar to coffee or tea, arranging the food on
the plate for ease of access, etc.—all of which are special adaptations of the meal for the patient.

•

Enter Response 2 if the patient is either unable to feed themselves and/or must be assisted or supervised
while eating.

•

If a tube is being used to provide all or some nutrition, enter Response 3 or 4, depending on the patient’s
ability to take in nutrients orally. If a patient is being weaned from tube feeding, Response 3 or 4 will
continue to apply until the patient no longer uses the tube for nutrition, at which time, enter Response 0, 1,
or 2. This is true, even if the tube remains in place, unused for a period of time.

•

Responses 4 and 5 include non-oral intake.

•

Response 5 is the best response for patients who are not able to take in nutrients orally or by tube feeding.
This may be the case for patients who receive all nutrition intravenously (such as TPN) or for patients who
are receiving only intravenous hydration.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Nutritional assessment.

•

Physician orders.

•

Plan of Care.

•

Referral information.

•

Review of past health history.

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Chapter 3: K-22

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1880) Current Ability to Plan and Prepare Light Meals (for example, cereal, sandwich) or reheat delivered
meals safely:
Enter Code

1
2

(a)
Able to independently plan and prepare all light meals for self or reheat delivered
meals; OR
(b)
Is physically, cognitively, and mentally able to prepare light meals on a regular basis
but has not routinely performed light meal preparation in the past (specifically: prior to this
home care admission).
Unable to prepare light meals on a regular basis due to physical, cognitive, or mental
limitations.
Unable to prepare any light meals or reheat any delivered meals.

ITEM INTENT
•

Identifies the patient’s physical, cognitive, and mental ability to plan and prepare meals, even if the patient
does not routinely perform this task.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely perform
light meal planning and preparation, given the current physical and mental/emotional/cognitive status,
activities permitted, and environment. The patient must be viewed from a holistic perspective in assessing
ability to perform IADLs. Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision, pain)

environmental barriers (for example, location of cooking appliances, food and meal prep supplies).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

•

In cases where a patient’s ability is different for various light meal preparation tasks, enter the response that
best describes the patient’s level of ability to perform the majority of light meal preparation tasks.

•

Response 0 indicates that during the day of assessment, the patient has the consistent physical and
cognitive ability to plan and prepare meals.

•

Response 1 indicates that during the day of assessment, the patient has inconsistent ability to prepare light
meals (for example, can’t prepare breakfast due to morning arthritic stiffness, but can prepare other meals
throughout day).

•

Response 2 indicates patient does not have the ability to prepare light meals at any point during the day of
assessment.

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Chapter 3: K-23

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1880)
•

While nutritional appropriateness of the patient’s food selections is not the focus of this item, any prescribed
diet requirements (and related planning/preparation) should be considered when entering a response.

•

When a patient’s prescribed diet consists either partially or completely of enteral nutrition, the clinician must
assess the patient’s ability to plan and prepare their prescribed diet, including their knowledge of the feeding
amount and ability to prepare the enteral feeding, based on product used. Note that the ability to set up,
monitor and change the feeding equipment is excluded from M1880, as it is addressed on row “e” of M2102.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Nutritional assessment.

•

Environmental assessment.

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Chapter 3: K-24

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1890) Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and
effectively using the telephone to communicate.
Enter Code

0
1
2
3
4
5
NA

Able to dial numbers and answer calls appropriately and as desired.
Able to use a specially adapted telephone (for example, large numbers on the dial, teletype
phone for the deaf) and call essential numbers.
Able to answer the telephone and carry on a normal conversation but has difficulty with
placing calls.
Able to answer the telephone only some of the time or is able to carry on only a limited
conversation.
Unable to answer the telephone at all but can listen if assisted with equipment.
Totally unable to use the telephone.
Patient does not have a telephone.

ITEM INTENT
•

Identifies the ability of the patient to answer the phone, dial number, and effectively use the telephone to
communicate.

•

The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance. "Willingness"
and "adherence" are not the focus of these items. These items address the patient's ability to safely use the
telephone, given the current physical and mental/emotional/cognitive status, activities permitted, and
environment. The patient must be viewed from a holistic perspective in assessing ability to perform IADLs.
Ability can be temporarily or permanently limited by:

physical impairments (for example, limited range of motion, impaired balance)

emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear)

sensory impairments (for example, impaired vision or hearing, pain)

environmental barriers (for example, phone type/features, size of numbers).

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are
imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to
do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability
more than 50% of the time period under consideration.

•

The telephone use scale presents the most independent level first, then proceeds to the most dependent.
Read each response carefully to determine which one best describes what the patient is able to do.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-25

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1890)
•

Ability to use telephone identifies the patient’s ability to safely answer the phone, dial a number, and
effectively use the telephone to communicate. If a speech impaired patient can only communicate using a
phone equipped with texting functionality, enter Response 1 - Able to use a specially adapted telephone.

DATA SOURCES / RESOURCES
•

Observation/demonstration is the preferred method.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

OASIS-C2 Guidance Manual
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Chapter 3: K-26

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1900) Prior Functioning ADL/IADL: Indicate the patient’s usual ability with everyday activities prior to his/her
most recent illness, exacerbation, or injury.

Enter Code

Self-Care (specifically: grooming, dressing, bathing, and toileting hygiene)
0 Independent
1 Needed Some Help
2 Dependent

Ambulation
0 Independent
1 Needed Some Help
2 Dependent

Transfer
0 Independent
1 Needed Some Help
2 Dependent

Household tasks (specifically: light meal preparation, laundry, shopping, and phone use )
0 Independent
1 Needed Some Help
2 Dependent

ITEM INTENT
•

Identifies the patient’s functional ability prior to the onset of the current illness, exacerbation of a chronic
condition, or injury (whichever is most recent) that initiated this episode of care. The intent of the item is to
identify the patient’s prior ABILITY, not necessarily actual performance. "Willingness" and "adherence" are
not the focus of these items.

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

For each functional area, enter a response.

•

“Independent” means that the patient had the ability to complete the activity by him/herself (with or without
assistive devices) without physical or verbal assistance from a helper.

•

“Needed some help” means that the patient contributed effort but required help from another person to
accomplish the task/activity safely.

•

“Dependent” means that the patient was physically and/or cognitively unable to contribute effort toward
completion of the task, and the helper must contribute all the effort.

•

“Self-care” refers specifically to grooming, dressing, bathing, and toileting hygiene. Medication management
is not included in the definition of self-care for M1900 as it is addressed in a separate question (M2040).

•

“Ambulation” refers to walking (with or without assistive device). Wheelchair mobility is not directly
addressed in this item. A patient who is unable to ambulate safely (even with devices and/or assistance), but

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: K-27

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1900)
is able to use a wheelchair (with or without assistance) would be reported as “Dependent” in Ambulation for
M1900.
•

”Transfer” refers specifically to tub, shower, commode, and bed to chair transfers.

•

“Household tasks” refers specifically to light meal preparation, laundry, shopping, and phone use.

•

If the patient was previously independent in some self-care tasks (or some transfers, or some household
tasks), but needed help or was completely dependent in others, pick the response that best describes the
patient’s level of ability to perform the majority of included tasks.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

•

Referral information.

•

Review of past health history.

•

Physician.

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: K-28

Chapter 3

Section K – ADLs / IADLs

OASIS ITEM
(M1910) Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated assessment
tool?
Enter Code

0
1
2

No.
Yes, and it does not indicate a risk for falls.
Yes, and it does indicate a risk for falls.

ITEM INTENT
•

Identifies whether the home health agency has assessed the patient and home environment for
characteristics that place the patient at risk for falls. The multi-factor falls risk assessment must include at
least one standardized, validated tool that 1) has been scientifically tested in a population with
characteristics similar to that of the patient being assessed (for example, community-dwelling elders,
noninstitutionalized adults with disabilities, etc.) and shown to be effective in identifying people at risk for
falls; and 2) includes a standard response scale. The standardized, validated tool must be both appropriate
for the patient based on their cognitive and physical status and appropriately administered per the tool’s
instructions.

•

TIME POINTS ITEM(S) COMPLETED
•

Start of care.

•

Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

CMS does not mandate that clinicians conduct falls risk screening for all patients, nor is there a mandate for
the use of a specific tool.

•

For Responses 1 and 2, an agency may use a single comprehensive multi-factor falls risk assessment tool
that meets the criteria as described in the item intent. Alternatively, an agency may incorporate several tools
as long as one of them meets the criteria as described in the item intent. For example, a physical
performance component (for example, Timed Up and Go), a medication review, review of patient history of
falls, assessment of lower limb function and selected OASIS items (for example, OASIS items for cognitive
status, vision, incontinence, ambulation, transferring).

•

Use the scoring parameters specified in the tool to identify if a patient is at risk for falls. Enter Response 1 if
the standardized, validated response scale rates the patient as no-risk, low-risk, or minimal risk. Enter
Response 2 if the standardized, validated response scale rates the patient as anything above low/minimalrisk. If the tool does not provide various levels, but simply has a single threshold separating those “at risk”
from those “not at risk,” then enter Response 2 for the patient scoring “at risk”.

•

In order to enter Response 1 or 2, the falls risk assessment must be conducted by the clinician responsible
for completing the comprehensive assessment during the time frame specified by CMS for completion of the
assessment.

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Chapter 3: K-29

Chapter 3

Section K – ADLs / IADLs

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1910)
•

Enter Response 0 if:

a standardized, validated multi-factor falls risk screening was NOT conducted by the home health
agency,

a standardized, validated multi-factor falls risk screening was conducted by the home health
agency but NOT during the required assessment time frame,

a standardized, validated multi-factor falls risk screening was conducted during the assessment
time frame, but NOT by the assessing clinician.

the patient is not able to participate in tasks required to allow the completion and scoring of the
standardized, validated assessment(s) that the agency chooses to utilize.

DATA SOURCES / RESOURCES
•

Observation.

•

Patient/caregiver interview.

•

Physical assessment.

•

Environmental assessment.

•

Referral information.

•

Review of past health history.

•

Several links to guidelines listing Falls Risk Assessment factors can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
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Chapter 3: K-30

Chapter 3

Section L – Medications

OASIS ITEM
(M2001)

Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?

Enter Code

No - No issues found during review [Go to M2010 ]

Yes - Issues found during review

NA - Patient is not taking any medications [Go to M2040 ]

ITEM INTENT
●

Identifies if review of the patient’s medications indicated any
potential clinically significant medication issues.

TIME POINTS ITEM(S) COMPLETED
●

Start of Care.

●

Resumption of Care.

RESPONSE—SPECIFIC INSTRUCTIONS

Definition: Medication interaction is
the impact of another substance (such
as another medication, nutritional
supplement including herbal products,
food, or substances used in diagnostic
studies) upon a medication. The
interactions may alter absorption,
distribution, metabolism, or elimination.
These interactions may decrease the
effectiveness of the medication or
increase the potential for adverse
consequences.

●

The drug regimen review in post-acute care is generally
considered to include medication reconciliation, a review of
all medications a patient is currently using and review of the
drug regimen to identify, and if possible, prevent potential
clinically significant medication issues.

●

The drug regimen review includes all medications,
prescribed and over the counter (including TPN and herbals),
administered by any route (for example, oral, topical,
inhalant, pump, injection, intravenous and via enteral tube).

●

In addition to “potential” issues, the item also includes the
identification of an existing clinically significant medication
issue that in the care provider’s clinical judgment requires
physician/physician-designee notification by midnight of the
next calendar day.

●

Potential or actual clinically significant medication issues may include but are not limited to: adverse
reactions to medications (such as a rash), ineffective drug therapy (analgesic that does not reduce pain),
side effects (potential bleeding from an anticoagulant), drug interactions (serious drug-drug, drug-food and
drug-disease interactions), duplicate therapy (generic name and brand name equivalent drugs are both
prescribed), omissions (missing drugs from an ordered regimen), dosage errors (either too high or too low),
and nonadherence (regardless of whether the nonadherence is purposeful or accidental).

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Definition: Adverse drug reaction
(ADR) is a form of adverse
consequences. It may be either a
secondary effect of a medication that is
usually undesirable and different from
the therapeutic effect of the medication
or any response to a medication that is
noxious and unintended and occurs in
doses for prophylaxis, diagnosis, or
treatment. The term “side effect” is
often used interchangeably with ADR,
however, side effects are but one of
five ADR categories, the others being
hypersensitivity, idiosyncratic
response, toxic reactions, and adverse
medication interactions. A side effect is
an expected, well-known reaction that
occurs with a predictable frequency
and may or may not constitute an
adverse consequence.

Chapter 3: L-1

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2001)
If portions of the drug regimen review (for example, identification of potential drug-drug interactions or potential
dosage errors) are completed by agency staff other than the clinician responsible for completing the SOC/ROC
OASIS, information on drug regimen review findings must be communicated to the clinician responsible for the
SOC/ROC OASIS assessment so that the appropriate response for M2001 may be entered. Collaboration in which
the assessing clinician evaluates patient status (for example, presence of potential ineffective drug therapy or patient
nonadherence), and another clinician (in the office) assists with review of the medication list (for example, possible
duplicate drug therapy or omissions) does not violate the requirement that the comprehensive patient assessment is
the responsibility of and must be ultimately completed by one clinician. Agency policy and practice will determine this
process and how it is documented. The M0090 date—the date the assessment is completed—would be the date the
two clinicians collaborated and the assessment was completed.
●

These are situations where based on clinical judgment during the drug regimen, the clinician may determine that
Response 0 – no issues found during review should be entered:
● Patient’s list of medications from the inpatient facility discharge instructions matches the medications the
patient shows the clinician at the SOC/ROC assessment visit.
●

Assessment shows that diagnoses/symptoms for which the patient is taking medications are adequately
controlled (as able to be assessed within the clinician’s scope of practice).

●

Patient possesses all medications prescribed.

●

Patient has a plan for taking medications safely at the right time.

●

Patient is not showing signs/symptoms that could be adverse reactions caused by medications.

These are situations where based on clinical judgment during the drug regimen review, the clinician may determine
that a potential clinically significant issues exists, and determine that Response 1 – issues found during review should
be entered:
● Patient’s list of medications from the inpatient facility discharge instructions DO NOT match the medications
the patient shows the clinician at the SOC/ROC assessment visit.
●

Assessment shows that diagnoses/symptoms for which the patient is taking medications are NOT
adequately controlled (as able to be assessed within the clinician’s scope of practice).

●

Patient seems confused about when/how to take medications indicating a high risk for medication errors.

●

Patient has not obtained medications or indicates that he/she will probably not take prescribed medications
because of financial, access, cultural, or other issues with medications.

●

Patient has signs/symptoms that could be adverse reactions from medications.

●

Patient takes multiple non-prescribed medications (OTCs, herbals) that could interact with prescribed
medications.

●

Patient has a complex medication plan with medications prescribed by multiple physicians and/or obtained
from multiple pharmacies so that the risk of drug interactions is high.

Any of these circumstances listed above must reach a level of clinical significance that warrants notification
of the physician/physician-designee for orders or recommendations—by midnight of the next calendar day,
at the latest. Any circumstance that does not require this immediate attention is not considered a potential or
actual clinically significant medication issue.

OASIS-C2 Guidance Manual
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Chapter 3: L-2

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2001)
Scoring Example
●

During the comprehensive assessment visit, the PT reviews all the patient’s medications and identifies no
problems except that the patient’s newly prescribed pain medication is not in the home. The daughter
states they were only going to pick it up from the pharmacy if “the pain got bad enough”. The PT
emphasizes the need to comply with the physician’s instructions for the new medication and prior to the PT
leaving the home, the daughter has gone to the drugstore and returned with the medication.

●

M2001: ENTER Response 0 – No – No issues found during review

●

Rationale: Because the issue did not require physician/physician-designee contact by midnight of the next
calendar day to resolve, it does not meet the criteria for a potential clinically significant medication issue.

DATA SOURCES / RESOURCES
●

Patient assessment, specifically the drug regimen review as required by Conditions of Participation
(§484.55).

●

Clinical record.

●

Communication notes.

●

Medication list.

●

Discussions with other agency staff responsible for completing drug regimen review.

●

Since medication issues continue to evolve and new medications are being approved regularly, it is
important to refer to a current authoritative source for detailed medication information such as indications
and precautions, dosage, monitoring or adverse consequences.

●

Physician’s Drug Reference (PDR) or other clinical medication handbook or software intended to provide
warning of severity levels of risk for medication review.

●

CMS OASIS Q&As can be accessed through the CMS OASIS web page.

●

Several online resources for evaluating drug reactions, side effects, interactions, etc., can be found in
Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: L-3

Chapter 3

Section L – Medications

OASIS ITEM
(M2003)

Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the
next calendar day and complete prescribed/recommended actions in response to the identified
potential clinically significant medication issues?

Enter Code
0

Yes

ITEM INTENT
●

Identifies if potential clinically significant medication issues identified through a medication review were
addressed with the physician (or physician-designee) by midnight of the next calendar day following their
identification.

●

A complete drug regimen review and identification of
actual or potential clinically significant medication
issues are medication management best practices in
health care settings. These best practices are not
necessarily required in the Conditions of Participation.

TIME POINTS ITEM(S) COMPLETED
●

Start of Care.

●

Resumption of Care.

RESPONSE—SPECIFIC INSTRUCTIONS

Definition: Contact with physician is
defined as communication to the physician
or physician-designee (made by
telephone, voicemail, electronic means,
fax, or any other means) that appropriately
conveys the message of patient status.
Communication can be directly to/from the
physician or physician-designee, or
indirectly through physician’s office staff
on behalf of the physician or physiciandesignee, in accordance with the legal
scope of practice.

●

Complete if Response 1 (Yes) is entered for M2001.

●

A potential clinically significant medication issue is an issue that in the care provider’s clinical judgment,
requires physician/physician-designee notification by midnight of the next calendar day (at the latest). The
term “potential” means that the clinician may identify a patient is at risk for occurrence of a clinically
significant medication issue before the issue occurs, and contacts the physician/physician-designee to
prevent the issue from occurring.

●

In addition to “potential” issues, the item also includes identification of existing clinically significant
medication issues that in the care provider’s clinical judgment require physician/physician-designee
notification by midnight of the next calendar day.

●

To enter Response 1 – Yes, the two-way communication AND completion of the prescribed/recommended
actions must have occurred by midnight of the next calendar day after the potential clinically significant
medication issue was identified.

●

If the physician/physician-designee recommends an action that will take longer than the allowed time to
complete, then Response 1 – Yes should be entered as long as by midnight of the next calendar day the
agency has taken whatever actions are possible to comply with the recommended action. Examples of
recommended actions that would take longer than the allowed time to complete might include physician
instruction to agency staff to continue to monitor the issue over the weekend and call if problem persists, or
the physician instructs the patient to address the concern with his PCP on a visit that is scheduled in two
days The actual type of actions recommended should be considered in determining if the agency has taken
whatever actions are possible by midnight of the next calendar day.

●

If the physician/physician-designee provides no new orders or instruction in response to timely reported
potential clinically significant medication issue(s), enter Response 1 – Yes, indicating that the
physician/physician-designee was contacted and prescribed/recommended actions were completed.

OASIS-C2 Guidance Manual
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Chapter 3: L-4

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2003)
●

When multiple potential clinically significant medication issues are identified at the SOC/ROC, all must be
communicated to the physician/physician-designee, with completion of all prescribed/recommended actions
occurring by midnight of the next calendar day in order to enter Response 1 –Yes.

●

If two potential clinically significant medication issues are identified at the SOC/ROC, both are
communicated to the physician/physician-designee timely, and the physician/physician-designee provides a
recommended action for each issue (for example, patient education for one medication, and a new dosage
for another); enter Response 1 – Yes if both recommended actions are completed by midnight of the next
calendar day. If both recommended actions could have been addressed by midnight of the next calendar
day, but only one was addressed, enter Response 0 – No.

●

If a potential clinically significant medication issue was identified, and the clinician attempted to
communicate with the physician, but did not receive communication back from the physician/physician
designee until after midnight of the next calendar day, enter Response 0 – No.

●

If agency staff other than the clinician responsible for completing the SOC/ROC OASIS contacted the
physician/physician-designee to follow up on clinically significant medication issues, this information must be
communicated to the clinician responsible for the SOC/ROC OASIS assessment so that the appropriate
response for M2003 may be entered. This collaboration does not violate the requirement that the
comprehensive patient assessment is the responsibility of, and must ultimately be completed by one
clinician.

●

A dash ( –) value is a valid response for this item. A dash (–) value indicates that no information is available,
and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred,
discharged or dies before assessment could be completed. However, providers should complete transfer
and discharge assessments to the best of their ability when a care episode ends unexpectedly. CMS
expects dash use to be a rare occurrence.

Scoring Example
●

During the SOC comprehensive assessment visit, the RN completes a drug review and identifies that the
patient is taking two antihypertensives; one which was newly prescribed during her recent hospital stay, and
another that she was taking prior to her hospitalization. During the home visit, the RN contacts the
physician’s office, and leaves a message with office staff providing notification of the potential duplicative
drug therapy and a request for clarification. The next day, the RN returns to the home to complete the
comprehensive assessment and again contacts the physician from the patient’s home. The physician’s
office nurse reports to the agency and patient that the physician would like the patient to continue with only
the newly prescribed antihypertensive and discontinue the previous medication.

●

M2001: ENTER Response 1 – Yes - Issues found during review.

●

M2003: ENTER Response 1 – Yes.

●

Rationale: Because the issue identified was determined by the clinician to be clinically significant, requiring
physician contact by midnight of the next calendar day, it meets the criteria for a potential clinically
significant medication issue (M2001). As the clinically significant issue was resolved by physician contact
and completion of prescribed/recommended actions by midnight of the next calendar day, the criteria for
M2003 were met.

DATA SOURCES / RESOURCES
●

Clinical record.

●

Communication notes.

●

Plan of Care.

●

Medication list.

●

Discussions with other agency staff responsible for completing drug regimen review.

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: L-5

Chapter 3

Section L – Medications

OASIS ITEM
(M2005)

Medication Intervention: Did the agency contact and complete physician (or physician-designee)
prescribed/recommended actions by midnight of the next calendar day each time potential clinically
significant medication issues were identified since the SOC/ROC?

Enter Code

Yes

NA – There were no potential clinically significant medication issues identified since SOC/ROC
or patient is not taking any medications

ITEM INTENT
●

Identifies if potential clinically significant medication issues such as adverse effects or drug reactions
identified at the time of or at any time since the SOC/ROC were addressed with the physician or physiciandesignee.

●

The best practices stated in the item are not necessarily required in the Conditions of Participation.

TIME POINTS ITEM(S) COMPLETED
●

Transfer to inpatient facility.

●

Death at home.

●

Discharge from agency— not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

●

In addition to “potential” issues, the item also includes physician/physician-designee follow-up when an
existing clinically significant medication issue is identified, that in the care provider’s clinical judgment
requires physician/physician-designee notification by midnight of the next calendar day.

●

Potential or actual clinically significant medication issues may include but are not limited to adverse
reactions to medications (such as a rash), ineffective drug therapy (analgesic that does not reduce pain),
side effects (potential bleeding from an anticoagulant), drug interactions (serious drug-drug, drug-food and
drug-disease interactions), duplicate therapy (generic name and brand name equivalent drugs are both
prescribed), omissions (missing drugs from an ordered regimen), dosage errors (either too high or too low),
nonadherence (regardless of whether the nonadherence is purposeful or accidental).

●

Contact with physician is defined as communication to the physician or physician-designee made by
telephone, voicemail, electronic means, fax, or any other means that appropriately conveys the message of
patient status. Communication can be directly to/from the physician or physician-designee, or indirectly
through physician’s office staff on behalf of the physician or physician-designee, in accordance with the legal
scope of practice.

●

To enter Response 1 – Yes, the two-way communication AND completion of the prescribed/recommended
actions must have occurred by midnight of the next calendar day each time a potential clinically significant
issue was identified.

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Chapter 3: L-6

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2005)
●

If the physician/physician-designee recommends an action that will take longer than the allowed time to
complete, then Response 1 - Yes should be entered as long as by midnight of the next calendar day the
agency has taken whatever actions are possible to comply with the recommended action. Examples of
recommended actions that would take longer than the allowed time to complete might include physician
instruction to agency staff to continue to monitor the issue over the weekend and call if problem persists, or
the physician instructs the patient to address the concern with his PCP on a visit that is scheduled in two
days The actual type of actions recommended should be considered in determining if the agency has taken
whatever actions are possible by midnight of the next calendar day.

●

If, when a potential clinically significant issue was identified, the physician/physician-designee provided no
new orders or instruction in response to the timely reported concern, Response 1 – Yes should be
reported, indicating that the physician/physician-designee was contacted and prescribed/recommended
actions were completed.

●

When multiple potential clinically significant medication issues were identified since the SOC/ROC, all must
have been communicated to the physician/physician-designee, with completion of all
prescribed/recommended actions occurring by midnight of the next calendar day in order to enter Response
1 –Yes.

●

If any potential clinically significant medication issue was identified at the time of or anytime since the SOC/
ROC, and was not both communicated to the physician/physician-designee AND addressed through
completion of any physician/physician-designee recommended action, enter Response 0 – No.

●

If the last OASIS assessment completed was the SOC or ROC, and a clinically significant medication issue
was identified at that SOC or ROC visit, the issue (and/or related physician/physician-designee
communication) would be reported at both the SOC/ROC (on M2003) and again at Transfer, Death or
Discharge (on M2005), since the time frame under consideration for M2005 is at the time of or at any time
since SOC/ROC.

●

A dash (–) value is a valid response for this item. A dash (–) value indicates that no information is available,
and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred,
discharged or dies before assessment could be completed. However, providers should complete transfer
and discharge assessments to the best of their ability when a care episode ends unexpectedly. CMS
expects dash use to be a rare occurrence.

Scoring Examples:

1) During the SOC comprehensive assessment, the RN completes the drug regimen review and identifies a
potential clinically significant medication issue. On that day of admission, the RN calls and leaves a message
with the physician’s office related to the medication issue. The physician does not return her call until after
midnight of the next calendar day. No other medication issues arise during the episode, and the patient is
discharged from home health.
At SOC:
● M2001: ENTER Response 1 – Yes—Issues found during review.
●
At DC:
●

M2003: ENTER Response 0 – No.

M2005: enter Response 0 – No.

Rationale: Because an issue identified was determined by the clinician to be clinically significant, requiring
physician contact by midnight of the next calendar day, it meets the criteria for a potential clinically significant
medication issue (1 – Yes for M2001). While the clinician initiated communication with the physician, the required
two-way communication did not occur until after midnight of the next calendar day, resulting in 0- No responses
for M2003 and M2005.

OASIS-C2 Guidance Manual
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Chapter 3: L-7

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2005)
2) During the Discharge assessment visit, the RN reviews the patient’s medication list and confirms that no
potential clinically significant medication issues are present. In reviewing the clinical record, there is
documentation that a drug regimen review was conducted earlier in the episode, and no potential clinically
significant medication issues were identified. There is no other documentation to indicate that potential clinically
significant medication issues occurred during the episode of care.
●

M2005: ENTER Response 9 (NA) – There were no potential clinically significant medication issues
identified since SOC/ROC or patient is not taking any medications.

●

Rationale: This item is reported as NA because there is documentation the agency looked for potential
clinically significant medication issues via completion of a drug regimen review conducted since the
SOC/ROC was completed, and no issues were found. Had there been documentation that a potential
clinically significant medication issue occurred during the episode, and there was no documentation
indicating follow-up with the physician/physician-designee by midnight of the next calendar day to
complete recommended actions, Response 0 (No) would be entered.

DATA SOURCES / RESOURCES
●

Clinical record.

●

Communication notes.

●

Medication list.

●

Plan of Care.

●

Discussions with other agency staff responsible for completing drug regimen review.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: L-8

Chapter 3

Section L – Medications

OASIS ITEM
(M2010)

Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on
special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how
and when to report problems that may occur?

Enter Code

Yes

NA Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about
special precautions associated with all high-risk medications

ITEM INTENT
●

Identifies if clinicians instructed the patient and/or caregiver about all high-risk medications the patient takes.
High-risk medications are those identified by quality organizations as having considerable potential for
causing significant patient harm when they are used erroneously.

●

This item is targeted to high-risk medications as it may be unrealistic to expect that patient education on all
medications occur on admission and failure to provide patient education on high-risk medications such as
hypoglycemics and anticoagulants (and others) at SOC/ROC could have severe negative impacts on patient
safety and health.

●

TIME POINTS ITEM(S) COMPLETED
●

Start of Care.

●

Resumption of Care.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Enter Response 0 – No, if the interventions are not completed as outlined in this item. However, in this case,
the care provider should document rationale in the clinical record unless the patient is not taking any drugs.

●

Enter Response 1 – Yes, if high-risk medications are prescribed and education was provided.

●

Enter Response NA – If patient/caregiver is fully knowledgeable about special precautions associated with
high-risk medications.

●

High-risk medications should be identified based on one or more authoritative sources.

●

If agency staff other than the clinician responsible for completing the SOC/ROC OASIS provided education
to the patient/caregiver on high-risk medications, this information must be communicated to the clinician
responsible for the SOC/ROC OASIS assessment so that the appropriate response for M2010 may be
selected. This collaboration does not violate the requirement that the comprehensive patient assessment is
the responsibility of and ultimately must be completed by one clinician.

DATA SOURCES / RESOURCES
●

Clinical record.

●

Communication notes.

●

Medication list.

●

Plan of Care.

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Centers for Medicare & Medicaid Services

Chapter 3: L-9

Chapter 3

Section L – Medications

DATA SOURCES / RESOURCES (cont’d for OASIS Item M2010)
●

Discussions with other agency staff responsible for educating patient/caregivers on medications.

●

Sources to identify high-risk medications for the purposes of responding to this item can include the Institute
for Safe Medication Practices High Alert Medication List, Beer's Criteria, Joint Commission's High Alert
Medication lists, or other authoritative resources.

●

Links to resources for identifying high-risk medications can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: L-10

Chapter 3

Section L – Medications

OASIS ITEM
(M2016)

Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent
SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care
provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side
effects, and how and when to report problems that may occur?

Enter Code

Yes

NA – Patient not taking any drugs

ITEM INTENT
●

Identifies if clinicians instructed the patient/caregiver about how to manage all medications effectively and
safely within the time period under consideration.

●

TIME POINTS ITEM(S) COMPLETED
●

Transfer to an inpatient facility.

●

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Drug education interventions for M2016 should address all medications the patient is taking, prescribed and
over-the-counter, by any route.

●

Effective, safe management of medications includes knowledge of effectiveness, potential side effects and
drug reactions, and when to contact the appropriate care provider.

●

If the interventions are not completed as outlined in this item, enter Response 0 (No). However, in this case,
the care provider should document rationale in the clinical record.

●

The timeframe should be considered at the time of or at any time since the most recent SOC/ROC
assessment.

DATA SOURCES / RESOURCES
●

Review of clinical record including teaching guidelines, flow sheets, clinical notes, etc.

●

Medication list.

●

Plan of Care.

●

Discussions with other agency staff responsible for educating patient/caregivers on medications.

●

Links to a resource for drug information can be found in Chapter 5 of this manual.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: L-11

Chapter 3

Section L – Medications

OASIS ITEM
(M2020)

Management of Oral Medications: Patient's current ability to prepare and take all oral medications
reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or
willingness.)
0

Able to independently take the correct oral medication(s) and proper dosage(s) at the correct
times.

Able to take medication(s) at the correct times if:

Enter Code

(a) individual dosages are prepared in advance by another person; OR
(b) another person develops a drug diary or chart.
2

Able to take medication(s) at the correct times if given reminders by another person at the
appropriate times

Unable to take medication unless administered by another person.

NA No oral medications prescribed.

ITEM INTENT
●

This item is intended to identify the patient’s ability to take all oral (p.o.) medications reliably and safely at all
times. The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance.
"Willingness" and "adherence" are not the focus of these items. These items address the patient's ability to
safely take oral medications, given the current physical and mental/emotional/cognitive status, activities
permitted, and environment. The patient must be viewed from a holistic perspective in assessing ability to
perform medication management. Ability can be temporarily or permanently limited by:
o
o
o
o

physical impairments (for example, limited manual dexterity);
emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment, fear);
sensory impairments (for example, impaired vision, pain);
environmental barriers (for example, access to kitchen or medication storage area, stairs, narrow
doorways).

TIME POINTS ITEM(S) COMPLETED
●

Start of care.

●

Resumption of care.

●

Discharge from agency - not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Includes all prescribed and OTC (over-the-counter) medications that the patient is currently taking and are
included on the Plan of Care.

●

Excludes topical, injectable, and IV medications.

●

Only medications whose route of administration is p.o. should be considered for this item. Medications are
considered to be p.o. if they are placed in the mouth and swallowed, with absorption occurring through the
gastrointestinal system. Medications administered by other routes, including sublingual, buccal, swish and
expectorate, or administered per gastrostomy (or other) tube are not to be considered for this item.

●

If the patient sets up her/his own "planner device" and is able to take the correct medication in the correct
dosage at the correct time as a result of this, enter Response 0.

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Chapter 3: L-12

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M2020)
●

Includes assessment of the patient’s ability to obtain the medication from where it is routinely stored, the
ability to read the label (or otherwise identify the medication correctly, for example patients unable to read
and/or write may place a special mark or character on the label to distinguish between medications), open
the container, select the pill/tablet or milliliters of liquid and orally ingest it at the correct times.

●

Enter Response 1 if the patient is independent in oral medication administration if another person must
prepare individual doses (for example, place medications in a medi-planner or other device) and/or if
another person in the home must modify the original medication container to enable patient access (for
example, removing childproof lids, marking labels for the visually impaired or those who cannot read), or if
someone in the home must develop a drug diary or chart which the patient relies on to take medications
appropriately.

●

Enter Response 2 if daily reminders to take medications are necessary, regardless of whether the patient is
independent or needs assistance in preparing individual doses (for example, setting up a “planner device”)
and/or developing a drug diary or chart. (Reminders provided by a device that the patient can independently
manage are not considered “assistance” or “reminders.”)

●

If a medication is ordered PRN and the medication is needed by the patient on the day of assessment—and
the patient needed a reminder to take this PRN medication on the day of assessment, Enter Response 2. If
the patient did not need any PRN medications on the day of the assessment and therefore no reminders
were necessary, assess the patient's ability on all of the medications taken on the day of assessment.

●

Enter Response 3 if the patient does not have the physical or cognitive ability on the day of assessment to
take all medications correctly (right medication, right dose, right time) as ordered and every time ordered,
and it has not been established (and therefore the clinician cannot assume) that set up, diary, or reminders
have already been successful. The clinician would need to return to assess if the interventions, such as
reminders or a med planner, were adequate assistance for the patient to take all medications safely.

●

If the patient’s ability to manage oral medications varies from medication to medication, consider the
medication for which the most assistance is needed when selecting a response.

●

For a patient residing in an assisted living facility where the facility holds and administers medications,
M2020 should continue to report the patient’s ability to take the correct oral medication(s) and proper
dosage(s) at the correct times. Report ability based on assessment of the patient’s vision, strength and
manual dexterity in the hands and fingers, as well as cognitive ability, despite the facility’s requirement.

DATA SOURCES / RESOURCES
●

Observation/demonstration is the preferred method.

●

Patient/caregiver interview.

●

Physical assessment.

●

Cognitive assessment.

●

Environmental assessment.

●

CMS OASIS Q&As can be accessed through the CMS OASIS web page.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: L-13

Chapter 3

Section L – Medications

OASIS ITEM
(M2030)

Management of Injectable Medications: Patient's current ability to prepare and take all prescribed
injectable medications reliably and safely, including administration of correct dosage at the appropriate
times/intervals. Excludes IV medications.
0

Able to independently take the correct medication(s) and proper dosage(s) at the correct
times.
Able to take injectable medication(s) at the correct times if:
(a) individual syringes are prepared in advance by another person; OR
(b) another person develops a drug diary or chart.
Able to take medication(s) at the correct times if given reminders by another person based on
the frequency of the injection
Unable to take injectable medication unless administered by another person.

Enter Code
1

2
3

NA No injectable medications prescribed.

ITEM INTENT
●

This item is intended to assess the patient’s ability to take all injectable medications reliably and safely at all
times. The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance.
"Willingness" and "adherence" are not the focus of these items. These items address the patient's ability to
safely manage injectable medications, given the current physical and mental/emotional/cognitive status,
activities permitted, and environment. The patient must be viewed from a holistic perspective in assessing
ability to perform medication management. Ability can be temporarily or permanently limited by:
o
o
o
o

TIME POINTS ITEM(S) COMPLETED
●

Start of care.

●

Resumption of care.

●

Follow-up.

●

Discharge from agency – not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Excludes IV medications, infusions (for example, medications given via a pump), and medications given in
the physician’s office or other settings outside the home.

●

Includes one-time injections administered in the home.

●

Includes assessment of the patient's ability to obtain the medication from where it is routinely stored, draw
up the correct dose accurately using aseptic technique, inject in an appropriate site using correct technique,
and dispose of the syringe properly.

●

Enter Response 0 if the patient sets up her/his own individual doses and is able to take the correct
medication in the correct dosage at the correct time as a result of this,

●

Enter Response 1 for a patient independent in injectable medication administration if another person must
prepare individual doses and/or if another person must develop a drug diary or chart.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: L-14

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M2030)
●

Enter Response 2 if reminders to take medications are necessary, regardless of the whether the patient is
independent or needs assistance in preparing individual doses and/or developing a drug diary or chart.
(Reminders provided by a device that the patient can independently manage are not considered
“assistance” or “reminders.”)

●

Enter Response 3 if the physician ordered the RN to administer an injection in the home

●

If the patient’s ability to manage injectable medications varies from medication to medication, consider the
medication for which the most assistance is needed when selecting a response.

●

PRN injectables, ordered and included on POC, are to be considered when determining the patient's ability
to manage injectable medications. If the PRN medication was not needed during the assessment timeframe,
use clinical judgment and make an inference regarding the patient's ability by asking them to describe and
demonstrate the steps for administration and needle disposal, considering the patient's cognitive and
physical status as well as any other barriers.

●

Assessment strategies: A combined observation/interview approach with the patient or caregiver is helpful in
determining the most accurate response for this item. Observe patient preparing the injectable medications.
If it is not time for the medication, ask the patient to describe and demonstrate the steps for administration.
The cognitive/mental status and functional assessments contribute to determining the appropriate response
for this item.

●

For a patient residing in an assisted living facility where the facility holds and administers medications,
M2030 should continue to report the patient’s ability to administer all injectable medication(s) reliably and
safely at all times. When medications are stored by the facility, use clinical judgment and make an inference
regarding the patient’s ability by asking the patient to describe and demonstrate the steps for administration
and needle disposal, considering the patient’s cognitive and physical status as well as any other barriers.

DATA SOURCES / RESOURCES
●

Observation/demonstration is the preferred method.

●

Patient/caregiver interview.

●

Physical assessment.

●

Cognitive assessment.

●

Environmental assessment.

●

CMS OASIS Q&As can be accessed through the CMS OASIS web page.

●

Chapter 5 of this manual has a link to the OASIS Q & As.

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Chapter 3: L-15

Chapter 3

Section L – Medications

OASIS ITEM
(M2040)

Prior Medication Management: Indicate the patient’s usual ability with managing oral and injectable
medications prior to his/her most recent illness, exacerbation or injury.

Enter Code

Oral medications
0

Independent

Needed Some Help

Dependent

NA Not Applicable
Enter Code

Injectable medications
0

Independent

Needed Some Help

Dependent

NA Not Applicable

ITEM INTENT
●

Identifies the patient’s ability to manage all prescribed oral and injectable medications prior to the onset of
the current illness, exacerbation of a chronic condition, or injury (whichever is most recent) that initiated this
episode of care. The intent of the item is to identify the patient’s prior ABILITY, not necessarily actual
performance. "Willingness" and "adherence" are not the focus of these items. This item is used for risk
adjustment and can be helpful for setting realistic goals for the patient.

TIME POINTS ITEM(S) COMPLETED
●

Start of Care.

●

Resumption of Care.

RESPONSE—SPECIFIC INSTRUCTIONS
●

A care episode is not the same as a payment episode. The care episode begins with the most recent SOC
or ROC and ends with a Transfer or Discharge. For example, if a patient is resuming home care services
after a recent inpatient admission, report the patient’s ability to manage medications prior to the most recent
illness, exacerbation or injury that is the cause of this resumption of home care services.

●

Includes all prescribed and OTC (over-the-counter) oral medications and all prescribed injectable
medications that the patient was taking prior to most recent illness, and are included on the Plan of Care.

●

For each functional area (oral medications and injectable medications), enter a response.

●

If the patient's prior ability to manage oral or injectable medications varied from medication to medication,
consider the medication for which the most assistance was needed when selecting a response.

●

“Independent” means that the patient completed the activity by him/herself (with or without assistive devices)
without physical or verbal assistance from a helper or reminders from another person. (Reminders provided
by a device that the patient can independently manage are not considered “assistance” or “reminders.”)

●

“Needed some help” means that the patient required some help from another person to accomplish the
task/activity.

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Effective 1/1/2017
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Chapter 3: L-16

Chapter 3

Section L – Medications

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2040)
●

“Dependent” means that the patient was incapable of performing any of the task/activity. For oral
medications, this means that the patient was capable only of swallowing medications that were given to
her/him. For injectable medications, this means that someone else must have prepared and administered
the medication.

●

Enter “NA” if there were no oral medications (row a) or no injectable medications (row b) used.

DATA SOURCES / RESOURCES
●

Patient/caregiver interview.

●

Referral information.

●

Review of past health history.

●

Physician.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: L-17

Chapter 3

Section M – Care Management

OASIS ITEM
(M2102) Types and Sources of Assistance: Determine the ability and willingness of non-agency caregivers
(such as family members, friends, or privately paid caregivers) to provide assistance for the following
activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code

ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding)
0
1
2
3
4

Enter Code

IADL assistance (for example, meals, housekeeping, laundry, telephone, shopping, finances)
0
1
2
3
4

Enter Code

Medical procedures/ treatments (for example, changing wound dressing, home exercise
program)
0
1
2
3
4

Enter Code

Management of Equipment (for example, oxygen, IV/infusion equipment, enteral/ parenteral
nutrition, ventilator therapy equipment or supplies)
0
1
2
3
4

Enter Code

Supervision and safety (for example, due to cognitive impairment)
0
1
2
3
4

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: M-1

Chapter 3

Section M – Care Management

Advocacy or facilitation of patient's participation in appropriate medical care (for example,
transportation to or from appointments)
0
1
2
3
4

ITEM INTENT
•

Identifies ability and willingness of the caregiver(s) (other than home health agency staff) to provide
categories of assistance needed by the patient.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care.
Resumption of care.
Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

At SOC/ROC, report what is known on the day of assessment regarding ability and willingness of nonagency caregivers to provide help in the various categories of assistance for the upcoming episode of care.
At Discharge, report what is known on the day of the discharge assessment regarding the ability and
willingness of non-agency caregivers to provide assistance to the patient at the time of the discharge.

•

For each row a-g, enter one description of caregiver assistance.

•

If patient needs assistance with any aspect of a category of assistance (such as needs assistance with
some IADLs but not others), consider the aspect that represents the most need.

•

If more than one response represents the non-agency caregiver’s ability to provide assistance, select the
response that represents the caregiver’s greatest barrier to meet the need. For example, the caregiver
provides assistance but also needs training or support. In this example, report that the caregiver needs
training/supportive services to provide assistance, because it represents the caregiver’s greatest barrier to
meeting the patient’s need.

•

Enter Response 3 if:

Non-agency Caregiver(s) are not likely to provide care due to an unwillingness and/or inability on the part of
the non-agency caregiver(s); and/or if there is a reluctance on the part of the non-agency caregiver(s) to
provide care.

Row a – ADLs include basic self-care activities such as the examples listed.

Row b – IADLs include activities associated with independent living necessary to support the ADLs such as
the examples listed.

Row c – Medication administration refers to any type of medication (prescribed or OTC) and any route of
administration including oral, inhalant, injectable, topical, or administration via g-tube/j-tube, etc.

Row d – Medical procedures/treatments include procedures/treatments that the physician or physiciandesignee has ordered for the purpose of improving health status. Some examples of these
procedures/treatments include wound care and dressing changes, range of motion exercises, intermittent
urinary catheterization, postural drainage, electromodalities, etc.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: M-2

Chapter 3

Section M – Care Management

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2102)
-

Devices such as anti-embolism stockings, prosthetic devices, orthotic devices, or other supports that have a
medical and/or therapeutic impact should be considered medical procedures/treatments, not as
ADL/dressing items in Row a.

Row e – Management of equipment refers to the ability to safely use medical equipment as ordered.
Examples of medical equipment include oxygen, IV/infusion equipment, enteral/parenteral nutrition,
ventilator therapy equipment or supplies, continuous passive motion machine, wheelchair, hoyer lift, etc.

Row f – Supervision and safety includes needs related to the ability of the patient to safely remain in the
home. This category of assistance needs includes a wide range of activities that may be necessary due to
cognitive, functional, or other health deficits. Such assistance may range from calls to remind the patient to
take medications, to in-person visits to ensure that the home environment is safely maintained, to the need
for the physical presence of another person in the home to ensure that the patient doesn’t wander, fall, or for
other safety reasons (for example, leaving the stove burner on).

Row g – Advocacy or facilitation of patient's participation in appropriate medical care includes taking patient
to medical appointments, following up with filling prescriptions, or making subsequent appointments, etc.

DATA SOURCES / RESOURCES
•
•

Patient/caregiver interview.
Review of previous health history.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: M-3

Chapter 3

Section M – Care Management

OASIS ITEM
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home
health agency staff)?
Enter Code

1
2
3
4
5
UK

At least daily
Three or more times per week
One to two times per week
Received, but less often than weekly
No assistance received
Unknown

ITEM INTENT
•

Identifies the frequency of the assistance with ADLs (for example, bathing, dressing, toileting, transferring,
ambulating, feeding) or IADLs (for example, medication management, meal preparation, housekeeping,
laundry, shopping, financial management) provided by any non-agency caregivers.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care.
Resumption of care.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Responses are arranged in order of most to least assistance received from caregivers.

•

Note that this question is concerned broadly with ADLs and IADLs, not just the ones specified in other
OASIS items. ADLs are defined as the tasks of everyday life. Basic ADLs include eating, dressing, getting
into or out of a bed or chair, taking a bath or shower, and using the toilet. Instrumental activities of daily
living (IADL) are activities related to independent living and include preparing meals, managing money,
shopping, doing housework, and using a telephone.

•

Enter the response that reports how often the patient receives assistance with any ADL or IADL.

DATA SOURCES / RESOURCES
•

Patient/caregiver interview.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: M-4

Chapter 3

Section N – Therapy Need Plan of Care

OASIS ITEM
(M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this
assessment will define a case mix group, what is the indicated need for therapy visits (total of
reasonable and necessary physical, occupational, and speech-language pathology visits combined)?
(Enter zero [“000”] if no therapy visits indicated.)

() Number of therapy visits indicated (total of physical, occupational and speech-language pathology
combined).

⃞ NA – Not Applicable: No case mix group defined by this assessment.
ITEM INTENT
●

Identifies the total number of therapy visits (physical, occupational, or speech therapy combined) planned for
the Medicare payment episode for which this assessment will determine the case mix group, and only
applies to payers utilizing a payment model based on case mix group assignment.

TIME POINTS ITEM(S) COMPLETED
●

Start of care.

●

Resumption of care.

●

Follow-up.

RESPONSE—SPECIFIC INSTRUCTIONS
●

Therapy visits must (a) relate directly and specifically to a treatment regimen established by the physician
through consultation with the therapist(s), and (b) be reasonable and necessary to the treatment of the
patient’s illness or injury. The Medicare payment episode ordinarily comprises 60 days beginning with the
start of care date, or 60 days beginning with the recertification date.

●

Enter a number that is “zero filled and right justified.” For example, 11 visits should be reported as “011.”

●

Enter "000" if no therapy services are needed.

●

Once patient eligibility has been confirmed and the Plan of Care contains physician orders for the qualifying
service as well as other Medicare covered home health services, the qualifying service does not have to be
rendered prior to the other Medicare covered home health services ordered in the Plan of Care. The
sequence of visits performed by the disciplines must be dictated by the individual patient’s Plan of Care. For
example, an eligible patient in an initial 60-day episode that has both physical therapy and occupational
therapy orders in the Plan of Care, the sequence of the delivery of the type of therapy is irrelevant as long as
the need for the qualifying service is established prior to the delivery of other Medicare covered services and
the qualifying discipline provides a billable visit prior to transfer or discharge in accordance with the
Conditions of Participation.

●

For multidisciplinary cases – Nursing and Therapy may collaborate to answer this item correctly. The PT,
OT, and/or SLP are responsible to communicate the number of visits ordered by the physician to the RN
completing this item. Coordination of patient care is specified in the Conditions of Participation.

●

When a patient is discharged home from an inpatient facility admission in the last five days of a certification
period (the requirement to complete a Resumption of Care assessment overlaps with the requirement to
complete a Recertification assessment), CMS allows the agency to complete a single ROC assessment to
meet the requirements of both timepoints. In such cases, the total number of therapy visits planned for the
upcoming 60-day episode should be reported in M2200.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: N-1

Chapter 3

Section N – Therapy Need Plan of Care

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M2200)
●

Answer “NA” (Not Applicable) when this assessment will not be used to determine a case mix group for
Medicare, or other payers using a Medicare PPS-like model. Usually, the “NA” response will be checked for
patients whose payment source is not Medicare fee-for-service (that is, M0150, Response 1 is not checked),
or for an assessment that will not be used to determine a Medicare case mix group. However, payers other
than the Medicare program may use this information in setting an episode payment rate. If the HHA needs a
case mix code (HIPPS code) for billing purposes, a response other than “NA” – Not Applicable is required to
generate the case mix code.

●

Assessment strategies: When the assessment and care plan are complete, review the Plan of Care to
determine whether therapy services are ordered by the physician. If not, enter "000." If therapy services are
ordered, how many total visits are indicated over the 60-day payment episode? If the number of visits that
will be needed is uncertain, provide your best estimate. As noted in item intent above, the Medicare payment
episode ordinarily comprises 60 days beginning with the start of care date, or 60 days beginning with the
recertification date.

DATA SOURCES / RESOURCES
●

Physician’s orders.

●

Referral information.

●

Plan of Care.

●

Clinical record.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: N-2

Chapter 3

Section N – Therapy Need Plan of Care

OASIS ITEM
(M2250) Plan of Care Synopsis: (Check only one box in each row.) Does the physician-ordered plan of care
include the following:
Plan / Intervention

Yes

Not Applicable

Patient-specific parameters for
notifying physician of changes in vital
signs or other clinical findings

⃞0

⃞1

⃞ NA

Physician has chosen not to establish
patient-specific parameters for this
patient. Agency will use standardized
clinical guidelines accessible for all care
providers to reference.

Diabetic foot care including
monitoring for the presence of skin
lesions on the lower extremities and
patient/caregiver education on proper
foot care

⃞0

⃞1

⃞ NA

Patient is not diabetic or is missing lower
legs due to congenital or acquired
condition (bilateral amputee).

Falls prevention interventions

⃞0

⃞1

⃞ NA

Falls risk assessment indicates patient
has no risk for falls.

Depression intervention(s) such as
medication, referral for other
treatment, or a monitoring plan for
current treatment and/or physician
notified that patient screened positive
for depression

⃞0

⃞1

⃞ NA

Patient has no diagnosis of depression
AND depression screening indicates
patient has: 1) no symptoms of
depression; or 2) has some symptoms of
depression but does not meet criteria for
further evaluation of depression based
on screening tool used.

Intervention(s) to monitor and
mitigate pain

⃞0

⃞1

⃞ NA

Pain assessment indicates patient has
no pain.

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞ NA

Pressure ulcer risk assessment (clinical
or formal) indicates patient is not at risk
of developing pressure ulcers.

Pressure ulcer treatment based on
principles of moist wound healing OR
order for treatment based on moist
wound healing has been requested
from physician

⃞0

⃞1

⃞ NA

Patient has no pressure ulcers OR has
no pressure ulcers for which moist
wound healing is indicated.

ITEM INTENT
●

Identifies if the physician-ordered home health Plan of Care incorporates specific best practices. Included in
the physician-ordered Plan of Care means that the patient condition has been discussed and there is
agreement as to the Plan of Care between the home health agency staff and the physician.

●

TIME POINTS ITEM(S) COMPLETED
●

Start of care.

●

Resumption of care.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: N-3

Chapter 3

Section N – Therapy Need Plan of Care

RESPONSE—SPECIFIC INSTRUCTIONS
●

Select “Yes” if the Plan of Care contains orders for best practice interventions as specified in each row,
based on the patient’s needs.
-

The physician Plan of Care includes all additional orders as an extension of the original Plan of Care.

●

“Yes” is an appropriate response if the intervention is in the Plan of Care even if the assessment indicated
the intervention was not applicable.

●

This question can be answered “Yes” prior to the receipt of signed orders if the clinical record reflects
evidence of communication with the physician to include specified best practice interventions in the Plan of
Care. Assuming all other OASIS information is completed, the Date Assessment Completed (M0090) then
becomes the date of the communication with the physician to establish the Plan of Care that includes
interventions listed in M2250.

●

If “NA” criteria does not apply, select “No" if orders for interventions have been requested but not authorized
by the end of the comprehensive assessment time period, unless otherwise indicated in rows d & g. This
means Plan of Care orders must be in place within five days for SOC in order to respond “Yes.” For ROC,
the Plan of Care orders must be in place within two days of inpatient discharge, or within two days of
becoming aware of an inpatient discharge, in order to respond “Yes” to M2250.

●

After reviewing physician orders for home health care and conducting a comprehensive assessment of the
patient, the Plan of Care should be developed as required by Conditions of Participation: 484.14 Standard:
Plan of Care. If the physician refers the patient under a Plan of Care that cannot be completed until after an
initial visit and eligibility has been determined, the physician is consulted to approve additions or modification
to the original plan.

●

If the assessing clinician chooses to wait to complete M2250 until after discussion with another discipline
that has completed their assessment and care plan development, this does not violate the requirement that
the comprehensive assessment be completed by one clinician within the required time frame (within five
days of SOC, within two days of discharge from the inpatient facility at ROC). For example, if the RN
identifies falls risk during the SOC comprehensive assessment, the RN can wait until the PT conducts
his/her evaluation and develops the PT care plan to determine if the patient’s Plan of Care includes
interventions to prevent falls risk. The M0090 date should reflect the last date that information was gathered
that was necessary for completion of the assessment.

●

For each row a-g, select one response.

●

Row a: If the physician-ordered Plan of Care contains specific clinical parameters relevant to the patient's
condition that, when out of specified range, would indicate that the physician should be contacted, select
“Yes.” The parameters may be ranges and may include temperature, pulse, respirations, blood pressure,
weight, wound measurements, pain intensity ratings, intake and output measurements, blood sugar levels,
or other relevant clinical assessment findings. Select “NA” if the physician chooses not to identify patientspecific parameters and the agency will use standardized guidelines that are made accessible to all care
team members.

●

If the Plan of Care includes specific parameters ordered by the physician for this specific patient or after
reviewing the agency's standardized parameters with the physician, s/he agrees they would meet the needs
of this specific patient, select “Yes.” If there are no patient-specific parameters on the Plan of Care and the
agency will not use standardized physician notification parameters for this patient, select “No.” If the
agency uses their own agency standardized guidelines, which the physician has NOT agreed to include in
the Plan of Care for this particular patient, select “NA.”

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: N-4

Chapter 3

Section N – Therapy Need Plan of Care

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2250)
●

Row b: If the physician-ordered Plan of Care contains both orders for a) monitoring the skin of the patient's
lower extremities for evidence of skin lesions AND b) patient education on proper foot care, select “Yes.” If
the physician-ordered Plan of Care contains orders for only one (or none) of the interventions, select “No”
unless “NA” applies. Select “NA” if the patient does not have a diagnosis of diabetes mellitus or is a bilateral
amputee or is missing lower legs due to a congenital or acquired condition.

●

Row c: If the physician-ordered Plan of Care contains specific interventions to reduce the risk of falls, select
“Yes.” Environmental changes and strengthening exercises are examples of possible fall prevention
interventions. If the Plan of Care does not include interventions for fall prevention, mark “No” unless “NA”
applies. Select “NA” if an informal or formal falls risk assessment indicates no risk for falls, or if the response
scale of a standardized, validated falls risk assessment tool rates the patient as no risk or low/minimal-risk. If
the tool does not provide various levels, but simply has a single threshold separating those “at risk” from
those “not at risk,” then patient scoring “not at risk” should be scored as “NA,” (unless fall prevention orders
are present). If more than one falls risk assessment was completed by the assessing clinician, all must be
negative in order to select “NA.”

●

Row d: If the physician-ordered Plan of Care contains orders for further evaluation or treatment of
depression, AND/OR if the physician has been notified about a positive depression screen, select “Yes.”
Examples of interventions for depression may include new or existing medications, adjustments to alreadyprescribed medications, psychotherapy, or referrals to agency resources (for example, social worker). If the
patient is already under physician care for a diagnosis of depression, interventions may include monitoring
medication effectiveness, teaching regarding the need to take prescribed medications, etc. If the patient has
no diagnosis of depression AND does not meet criteria for further evaluation based on a formal or informal
depression assessment, select “NA” (unless the physician has been notified about a positive depression
screen, or orders for further evaluation or treatment of depression are present). If more than one depression
screen was completed by the assessing clinician, all must be negative in order to select “NA.”

●

Row e: If the physician-ordered Plan of Care contains interventions to monitor AND mitigate pain, select
“Yes.” Examples of interventions to mitigate pain include medication, massage, visualization, and
biofeedback. If the physician-ordered Plan of Care contains orders for only one (or none) of the interventions
(for example, pain medications but no monitoring plan), select “No,” unless “NA” applies. If the clinician
completed a formal or informal assessment that indicated the patient has no pain, select “NA” (unless orders
for further monitoring and mitigating pain are present). If more than one pain assessment was completed by
the assessing clinician, all must be negative in order to select “NA.”

●

Row f: If the physician-ordered Plan of Care includes planned clinical interventions to reduce pressure on
bony prominences or other areas of skin at risk for breakdown, select “Yes.” Planned interventions can
include teaching on frequent position changes, proper positioning to relieve pressure, careful skin
assessment and hygiene, use of pressure-relieving devices such as enhanced mattresses, etc. If the
clinician completed a formal or informal assessment that indicated the patient is not at risk for pressure
ulcers, select “NA” (unless orders for interventions to reduce pressure on areas of skin at risk for breakdown
are present). If more than one pressure ulcer risk assessment was completed by the assessing clinician, all
must be negative in order to select “NA.”

●

Row g: If the physician-ordered Plan of Care contains orders for pressure ulcer treatments based on
principles of moist wound healing (for example, moisture retentive dressings) OR if such orders have been
requested from the physician, select “Yes.” If the patient has no pressure ulcers OR no pressure ulcers
needing moist wound healing treatments per physician, select “NA” (unless orders for pressure ulcer
treatments based on principles of moist wound healing are present).
-

Moist wound healing treatment is any primary dressing that hydrates or delivers moisture to a wound
thus promoting an optimal wound environment and includes films, alginates, hydrocolloids, hydrogels,
collagen, negative pressure wound therapy, Unna boots, medicated creams/ointments.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: N-5

Chapter 3

Section N – Therapy Need Plan of Care

DATA SOURCES / RESOURCES
●

Plan of Care.

●

Physician’s orders.

●

Clinical record.

●

Communication notes.

●

See Chapter 5 of this manual for links to additional resources.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: N-6

Chapter 3

Section O – Emergent Care

OASIS ITEM
(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the
patient utilized a hospital emergency department (includes holding/observation status)?

Enter Code

No [Go to M2401 ]

1
2

Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission

Unknown [Go to M2401 ]

ITEM INTENT
•

Identifies whether the patient was seen in a hospital emergency department at the time of or at any time
since the most recent SOC/ROC assessment. Responses to this item include the entire period at or since
the most recent SOC/ROC assessment, including use of hospital emergency department that results in a
qualifying hospital admission, necessitating Transfer OASIS data collection. This item includes current
events.

TIME POINTS ITEM(S) COMPLETED
•
•

Transfer to an inpatient facility—with or without agency discharge.
Discharge from agency.

RESPONSE—SPECIFIC INSTRUCTIONS
•

This item excludes urgent care services not provided in a hospital emergency department, including care
provided at doctor's office, care provided by an ambulance crew, or care received in urgent care facilities.
This item includes holding and observation only in the hospital emergency department setting.

•

An urgent care facility is defined as a freestanding walk-in clinic (not a department of a hospital) for patients
in need of immediate medical care. Urgent care centers treat many problems that can be seen in a primary
care physician's office, but urgent care centers offer some services that are generally not available in
primary care physician offices. For example, X-ray facilities allow for treatment of minor fractures and foreign
bodies, such as nail gun injuries. Most urgent care centers offer extended hours in evenings and on
weekends for patients to receive treatment when their personal physician is not available.

•

If a patient went to a hospital emergency department, regardless of whether the patient/caregiver
independently made the decision to seek emergency department services or was advised to go the
emergency department by the physician, home health agency, or other health care provider, then Response
1 or 2 should be entered depending on whether or not a hospital admission occurred.

•

If a patient went to a hospital emergency department, was “held” at the hospital for observation, then
released, the patient did receive emergent care. The time period that a patient can be "held" without
admission can vary. "Holds" can be longer than 23 hours but emergent care should be reported regardless
of the length of the observation "hold." An OASIS transfer assessment is not required if the patient was
never actually admitted to an inpatient facility.

•

If a patient went to a hospital emergency department and was subsequently admitted to the hospital, enter
Response 2. An OASIS transfer assessment is required (assuming the patient stay was for 24 hours or
more for reasons other than diagnostic testing).

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: O-1

Chapter 3

Section O – Emergent Care

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M2301)
•

If a patient is admitted to the hospital for a stay requiring an OASIS Transfer, Response 0 – No, should only
be marked if the patient was directly admitted to the hospital (was not treated or evaluated in the emergency
room), and had no other emergency department visits at or since the most recent SOC/ROC assessment.

•

Enter Response 1 for a patient who, at the time of or at any time since the most recent SOC/ROC was
collected, accessed a hospital emergency department that did not result in an admission to the hospital.

•

If a patient utilized a hospital emergency department more than once at the time of or at any time since the
most recent SOC/ROC, enter Response 2 if any emergency department visit at or since the most recent
SOC/ROC resulted in hospital admission. If no admission, enter Response 1.

•

In Responses 1 and 2, “hospital admission” is defined as admission to a hospital where the stay is for 24
hours or longer, for reasons other than diagnostic testing.

•

A patient who dies in a hospital emergency department is considered to have been under the care of the
emergency department, not the home health agency. In this situation, a Transfer assessment, not an
assessment for "Death at Home," should be completed. For M2301, enter Response 1 – Yes, used hospital
emergency department WITHOUT hospital admission.

DATA SOURCES / RESOURCES
•
•
•
•
•

Patient/caregiver interview.
Clinical record.
Hospital emergency department discharge information.
Physician.
Hospital emergency department staff.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: O-2

Chapter 3

Section O – Emergent Care

OASIS ITEM
(M2310) Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care
(with or without hospitalization)? (Mark all that apply.)

⃞1

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis

⃞2

Injury caused by fall

⃞3

Respiratory infection (for example, pneumonia, bronchitis)

⃞4

Other respiratory problem

⃞5

Heart failure (for example, fluid overload)

⃞6

Cardiac dysrhythmia (irregular heartbeat)

⃞7

Myocardial infarction or chest pain

⃞8

Other heart disease

⃞9

Stroke (CVA) or TIA

⃞ 10

Hypo/Hyperglycemia, diabetes out of control

⃞ 11

GI bleeding, obstruction, constipation, impaction

⃞ 12

Dehydration, malnutrition

⃞ 13

Urinary tract infection

⃞ 14

IV catheter-related infection or complication

⃞ 15

Wound infection or deterioration

⃞ 16

Uncontrolled pain

⃞ 17

Acute mental/behavioral health problem

⃞ 18

Deep vein thrombosis, pulmonary embolus

⃞ 19

Scheduled treatment or procedure

⃞ 20

Other than above reasons

⃞ UK

Reason unknown

ITEM INTENT
•

Identifies the reasons for which the patient sought and/or received care in a hospital emergency department.

TIME POINTS ITEM(S) COMPLETED
•
•

Transfer to an inpatient facility - with or without agency discharge.
Discharge from agency.

RESPONSE—SPECIFIC INSTRUCTIONS
•

This item excludes urgent care services not provided in a hospital emergency department, including care
provided in a doctor's office, care provided by an ambulance crew, or care received in urgent care facilities.

•

If more than one reason contributed to the hospital emergency department visit, mark all appropriate
responses. For example, if a patient received care for a fall at home and was found to have medication side
effects, mark both responses.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: O-3

Chapter 3

Section O – Emergent Care

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M2310)
•

Response 2 should be selected when the patient sought care in the hospital emergency department for an
injury caused by a fall, regardless of where the fall occurred.

•

Select Response 19 if a patient seeks emergent care in the hospital emergency department for a new
wound that was not the result of a fall.

•

If a patient seeks care in a hospital emergency department for a specific suspected condition, report that
condition, even if the suspected condition was ruled out (for example, patient was sent to ED for suspected
DVT but diagnostic testing and evaluation were negative for DVT).

•

If the reason is not included in the choices, select Response 19 - Other than above reasons.

•

If the patient has received emergent care in a hospital emergency department multiple times since the most
recent SOC/ROC, include the reasons for all visits.

DATA SOURCES / RESOURCES
•
•
•
•
•

Patient/caregiver interview.
Clinical record.
Hospital emergency department discharge information.
Physician.
Hospital emergency department.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: O-4

Chapter 3

Section P – Discharge

OASIS ITEM
(M2401) Intervention Synopsis: (Check only one box in each row.) At the time of or at any time since the most
recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered
plan of care AND implemented?
Plan / Intervention
a.

Diabetic foot care including
monitoring for the presence of skin
lesions on the lower extremities
and patient/caregiver education on
proper foot care
Falls prevention interventions

Depression intervention(s) such as
medication, referral for other
treatment, or a monitoring plan for
current treatment

Intervention(s) to monitor and
mitigate pain

Intervention(s) to prevent pressure
ulcers

Pressure ulcer treatment based on
principles of moist wound healing

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

⃞0

Yes

⃞1

Not Applicable

⃞ NA

⃞0

⃞1

⃞ NA

⃞0

⃞1

⃞ NA

⃞0

⃞1

⃞ NA

⃞0

⃞1

⃞ NA

⃞0

⃞1

⃞ NA

Patient is not diabetic or is missing
lower legs due to congenital or
acquired condition (bilateral amputee).

Every standardized, validated multifactor fall risk assessment conducted at
or since the most recent SOC/ROC
assessment indicates the patient has
no risk for falls.
Patient has no diagnosis of depression
AND every standardized, validated
depression screening conducted at or
since the most recent SOC/ROC
assessment indicates the patient has:
1) no symptoms of depression; or 2)
has some symptoms of depression but
does not meet criteria for further
evaluation of depression based on
screening tool used.
Every standardized, validated pain
assessment conducted at or since the
most recent SOC/ROC assessment
indicates the patient has no pain.
Every standardized, validated pressure
ulcer risk assessment conducted at or
since the most recent SOC/ROC
assessment indicates the patient is not
at risk of developing pressure ulcers.
Patient has no pressure ulcers OR has
no pressure ulcers for which moist
wound healing is indicated.

Chapter 3: P-1

Chapter 3

Section P – Discharge

ITEM INTENT
•

Identifies if specific interventions focused on specific problems were both included on the physician-ordered
home health Plan of Care AND implemented as part of care provided during the home health care episode
(at the time of or at any time since the most recent SOC/ROC assessment). “Included in the physicianordered Plan of Care” means that the patient condition was discussed and there was agreement as to the
Plan of Care between the home health agency staff and the patient’s physician.

•

This item is used to calculate process measures to capture the use of best practices. The problem-specific
interventions referenced in the item may or may not directly correlate to stated requirements in the
Conditions of Participation.

•

The formal assessment that is referred to in the last column for rows b–e refers to the assessment defined in
OASIS items for M1240, M1300, M1730, and M1910.

TIME POINTS ITEM(S) COMPLETED
•
•

Transfer to inpatient facility—with or without agency discharge.
Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Select "Yes" if the physician-ordered Plan of Care includes the specified best practice interventions as
specified in each row, at the time of or at any time since the most recent SOC/ROC assessment, and there
is evidence of implementation in the clinical record. If orders are present and implemented, “Yes” may be
selected even if the formal assessment was not conducted, or did not suggest a need for the particular
intervention.

•

Select “No” if the interventions are not on the Plan of Care OR if the interventions are on the Plan of Care
but the interventions were not implemented by the time the Discharge or Transfer assessment was
completed, unless “NA” applies.

•

Select “NA” if the plans/interventions specified in the row are not applicable for this patient. See guidance on
selecting “NA” for each row below.

•

Interventions provided by home health agency staff, including the assessing clinician, may be reported by
the assessing clinician in M2401. For example, if the RN finds a patient to be at risk for falls, and the
physical therapist implements fall prevention interventions included on the Plan of Care prior to the end of
the allowed assessment time frame, the RN may select “Yes” for row b of M2401. The M0090 Date
Assessment Completed should report the date the last information was gathered to complete the
comprehensive assessment.

•

For each row a-f, select one response.

•

For rows b, c, e, and f, the intervention specified in the first column must be both on the physician-ordered
Plan of Care AND implemented for “Yes” to be selected.

•

For rows a and d, BOTH of the interventions specified in the first column must be both on the physicianordered Plan of Care AND implemented for “Yes” to be selected.

•

For rows b-e, a formal assessment (as defined in the relevant OASIS item M1240, M1300, M1730, and
M1910) must have been performed to select “NA.”

•

An evaluation of clinical factors is not considered a formal assessment for M1300 pressure ulcer risk.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: P-2

Chapter 3

Section P – Discharge

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2401)
•

Row a: If the physician-ordered Plan of Care contains both orders for a) monitoring the skin of the patient's
lower extremities for evidence of skin lesions AND b) patient education on proper foot care and the clinical
record contains documentation that these interventions were performed at the time of or at any time since
the most recent SOC/ROC assessment, select “Yes.” If the physician-ordered Plan of Care contains orders
for only one of the interventions and/or only one type of intervention (monitoring or education) or no
intervention is documented in the clinical record, select “No,” unless “NA” applies. Select “NA” if the patient
does not have a diagnosis of diabetes mellitus or is missing lower legs due to congenital or acquired
condition (bilateral amputee).

•

Row b: If the physician-ordered Plan of Care contains specific interventions to reduce the risk of falls and the
clinical record contains documentation that these interventions were performed at the time of or at any time
since the most recent SOC/ROC assessment, select “Yes.” Environmental changes, strengthening
exercises, and consultation with the physician regarding medication concerns are examples of possible falls
prevention interventions. If the Plan of Care does not include interventions for fall prevention, and/or there is
no documentation in the clinical record that these interventions were performed at the time of or at any time
since the most recent SOC/ROC assessment, select “No,” unless “NA” applies. If all formal multi-factor falls
risk assessments conducted at the time of or at any time since the most recent SOC/ROC assessment
indicates the patient was not at risk for falls (if a single-threshold assessment is used), or at low, minimal, or
no risk for falls (if a multi-threshold tool is used), select “NA” (unless orders for fall prevention are present
and were implemented).

•

Row c: If the physician-ordered Plan of Care contains interventions for evaluation or treatment of depression
and the clinical record contains documentation that these interventions were performed at the time of or at
any time since the most recent SOC/ROC assessment, select “Yes.”

•

Interventions for depression may include new medications, adjustments to already-prescribed medications,
psychotherapy or referrals to agency resources (for example, social worker). If the patient is already under
physician care for a diagnosis of depression, interventions may include monitoring medication effectiveness,
teaching regarding the need to take prescribed medications, etc. If the Plan of Care does not include
interventions for treating depression and/or if no interventions related to depression are documented in the
clinical record at the time of or at any time since the most recent SOC/ROC assessment, select “No,” unless
“NA” applies. If every standardized, validated assessment conducted at the time of or any time since the
most recent SOC/ROC assessment indicates patient did not meet criteria for further evaluation of
depression AND patient did not have diagnosis of depression, select “NA” (unless orders for further
evaluation or treatment of depression are present and were implemented).

•

Row d: If the physician-ordered Plan of Care contains interventions to monitor AND mitigate pain and the
clinical record contains documentation that these interventions were performed at the time of or at any time
since the most recent SOC/ROC assessment, select “Yes.” Medication, massage, visualization,
biofeedback, and other intervention approaches have successfully been used to mitigate pain severity. If the
physician-ordered Plan of Care contains orders for only one of the interventions (for example, pain
medications but no monitoring plan) and/or only one type of intervention (for example, administering pain
medications but no pain monitoring) or no interventions were documented at the time of or at any time since
the most recent SOC/ROC assessment, select “No”, unless “NA” applies. If every standardized, validated
pain assessment conducted at or since the most recent SOC/ROC assessment was negative for pain, select
“NA” (unless orders for monitoring and mitigating pain are present and were implemented).

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: P-1

Chapter 3

Section P – Discharge

RESPONSE—SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2401)
•

Row e: If the physician-ordered Plan of Care includes planned clinical interventions to reduce pressure on
bony prominences or other areas of skin at risk for breakdown and the clinical record contains
documentation that these interventions were performed at the time of or at any time since the most recent
SOC/ROC assessment, select “Yes.” Planned interventions can include teaching on frequent position
changes, proper positioning to relieve pressure, careful skin assessment and hygiene, use of pressurerelieving devices such as enhanced mattresses, etc. If the Plan of Care does not include interventions to
prevent pressure ulcers and/or no interventions were documented in the clinical record at the time of or at
any time since the most recent SOC/ROC assessment, select “No,” unless “NA” applies. If every
standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC
assessment indicates the patient is not at risk of developing pressure ulcers, select “NA” (unless orders for
interventions to reduce pressure on areas of skin at risk for breakdown are present and were implemented).

•

Row f: If the physician-ordered Plan of Care contains orders for pressure ulcer treatments based on
principles of moist wound healing (for example, moisture retentive dressings) and the clinical record contains
documentation that these interventions were performed at the time of or at any time since the most recent
SOC/ROC assessment, select “Yes.” If the Plan of Care does not contain orders for pressure ulcer
treatments based on principles of moist wound healing and/or no pressure ulcer treatments based on
principles of moist wound healing were documented at the time of or at any time since the most recent
SOC/ROC assessment, select “No,” unless “NA” applies. If patient has no pressure ulcers OR has no
pressure ulcers for which moist wound healing is indicated per physician, select “NA” (unless orders for
pressure ulcer treatments based on principles of moist wound healing are present and were implemented).

DATA SOURCES / RESOURCES
•
•
•
•
•
•
•

Plan of Care.
Physician’s orders.
Clinical record.
Clinical assessment.
Communication notes.
Home Health Conditions of Participation.
Guidance on each particular item for the Plan of Care and intervention can be found in other item-by-item
tips within this document.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: P-2

Chapter 3

Section P – Discharge

OASIS ITEM
(M2410) To which Inpatient Facility has the patient been admitted?

Enter Code

Hospital [Go to M2430 ]

Rehabilitation facility [Go to M0903 ]

Nursing home [Go to M0903 ]

Hospice [Go to M0903 ]

No inpatient facility admission [Omit “NA” option on TRN ]

ITEM INTENT
•

Identifies the type of inpatient facility to which the patient was admitted.

TIME POINTS ITEM(S) COMPLETED
•
•

Transfer to inpatient facility—with or without agency discharge.
Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

If the patient was admitted to more than one facility, indicate the facility type to which the patient was
admitted first (for example, the facility type that they were transferred to from their home).

•

When a patient dies in a hospital emergency department, the RFA 7 – Transfer to an Inpatient Facility
OASIS is completed. In this unique situation, clinicians are directed to enter Response 1 – Hospital for
M2410, even though the patient was not admitted to the inpatient facility.

•

Admission to a freestanding rehabilitation hospital, a certified distinct rehabilitation unit of a nursing home, or
a distinct rehabilitation unit that is part of a short-stay acute hospital is considered a rehabilitation facility
admission.

•

Admission to inpatient drug rehabilitation is considered an inpatient admission. Enter Response 1 – Hospital,
whether it was a freestanding drug rehabilitation unit or a distinct drug rehabilitation unit that is part of a
short-stay acute hospital.

•

Admission to a skilled nursing facility (SNF), an intermediate care facility for individuals with intellectual
disabilities (ICF/IID), or a nursing facility (NF) is a nursing home admission

•

When completing a Transfer, enter Response 1, 2, 3, or 4. “NA” should not be an active/available response
at transfer.

•

When completing a Discharge from Agency – Not to an Inpatient Facility, enter Response “NA.”

DATA SOURCES / RESOURCES
•
•
•

Patient family interview (for agency discharge).
Telephone contact with caregiver or family if patient was transferred.
Facility.

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Chapter 3: P-3

Chapter 3

Section P – Discharge

OASIS ITEM
(M2420) Discharge Disposition: Where is the patient after discharge from your agency?
(Choose only one answer.)
Enter Code

1
2
3
4
UK

ITEM INTENT
•

Identifies where the patient resides after discharge from the home health agency.

TIME POINTS ITEM(S) COMPLETED
•

Discharge from agency—not to an inpatient facility.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Patients who are in assisted living or board and care housing are considered to be living in the community
with formal assistive services.

•

Formal assistive services refers to community-based services provided through organizations or by paid
helpers. Examples: homemaking services under Medicaid waiver programs, personal care services provided
by a home health agency, paid assistance provided by an individual, home-delivered meals provided by
organizations like Meals-on-Wheels.
-

Therapy services provided in an outpatient setting would not be considered formal assistance.

•

Informal services are provided by friends, family, neighbors, or other individuals in the community for which
no financial compensation is provided. Examples: assistance with ADLs provided by a family member,
transportation provided by a friend, meals provided by church members (specifically, meals not provided by
the church organization itself, but by individual volunteers).

•

Noninstitutional hospice is defined as the patient receiving hospice care at home or a caregiver’s home, not
in an inpatient hospice facility.

DATA SOURCES / RESOURCES
•
•
•

Patient/caregiver/family interview.
Physician.
Community resources.

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Chapter 3: P-4

Chapter 3

Section P – Discharge

OASIS ITEM
(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization?
(Mark all that apply.)

⃞1

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis

⃞2

Injury caused by fall

⃞3

Respiratory infection (for example, pneumonia, bronchitis)

⃞4

Other respiratory problem

⃞5

Heart failure (for example, fluid overload)

⃞6

Cardiac dysrhythmia (irregular heartbeat)

⃞7

Myocardial infarction or chest pain

⃞8

Other heart disease

⃞9

Stroke (CVA) or TIA

⃞ 10

Hypo/Hyperglycemia, diabetes out of control

⃞ 11

GI bleeding, obstruction, constipation, impaction

⃞ 12

Dehydration, malnutrition

⃞ 13

Urinary tract infection

⃞ 14

IV catheter-related infection or complication

⃞ 15

Wound infection or deterioration

⃞ 16

Uncontrolled pain

⃞ 17

Acute mental/behavioral health problem

⃞ 18

Deep vein thrombosis, pulmonary embolus

⃞ 19

Scheduled treatment or procedure

⃞ 20

Other than above reasons

⃞ UK

Reason unknown

ITEM INTENT
•

Identifies the specific condition(s) necessitating hospitalization.

TIME POINTS ITEM(S) COMPLETED
•

Transfer to inpatient facility—with or without agency discharge.

RESPONSE—SPECIFIC INSTRUCTIONS
•

Select all that apply. For example, if a psychotic episode results from an untoward medication side effect,
both Response 1 and Response 17 would be marked. As another example, if a patient requires
hospitalization for both heart failure and pneumonia, both Response 3 and Response 5 would be selected.

•

Response 2 should be selected if patient is hospitalized for an injury caused by a fall, regardless of where
the fall occurred.

•

Response 20 should be selected if the patient is hospitalized for a new wound that is not the result of a fall.

•

If the reason is not included in the choices, select Response 20 “Other than above reasons.”

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: P-5

Chapter 3

Section P – Discharge

DATA SOURCES / RESOURCES
•
•
•
•

Telephone contact with patient/caregiver/family.
Facility discharge planner or case manager.
Physician.
Insurance case manager.

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Effective 1/1/2017
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Chapter 3: P-6

Chapter 3

Section P – Discharge

OASIS ITEM
(M0903) Date of Last (Most Recent) Home Visit:

month

day

year

ITEM INTENT
•

Identifies the last or most recent home visit by any agency provider.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Transfer to an inpatient facility—with or without agency discharge.
Death at home.
Discharge from agency.

RESPONSE—SPECIFIC INSTRUCTIONS
•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits of the year.

•

If the agency policy is to have an RN complete the comprehensive assessment in a therapy-only case, the
RN can perform the discharge assessment after the last visit by the therapist.

•

Report the date of the last visit made to the home by agency staff, whether or not it was included on the Plan
of Care.

DATA SOURCES / RESOURCES
•

Clinical record.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 3: P-7

Chapter 3

Section P – Discharge

OASIS ITEM
(M0906) Discharge/Transfer/Death Date: Enter the date of the
discharge, transfer, or death (at home) of the patient.

month

day

year

ITEM INTENT
•

Identifies the actual date of discharge, transfer, or death (at home), depending on the reason for
assessment.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Transfer to an inpatient facility—with or without agency discharge.
Death at home.
Discharge from agency.

RESPONSE—SPECIFIC INSTRUCTIONS
•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2017 = 05/04/2017).
Enter all four digits for the year.

•

The date of discharge is determined by agency policy or physician order.

•

The transfer date is the actual date the patient was admitted to an inpatient facility.

•

The death date is the actual date of the patient’s death at home. Exclude death occurring in an inpatient
facility or in an emergency department, as both situations would result in Transfer OASIS collection and
would report the date of transfer. Include death that occurs while a patient is being transported to an
emergency department or inpatient facility (before being seen in the emergency department or admitted to
the inpatient facility).

DATA SOURCES / RESOURCES
•

Agency policy or physician order.

•

Telephone contact with the family or medical service provider may be required to verify the date of transfer
to an inpatient facility or death at home.

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Chapter 3: P-8

CHAPTER 4

ILLUSTRATIVE CLINICAL RECORD FORM PAGES WITH OASIS
ITEMS INTEGRATED

Chapter 4 of this manual contains sample pages from illustrative clinical record forms showing the integration of
OASIS C2 items. These illustrative forms pages are included for the following time points.
•
•
•
•

Illustration 1 – Start of Care Assessment.
Illustration 2 – Start of Care Assessment.
Illustration 3 – Discharge Assessment.
Illustration 4 – Transfer to Inpatient Facility.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 4-1

Chapter 4

Examples of Clinical Records
ILLUSTRATION 1
Sample Page from Clinical Record Form with Integrated OASIS Items.
START OF CARE ASSESSMENT
Client's Name:

(Also used for Resumption of Care Following Inpatient Stay)
Client Record No.
(Page 1 of __)
_____________________________________________
A. DEMOGRAPHIC INFORMATION – Complete Patient Tracking Sheet at SOC and Update at ROC
(M0080) Discipline of Person Completing Assessment
Enter
1
RN
Code
2
PT
3
SLP/ST
4
OT
(M0090) Date Assessment Completed:
/
/
month
day
year
(M0100) This Assessment is Currently Being Completed for the
Following Reason:
Enter
Code
Start/Resumption of Care
1
Start of care—further visits planned
3
Resumption of care (after inpatient stay)

(M0110) Episode Timing: Is the Medicare home health payment
episode for which this assessment will define a case mix
group an “early” episode or a “later” episode in the patient’s
current sequence of adjacent Medicare home health
payment episodes?
Enter
1
Early
Code
2
Later
UK
Unknown
NA
Not Applicable: No Medicare case mix group to
be defined by this assessment.

(M0102) Date of Physician-ordered Start of Care
(Resumption of Care): If the physician indicated a specific
start of care (resumption of care) date when the patient was
referred for home health services, record the date specified.
/
/
month day
year
[Go to M0110, if date entered ]
 NA –No specific SOC date ordered by physician

(M0104) Date of Referral: Indicate the date that the written
or verbal referral for initiation or resumption of care was
received by the HHA.
/
month

/
day

year

(M1011) List each Inpatient Diagnosis and ICD-10-CM code
at the level of highest specificity for only those conditions
actively treated during an inpatient stay having a discharge
date within the last 14 days (no V, W, X, Y, or Z codes or
surgical codes):
Inpatient Facility Diagnosis
ICD-10-CM code
a.
b.
c.
d.

Economic/Financial Problems or Needs (describe):

e.
f.

(M1000) From which of the following Inpatient Facilities was the patient
discharged within the past 14 days? (Mark all that apply.)








1 – Long-term nursing facility (NF)
2 – Skilled nursing facility (SNF / TCU)
3 – Short-stay acute hospital (IPPS)
4 – Long-term care hospital (LTCH)
5 – Inpatient rehabilitation hospital or unit (IRF)
6 – Psychiatric hospital or unit
7 – Other (specify)
____________________________________
 NA-Patient was not discharged from an inpatient facility
[Go to M1017 ]

(M1017) Diagnoses Requiring Medical or Treatment
Regimen Change Within Past 14 Days: List the patient's
Medical Diagnoses and ICD-10-C M codes at the level of
highest specificity for those conditions requiring changed
medical or treatment regimen within the past 14 days (no V,
W, X, Y, or Z codes or surgical codes):
Changed Medical Regimen
ICD-10-CM code
Diagnosis
a.
b.
c.
d.
e.

(M1005) Inpatient Discharge Date (most recent):
/
/
month
day
year

UK - Unknown

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

f.


NA - Not applicable (no medical or treatment
regimen changes within the past 14 days)

Chapter 4-2

Chapter 4

Examples of Clinical Records

ILLUSTRATION 2
Sample Page from Clinical Record Form with Integrated OASIS Items.
START OF CARE ASSESSMENT
Client's Name:
(Also used for Resumption of Care Following Inpatient Stay)
Client Record No.
(Page 1 of __)
_____________________________________
__________
L. Review of Systems/Physical Assessment (cont’d).
14. NEURO/EMOTIONAL/BEHAVIORAL STATUS
History of previous psychiatric illness __________
Other (specify) ____________________________
(M1700) Cognitive Functioning: Patient's current (day of
(M1710) When Confused (Reported or Observed
Within the Last 14 Days):
assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for
0
Never
simple commands.
Enter 1
In new or complex situations only
0 Alert/oriented, able to focus and shift attention,
Code 2
On awakening or at night only
Enter
comprehends and recalls task directions
3
During the day and evening, but not
Code
independently.
constantly
1 Requires prompting (cuing, repetition, reminders) only
4
Constantly
NA
Patient nonresponsive
under stressful or unfamiliar conditions.
2 Requires assistance and some direction in specific
situations (for example, on all tasks involving shifting
(M1720) When Anxious (Reported or Observed
of attention) or consistently requires low stimulus
Within the Last 14 Days):
environment due to distractibility.
0
None of the Time
3 Requires considerable assistance in routine
Enter 1
In new or complex situations only
situations. Is not alert and oriented or is unable to
Code 2
On awakening or at night only
shift attention and recall directions more than half the
3
During the day and evening, but not
time.
constantly
4 Totally dependent due to disturbances such as
4
Constantly
constant disorientation, coma, persistent vegetative
NA
Patient nonresponsive
state, or delirium.
(M1730) Depression Screening: Has the patient been screened for depression, using a standardized, validated depression
screening tool?
0
No
Enter
1
Yes, patient was screened using the PHQ-2©* scale.
Code

Instructions for this two-question tool: Ask patient: “Over the last two weeks, how often have you been bothered by
any of the following problems?”

a)
b)

2
3

PHQ-2©*

Not at all
0–1 day

Several days
2–6 days

More than half
of the days
7–11 days

Nearly
every day
12–14 days

NA
Unable to
respond

Little interest or pleasure in doing
things
Feeling down, depressed, or
hopeless?

⃞0

⃞1

⃞2

⃞3

⃞NA

⃞0

⃞1

⃞2

⃞3

⃞NA

Yes, patient was screened with a different standardized, validated assessment and the patient meets criteria for
further evaluation for depression.
Yes, patient was screened with a different standardized, validated assessment and the patient does not meet criteria
for further evaluation for depression.
*Copyright© Pfizer Inc. All rights reserved. Reproduced with permission.

(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated
at least once a week (Reported or Observed): (Mark all that apply.)
1- Memory deficit: failure to recognize familiar persons/places, inability to recall
events of past 24 hours, significant memory loss so that supervision is required
2- Impaired decision-making: failure to perform usual ADLs or IADLs, inability to
appropriately stop activities, jeopardizes safety through actions
3- Verbal disruption: yelling, threatening, excessive profanity, sexual
references, etc.
4- Physical aggression: aggressive or combative to self and others (for
example, hits self, throws objects, punches, dangerous maneuvers with
wheelchair or other objects)
5- Disruptive, infantile, or socially inappropriate
behavior (excludes verbal actions)
6- Delusional, hallucinatory, or paranoid behavior
7- None of the above behaviors demonstrated

OASIS-C2 Guidance Manual
Effective 1/1/2017
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(M1745) Frequency of Disruptive Behavior Symptoms
(Reported or Observed): Any physical, verbal, or
other disruptive/dangerous symptoms that are injurious
to self or others or jeopardize personal safety.
0
Never
Enter
1
Less than once a month
2
Once a month
Code
3
Several times each month
4
Several times a week
5
At least daily

Chapter 4-3

Chapter 4

Examples of Clinical Records
ILLUSTRATION 3
Sample Page from Clinical Record Form with Integrated OASIS Items.
DISCHARGE ASSESSMENT
(Page ___ of __)

C. IMMUNIZATIONS
(M1041) Influenza Vaccine Data Collection Period: Does
this episode of care (SOC/ROC to
Transfer/Discharge) include any dates on or between
October 1 and March 31?
Enter
Code
0
No [Go to M1051 ]
1
Yes

(M1046) Influenza Vaccine Received: Did the patient
receive the influenza vaccine for this year’s flu
season?
Enter
Code

1
Yes; received from your agency during this
episode of care (SOC/ROC to Transfer/Discharge)
2
Yes; received from your agency during a
prior episode of care (SOC/ROC to
Transfer/Discharge)
3
Yes; received from another health care
provider (for example, physician, pharmacist)
4
No; patient offered and declined
5
No; patient assessed and determined to
have medical contraindication(s)
6
No; not indicated—patient does not meet
age/condition guidelines for influenza vaccine
7
No; inability to obtain vaccine due to
declared shortage
8
No; patient did not receive the vaccine due
to reasons other than those listed in responses 4–7.

(M1056) Reason Pneumococcal Vaccine not received: If
patient has never received the pneumococcal
vaccination (for example, pneumovax), state reason:
Enter
1
Offered and declined
Code
2
Assessed and determined to have medical
contraindication(s)
3
Not indicated; patient does not meet
age/condition guidelines for Pneumococcal Vaccine
4
None of the above

Client's Name:
Client Record No.
________________________________________
___________
D. SENSORY/PAIN ASSESSMENT
(M1230) Speech and Oral (Verbal) Expression of
Language (in patient's own language):
0
Expresses complex ideas, feelings, and
Enter needs clearly, completely, and easily in all
Code situations with no observable impairment.
1
Minimal difficulty in expressing ideas and
needs (may take extra time; makes occasional
errors in word choice, grammar or speech
intelligibility; needs minimal prompting or
assistance).
2
Expresses simple ideas or needs with
moderate difficulty (needs prompting or assistance,
errors in word choice, organization or speech
intelligibility). Speaks in phrases or short
sentences.
3
Has severe difficulty expressing basic
ideas or needs and requires maximal assistance or
guessing by listener. Speech limited to single
words or short phrases.
4
Unable to express basic needs even
with maximal prompting or assistance but is not
comatose or unresponsive (for example, speech is
nonsensical or unintelligible).
5
Patient nonresponsive or unable to
speak.
(M1242) Frequency of Pain Interfering with patient's activity
or movement:
Enter
0
Patient has no pain
Code 1
Patient has pain that does not interfere
with activity or movement
2
Less often than daily
3
Daily, but not constantly
4
All of the time
10. Pain notes (location, time of day, activities that exacerbate
pain, avoidance of activities, etc.)

E. INTEGUMENTARY STATUS
(M1306) Does this patient have at least one Unhealed
Pressure Ulcer at Stage 2 or Higher or designated
as Unstageable? (Excludes Stage 1 pressure ulcers
and healed Stage 2 pressure ulcers)
Enter
Code
0
No [Go to M1322 ]
1
Yes

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

(M1307) The Oldest Stage 2 Pressure Ulcer that is present
at discharge: (Excludes healed Stage 2 Pressure Ulcers)
1
Was present at the most recent SOC/ROC
assessment
2
Developed since the most recent SOC/ROC
assessment. Record date pressure ulcer first identified:
/
/
month
day
year
NA
No Stage 2 pressure ulcers are present at
discharge
Chapter 4-4

Chapter 4

Examples of Clinical Records
ILLUSTRATION 4
Sample Page from Clinical Record Form with Integrated OASIS Items.
TRANSFER TO INPATIENT FACILITY
(Page 1 of __)

Client's Name:
Client Record No.
________________________________________
____________

B. EMERGENT CARE
(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a
hospital emergency department (includes holding/observation status)?
Enter
0
No [Go to M2401 ]
Code
1
Yes, used hospital emergency department WITHOUT hospital admission
2
Yes, used hospital emergency department WITH hospital admission
UK Unknown [Go to M2401 ]
(M2310) Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without
hospitalization)? (Mark all that apply.)
 1-Improper medication administration, adverse drug
 11-GI bleeding, obstruction, constipation, impaction
reactions, medication side effects, toxicity, anaphylaxis


2-Injury caused by fall

 12-Dehydration, malnutrition



3-Respiratory infection (for example, pneumonia, bronchitis)

 13-Urinary tract infection



4-Other respiratory problem

 14-IV catheter-related infection or complication



5-Heart failure (for example, fluid overload)

 15-Wound infection or deterioration



6-Cardiac dysrhythmia (irregular heartbeat)

 16-Uncontrolled pain



7-Myocardial infarction or chest pain

 17-Acute mental/behavioral health problem



8-Other heart disease

 18-Deep vein thrombosis, pulmonary embolus



9-Stroke (CVA) or TIA

 19-Other than above reasons



10-Hypo/Hyperglycemia, diabetes out of control

 UK – Reason Unknown

(M2400) Intervention Synopsis: (Check only one box in each row.) At the time of or at any time since the previous OASIS
assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?
Plan / Intervention
No Yes Not Applicable
a. Diabetic foot care including monitoring for the
 0  1  NA Patient is not diabetic or is missing lower legs due to
presence of skin lesions on the lower
congenital or acquired condition (bilateral amputee).
extremities and patient/caregiver education
b. Falls prevention interventions
 0  1  NA Every standardized, validated multi-factor fall risk
assessment conducted at or since the last OASIS
assessment indicates the patient has no risk for falls
c. Depression intervention(s) such as
 0  1  NA Patient has no diagnosis of depression AND every
medication, referral for other treatment, or
standardized, validated depression screening conducted at
a monitoring plan for current treatment
or since the last OASIS assessment indicates the patient
has: 1) no symptoms of depression; or 2) has some
symptoms of depression but does not meet criteria for
d. Intervention(s) to monitor and mitigate pain
 0  1  NA Every standardized, validated pain assessment
conducted at or since the last OASIS assessment
e. Intervention(s) to prevent pressure ulcers
 0  1  NA Every standardized, validated pressure ulcer risk
assessment conducted at or since the last OASIS
assessment indicates the patient is not at risk of developing
f. Pressure ulcer treatment based on principles of  0  1  NA Patient has no pressure ulcers OR has no pressure ulcers
moist wound healing
for which moist wound healing is indicated.
(M2410) To which Inpatient Facility has the patient been admitted?
Enter
Code

1
2
3
4
NA

Hospital [Go to M2430 ]
Rehabilitation facility [Go to M0903 ]
Nursing home [Go to M0903 ]
Hospice [Go to M0903 ]
No inpatient facility admission [Omit “NA” option on TRN ]

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 4-5

Chapter 5

Resources, Links to General Sources, Publications, and Web Sites

This chapter provides information on print and electronic resources available to support you in OASIS accuracy,
quality, safety and best practice.

Disclaimer
The links are valid at the time this document is being prepared but cannot be expected to remain unchanged
indefinitely. CMS does not control the content of the websites that are not listed as CMS. The opinions expressed
may or may not match those of CMS policy. Users are urged to work with their OASIS Education Coordinators for
questions regarding official CMS policy.
OASIS Q&A Help Desk: [email protected]
Questions related to OASIS data collection (scoring convention, time points, patient populations, itemspecific guidance)
Home Health Quality Help Desk: [email protected]
Questions related to: Home Health Quality Measures including, but not limited to: quality manuals, quality
measures, measure calculation (OBQI, OBQM, PBQI, Quality of Patient Care Stars, Home Health
Compare), risk adjustment, public reporting, and Quality Assessment Only (QAO)/Pay for Reporting
(P4R). EXCLUDES ALL INQUIRIES FOR HHVBP.

CMS websites
Outcome and Assessment Information Set (OASIS)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/OASIS/index.html
Background & Regulations
iHAVEN
Data Set
Data Specifications

User Manual
Education Coordinators
Automation Coordinators
OASIS PPS

Home Health Agency Q&A
Reports
Training
Archives

Home Health Agency (HHA Center)
https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html
Enrollment, Participation & Certification
Billing/Payment
CMS Manuals & Transmittals
Initiatives (Quality Initiative, Home Health Compare, etc.)

Policies/Regulations
Educational Resources
Demonstrations
Research & Analysis

Medicare Learning Network
http://www.cms.hhs.gov/MLNGenInfo/
National Provider Identifier (NPI) Registry
https://npiregistry.cms.hhs.gov/
Quality Measures Management System (MMS)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/index.html
e-Rulemaking: Electronic Comments on CMS Regulations – instructions for viewing documents open for
public comment, submitting public comments and reviewing public comments received on regulations
https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html
OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 5-1

Chapter 5

Resources, Links to General Sources, Publications, and Web Sites

Guidelines and Best Practices
Evidence-Based Practice Guidelines, University of Iowa, College of Nursing
http://www.nursing.uiowa.edu/excellence/evidence-based-practice-guidelines
National Guideline Clearinghouse (NGC): http://www.guideline.gov
American Heart Association Statements and Practice Guidelines
http://professional.heart.org/professional/GuidelinesStatements/UCM_316885_Guidelines-Statements.jsp
Home Health Best Practice Intervention Packages (Home Health Quality Improvement National Campaign)
Includes packages for cardiovascular health, immunization and infection prevention, medication management,
underserved populations, patient self-management, reducing hospitalizations, management of oral medications, fall
prevention, and cross setting care (transitions, disease management, telehealth, and care delivery changes).
Registration is required.
http://www.homehealthquality.org/Education/Best-Practices.aspx
Collaboration for Home Care Advances in Management and Practice (VNSNY) – Tools and Toolkits
http://www.champ-program.org/page/40/resources

Healthcare Technology
National Quality Forum and Health Information Technology http://www.qualityforum.org/HealthIT/
Office of the National Coordinator for Health Information Technology (ONC)
Home Page
http://www.healthit.gov
About ONC
http://www.healthit.gov/newsroom/about-onc
Healthcare Information and Management Systems Society (HIMSS) http://www.himss.org
Healthcare Information Technology Standards Panel

http://www.hitsp.org/news.aspx

ICD-10-CM Official Guidelines for Coding and Reporting
ICD-10-CM Release

http://www.cdc.gov/nchs/icd/icd10cm.htm#icd

Influenza Control and Immunizations
Centers for Disease Control and Prevention Vaccines
Vaccines Home Page
http://www.cdc.gov/vaccines/default.htm
Guidelines
http://www.cdc.gov/vaccines/recs/vac-admin/default.htm#guide
Influenza Home Page
http://www.cdc.gov/flu

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Chapter 5-2

Chapter 5

Resources, Links to General Sources, Publications, and Web Sites

Clinical Resources
Activities of Daily Living Definitions: Definition and
History http://aspe.hhs.gov/daltcp/reports/guide.htm
Heart Failure
http://www.heart.org/HEARTORG/Conditions/HeartFailure/HeartFailure_UCM_002019_SubHomePage.jsp
http://www.nlm.nih.gov/medlineplus/ency/article/000158.htm
Diabetes
http://www.diabetes.org
http://www.niddk.nih.gov/health-information/health-topics/diabetes/Pages/default.aspx
Diabetic Foot Care
http://www.niddk.nih.gov/health-information/health-topics/Diabetes/prevent-diabetesproblems/Pages/index.aspx
Medications (MEDLINE)
http://www.nlm.nih.gov/medlineplus/druginformation.html
Diversity: The Provider’s Guide to Quality and Culture
http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English
Caregivers
http://www.aarp.org/home-family/caregiving/caregiving-tools/
http://www.nextstepincare.org/

Mental Health Resources
Alzheimer’s
http://www.alz.org/care/overview.asp
Brief Interview for Mental Status (BIMS) – Assessment Tool
MDS 3.0 Report
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/Downloads/MDS30FinalReport-Appendices.zip
Journal Article
Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief
Instrument on Mental Status
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2008.01944.x/abstract
Depression Recognition & Assessment in Older Home Care Patients
Online Training
http://www.geriu.org/uploads/applications/DepressionInHomecare/DinHomecare.html
Training Nursing Staff to Recognize Depression in Home Healthcare.
Journal Article
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02626.x/abstract
Cognitive Assessment
Clock Drawing Test
Tools
MMSE

http://alzheimers.about.com/od/testsandprocedures/a/The-Clock-Drawing-Test.htm
http://www.alz.org/health-care-professionals/cognitive-tests-patient-assessment.asp
https://www.mountsinai.on.ca/care/psych/on-call-resources/on-call-resources/mmse.pdf

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Chapter 5-3

Chapter 5

Resources, Links to General Sources, Publications, and Web Sites

Risk Assessment Tools
Depression: Patient Health Questionnaire Resources
AHRQ (PHQ2) https://innovations.ahrq.gov/qualitytools/patient-health-questionnaire-phq-2
U of Washington (PHQ9) http://impact-uw.org/tools/phq9.html
Fall Risk

Missouri Alliance for Home Care
http://www.homecaremissouri.org/projects/falls/index.php
Multi-Factorial Fall Risk Assessment Tool (MAHC-10) designed for home care patients
Iowa Geriatric Education Center, University of Iowa
http://www.healthcare.uiowa.edu/igec/tools/categoryMenu.asp?categoryID=3
Screen for Obesity – BMI
National Heart, Lung, and Blood Institute
http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Pain
City of Hope Pain & Palliative Care Resource Center, Pain Assessment Tools
http://prc.coh.org/pain_assessment.asp
Iowa Geriatric Education Center, University of Iowa
http://www.healthcare.uiowa.edu/igec/tools/categoryMenu.asp?categoryID=7
Pressure Ulcer Risk
Braden Scale for Predicting Pressure Sore Risk
http://www.healthcare.uiowa.edu/igec/tools/pressureulcers/bradenscale.pdf
Norton Pressure Sore Risk Assessment
http://www.nutrition411.com/sites/default/files/w0513_norton_presure_sore_risk_assessment_scale_scoring_
system.pdf
NQF Framework
http://www.qualityforum.org/Publications/2011/12/National_Voluntary_Consensus_Standards_for_
Developing_a_Framework_for_Measuring_Quality_for_Prevention_and_Management_of_Pressure
_Ulcers.aspx
National Pressure Ulcer Advisory Panel (NPUAP) www.npuap.org
Guidance on OASIS Integumentary items, Wound Ostomy and Continence Nurses Society (WOCN)
http://www.wocn.org/?page=oasis
Wound Ostomy and Continence Nurses Society (WOCN)

http://www.wocn.org/

Leg ulcers http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28BC41E24551CCC/A_Quick_Reference_Guide_for_LE_Wounds_%282013%29.pdf

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Chapter 5-4

Chapter 5

Resources, Links to General Sources, Publications, and Web Sites

Professional Organizations
ANA
AOTA
APTA
ASHA

http://www.nursingworld.org/
http://www.aota.org/
http://www.apta.org/
http://www.asha.org/

Quality Resources
Agency for Healthcare Research and Quality http://www.ahrq.gov/
AHRQ's Health Care Innovations Exchange Web site (Innovations and Quality Tools classified by
disease or clinical category, patient population, stage of care, setting of care, and more.)
https://innovations.ahrq.gov/
AHRQ's Quality Measures Database National Quality Measures Clearinghouse
(NQMC).
https://www.qualitymeasures.ahrq.gov/
Institute for Clinical Systems Improvement
https://www.icsi.org/
https://www.icsi.org/guidelines_more/
Institute for Healthcare Improvement
http://www.ihi.org/Pages/default.aspx
Institute of Medicine
Crossing the Quality Chasm

http://www.nationalacademies.org/hmd/
http://books.nap.edu/openbook.php?isbn=0309072808&page=1

Care Transitions
Transitional Care Model
http://www.transitionalcare.info
Care Transitions Intervention
http://www.caretransitions.org
A Home Health Model of Care Transitions, Alliance for Home Care Quality
http://ahhqi.org/images/uploads/AHHQI_Care_Transitions_Tools_Kit_r011314.pdf
http://www.ntocc.org/
National Transitions of Care Coalition (NTOCC)

Safety Resources
Agency for Healthcare Research and Quality
PSNET Patient Safety Network
http://www.psnet.ahrq.gov/
TeamSTEPPS http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html
VA National Center for Patient Safety
Joint Commission

http://www.patientsafety.va.gov/

http://www.jointcommission.org/accreditation/home_care_accreditation_requirements.aspx

Medication Safety – Institute for Safe Medication Practices (ISMP)
http://www.ismp.org/Tools/anticoagulantTherapy.asp
http://www.ismp.org/Tools/highalertmedications.pdf

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Chapter 5-5

Appendix A
1.

OASIS and the Comprehensive Assessment

WHAT IS A COMPREHENSIVE ASSESSMENT?

Patient assessment is an essential component of health care delivery. Assessment requires the collection of
pertinent data regarding the patient, supportive assistance, and the patient’s environment. Clinicians of all types
systematically collect and categorize such data, analyze and evaluate these data, and draw conclusions from the
data that guide their subsequent interventions. It is the interventions that then are directed toward improving or
maintaining health status (or supporting the patient in a dignified dying process). Assessment involves the active
gathering of accurate and well-defined patient status information.
A comprehensive assessment involves collecting data on multiple aspects of the patient and the environment. The
patient receiving home care particularly benefits from a comprehensive assessment because the interrelated aspects
of patient and environment all influence current and future health status. An assessment with too narrow a focus omits
many components relevant to care delivery. Consider the example of a patient with an open surgical wound requiring
dressing changes. A narrowly focused assessment would evaluate only the wound status. Such an assessment fails
to take into account other factors relevant for wound healing, such as nutrition. The comprehensive assessment will
consider the patient’s nutritional status, which must address the actual food intake, the ability to prepare food, the
ability to shop for food, and the presence of financial factors that may limit the ability to purchase food. The presence
(or absence) of sanitation hazards, also important for wound healing, can be identified by the comprehensive
assessment. In addition, the patient’s ability to perform his/her own dressing change or the availability, willingness,
and ability of a family member (or other caregiver) to change the dressing will also be evaluated in the comprehensive
assessment. By collecting data on the variety of interrelated aspects of patient and environment that affect health
status, such an assessment clearly provides a better base for care planning and delivery.
It should be noted that the data items in OASIS are not, in and of themselves, a complete or comprehensive
assessment. Home health agencies will need to supplement the OASIS data items with others necessary for a full
assessment. For example, the OASIS items do not include vital signs, assessment of breath sounds, or collection
of data on fluid intake, which are part of a more complete assessment. Each agency will be expected to incorporate
the OASIS items into its own comprehensive assessment documentation and related policies and procedures.

HOW ARE THE COMPREHENSIVE ASSESSMENT DATA COLLECTED AND
DOCUMENTED?

Patient assessment data are collected through a combination of methods -- including interaction with patient/family,
observation, and measurement. When used in combination, these methods provide a full picture of the patient’s
health status. Interaction and interview (specifically, a patient and/or caregiver report) data can be verified through
observation and measurement; observation data can identify factors that require additional interview questions.
Interaction and interview involve purposeful communication with the patient or family. Some interview questions are
short and direct (for example, what is your birth date? are you taking/receiving any injectable medications?), while
others begin with an open-ended question that leads to further inquiries with a more specific focus (for example, what
kind of assistance do you receive from family or friends?) can be followed by more specific questions about types and
frequency of assistance if an affirmative response is obtained). In all cases, the patient is the preferred source for
interview/interaction data, though the family/caregiver (or other health care provider) can provide information if the
patient is unable to do so. Information such as biographical data, pertinent health and social history, and the review
of body systems can only be obtained through interview/interaction. Observation often supplements and enriches the
interview data. For example, the clinician observing a healed surgical wound scar may supplement the health history
when additional questions identify disease conditions not previously mentioned.
Observation techniques obtain data through the senses. Using sight, sound, smell, and touch, the clinician collects
and records patient status information. Measurement is a form of observation that uses a calibrated “instrument” to
obtain data. For example, blood pressure, joint range of motion, height, and weight are all obtained by
measurement. In all observational approaches, consistency and objectivity are particularly important. Professional
standards for clinical observation are important to apply in conducting patient assessment.

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Appendix A-1

Appendix A

OASIS and the Comprehensive Assessment

All these methods and techniques should be used in conducting the comprehensive assessment and collecting
OASIS data. Using only one approach limits both the amount and quality of the information obtained. Direct
observation is the preferred method for data collection, but some historical data may only be obtained by interview.
The interview should supplement, not replace, observational techniques.
The patient receiving care at home presents both unique opportunities and challenges for clinicians in assessing
patients. One opportunity is that the clinician is able to collect data on environmental characteristics (such as safety
features) through first-hand observation rather than needing to rely exclusively on report. Thus, the accuracy of the
patient status information is increased, which also increases the likelihood of appropriate pertinent interventions.
Within this setting, however, the patient and family exercise control, in contrast to other health care delivery
settings where the provider controls the environment. The clinician does not have the immediate and constant
support of rules, policies, and colleagues to aid in data verification or compliance. The home care clinician often is
required to exercise creativity and flexibility in collecting patient assessment data for care planning. For example,
assessment of the home care patient begins even before the clinician enters the home. The initial referral provides
an introduction to the client situation. A telephone contact with the patient/family to arrange the visit furnishes
additional data. Environmental characteristics of the neighborhood and the patient residence are apparent as the
clinician approaches the home. When the comprehensive assessment is documented, the clinician’s actual
observations that describe the patient’s current status should be recorded. The conclusions derived from these
assessment data will direct the subsequent care planning activities.

COMPREHENSIVE ASSESSMENT AND OASIS REGULATION

In 1999, the Centers for Medicare & Medicaid Services (CMS) revised the Conditions of Participation (CoP) that home
health agencies (HHAs) must meet to participate in the Medicare program. Specifically, this added rule states that
each patient receive from the HHA a patient-specific, comprehensive assessment that identifies the patient’s need for
home care and that meets the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. The rule
requires that as part of the comprehensive assessment, HHAs use OASIS when evaluating adult, non-maternity
patients. Additionally, the OASIS meets the condition specified in §1891(d) of the Social Security Act, which requires
the Secretary of the Department of Health and Human Services to designate an assessment instrument for use by an
agency in order to evaluate the extent to which the quality and scope of services furnished by the HHA attain and
maintain the highest practicable functional capacity of the patient as reflected in the plan of care.
These components were identified as an integral part of CMS’ efforts to achieve broad-based improvements in the
quality of care furnished through Federal programs and in the measurement of that care. The following briefly
describes the CoP relevant to OASIS data collection. Specific regulatory language can be found within the CoP
(See the link for Home Health CoP at the CMS.gov Home Health Agency Center
https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html).
Condition of Participation: Comprehensive Assessment of Patients
HHAs are required to provide patients with a patient-specific, comprehensive assessment that accurately reflects
the patient’s current health status and includes information that may be used to demonstrate the patient’s progress
toward achievement of desired outcomes. The comprehensive assessment must (1) identify the patient’s continuing
need for home care; (2) meet the patient’s medical, nursing, rehabilitative, social, and discharge planning needs; and
(3) for Medicare patients, identify eligibility for the home health benefit, including the patient’s homebound status. The
comprehensive assessment must also incorporate the exact use of the current version of the OASIS data set,
available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/OASIS-Data-Sets.html. A comprehensive assessment identifies patient progress
toward desired outcomes or goals of the care plan.
CMS expects that HHAs will collect OASIS data in the context of a comprehensive assessment on adult
Medicare or Medicaid patients (age 18 or over) receiving skilled health services from the HHA, except for
patients receiving care for pre- and post-partum conditions. Patients receiving skilled health services, whose
care is reimbursed by other than Medicare or Medicaid, must receive comprehensive assessments, but the
collection of OASIS data is not required. For patients receiving only personal care services, regardless of payer
source, a comprehensive assessment is also required, but not the collection of OASIS data. Patients who
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Appendix A-2

Appendix A

OASIS and the Comprehensive Assessment

receive only services such as homemaker, chore, or companion services do not require the comprehensive
assessment.
Standards in the CoP include:
•

Initial Assessment Visit
The initial visit is performed to determine the immediate care and support needs of the patient. This visit is
conducted within 48 hours of referral or within 48 hours of a patient’s return home from an inpatient stay, or
on the physician-ordered start of care date. The initial assessment visit is intended to ensure that the
patient’s most critical needs for home care services are identified and met in a timely fashion. For Medicare
patients, this initial assessment determines eligibility for the Medicare home health benefit, including
homebound status. The initial assessment visit must be conducted by a registered nurse unless
rehabilitation therapy services are the only services ordered by the physician. Under the Medicare home
health benefit, any one of three services (skilled nursing, physical therapy, or speech-language pathology)
can establish program eligibility. If rehabilitation therapy services are the only services ordered by the
physician, the initial assessment may be made by the appropriate rehabilitation skilled professional if the
need for that service establishes eligibility for the home health benefit.
The law governing home health eligibility prevents occupational therapy from establishing eligibility for the
Medicare home health benefit at the initial assessment, though once eligibility is established, then
continuing occupational therapy could establish eligibility for a subsequent episode (meaning that the
occupational therapist could complete the Recertification assessment). If no skilled service is delivered at
this initial assessment, this visit will not be considered the SOC nor is it considered a reimbursable visit for
the Medicare home health benefit.
Note that for payers other than Medicare, the occupational therapist may complete the initial assessment if
the need for occupational therapy establishes program eligibility. The comprehensive assessment is not
required to be completed at the initial assessment visit, although the HHA may choose to do so. If a skilled
service is delivered at the initial assessment visit, thus establishing the SOC, the comprehensive
assessment may be initiated at this visit and completed by the same clinician within the time frames
discussed below. Agency policy may make the time frames for completion more restrictive than the CoP.

•

Completion of the Comprehensive Assessment
The comprehensive assessment must be completed in a timely manner, consistent with the patient’s
immediate needs, but no later than five calendar days after the start of care.
This requirement does not preclude an HHA from completing the comprehensive assessment during the
SOC visit, and many HHAs currently operate in such a manner. This time frame provides operational
flexibility to the HHA while maintaining patient safety in ensuring that all patient needs will be identified
within a standard time period. Some HHAs have policies requiring that a nurse conduct the comprehensive
assessment. Home care staff should follow agency policies governing which disciplines can complete the
comprehensive assessment.

•

Drug Regimen Review
Under this requirement, the comprehensive assessment must include a review of all medications the
patient is currently using to identify any potential adverse effects and drug reactions, including ineffective
drug therapy, significant side effects and drug interactions, duplicate drug therapy, and noncompliance with
drug therapy.
While patients receive their drug regimen from the physician, review of this regimen is an integral part of the
comprehensive assessment. In addition, this review is an important safeguard for patients who may receive
medications from a variety of physicians and pharmacies. Some agencies have policies requiring nurses to
do the drug regimen review. In addition, some state practice acts may preclude therapists from completing
the drug regimen review. Home care staff should follow state regulations and agency polices governing
which disciplines can complete the drug regimen review.

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Appendix A-3

Appendix A
•

OASIS and the Comprehensive Assessment

Update of the Comprehensive Assessment
The comprehensive assessment, which includes OASIS items for Medicare and Medicaid patients, must be
updated and revised as frequently as the patient’s condition requires, but not less frequently than every 60
days beginning with the start of care date; within 48 hours of the patient’s return home from an inpatient
facility stay of 24 hours or more for any reason except diagnostic testing; and at discharge. The update of
the comprehensive assessment must include completion of all required OASIS items for that time point,
plus any others determined necessary by the HHA for a comprehensive assessment. This assessment
provides information for determination of changes in treatment or plan of care. Therefore, a comprehensive
assessment also is required when there is a major decline or improvement in a patient’s health status as
defined by the HHA.
An inpatient facility admission as an event is generally a predictor of a change in the patient’s health status
and therefore should be captured in the OASIS data. In addition, because patients frequently improve
rapidly upon returning home from an inpatient facility, it is important for the HHA to assess the patient’s true
needs as quickly as possible after discharge from the inpatient facility. Therefore, the comprehensive
assessment is required within 48 hours of the patient’s return to the home from an inpatient facility
admission of 24 hours or more for any reason other than diagnostic tests.
Follow-up assessments must be completed every 60 days that a patient is under care. For Medicare and
Medicaid patients, when a follow-up assessment is due, it must be completed no earlier than four calendar
days before, and no later than the day marking the end of the 60-day period (that is, day 56 through day 60
of the period).

•

Incorporation of the OASIS Data Set
OASIS must be incorporated into the HHA’s own assessment, exactly as written. Both the language and
the groupings of the OASIS items must be maintained. Integrating the OASIS items into the agency’s own
assessment system in the sequence presented in the OASIS form would facilitate data entry of the items
into data collection and reporting software. However, HHAs may integrate the items in such a way that best
suits the agency’s own assessment.
The OASIS data set is not intended to constitute a complete comprehensive assessment instrument.
Rather, the data set comprises items that are a necessary part of a complete comprehensive assessment
and that are essential to uniformly and consistently measure patient outcomes. An HHA can use the data
set as the foundation for valid and reliable information for patient assessment, care planning, service
delivery, and improvement efforts.
The OASIS items are already used in one form or another by virtually all HHAs that conduct thorough
assessments, and simply adding the OASIS data set to the rest of the HHA’s paperwork would be
burdensome and duplicative. Therefore, we expect HHAs to replace similar assessment items with OASIS
items in their assessment forms to avoid lengthening the assessment unnecessarily. This may be
accomplished by modification of existing forms or using commercially available comprehensive assessment
forms that include OASIS items. The Mxxxx numbers for each OASIS data item should be retained to allow
for easy recognition of the required OASIS item in the HHA comprehensive assessments.

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Appendix A-4

Appendix B
1.

OASIS Data Accuracy

DATA ACCURACY

Medicare Home Health Care Conditions of Participation Standard: Accuracy of Encoded OASIS Data (See the link for
Home Health CoP at the CMS.gov Home Health Agency Center https://www.cms.gov/center/provider-Type/homeHealth-Agency-HHA-Center.html ) stipulates that the encoded OASIS data must accurately reflect the patient’s status
at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical
record match the encoded data that are sent to CMS. Once the qualified skilled professional (specifically, RN, PT,
SLP/ST, or OT) completes the assessment, the HHA should develop means to ensure that the OASIS data input into
the computer and transmitted to the CMS exactly reflect the data collected by the skilled professional. In addition, the
State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to
the CMS.

DATA QUALITY AUDITS

Data-driven systems, such as OASIS data collection and outcome measurement, depend on the accuracy of source
data describing patient health status. It follows that minimizing data errors that could affect accuracy of clinical data or
outcome analyses is a necessary condition. This function is the responsibility of the agency since, ultimately, agencylevel outcome reports reflect the data agencies input into the system. Internal staff development and training must
focus on data accuracy not only at the start-up of OASIS data collection, but on a continuing basis. We recommend
that data quality audits be conducted in agencies on a routine basis. Some data audit activities should be conducted
monthly, while others can be conducted at less frequent intervals, such as quarterly.
The following guidelines provide a method for monitoring the quality of data in an agency. Types of audits, their
recommended frequency, and categories of staff members (to conduct data audit activities and summarize findings)
are suggested. If problems are identified, it is also recommended that the agency develop and implement a plan to
correct data quality problems. Table B.1 displays the data quality audit approaches discussed and summarizes the
purpose, frequency, and procedures for each.

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Appendix B-1

Appendix B

OASIS Data Accuracy

Table B.1: Data Quality Audits
Audit
Type

Purpose

Frequency

Overview of Procedure

Performed By

Clinical
Record
Audit

To verify accuracy of
OASIS patient status items
compared to other related
patient documentation

Monthly

Review at least five SOC
records and five discharge
records. Compare OASIS
items to other documentation
from the SOC or discharge
visits and from other visits
surrounding SOC or
discharge.

QI
coordinator
or clerical
staff

Data
Entry
Audit

To verify accuracy of
OASIS data entry and the
data in the clinical record
(or using double data
entry)

Monthly

Either:

QI
coordinator,
IS/IT
coordinator,
or data entry
staff

Obtain a hardcopy of OASIS
data that were entered for five
patients. Compare to OASIS
items in clinical record;
or
Data enter OASIS information
for five patients twice.
Compare data entered the
first time to data entered the
second time for each patient.

Clinical
Audit
Visits

To verify accuracy of
OASIS assessment data
(that is, evaluate
assessment methodology
and assessment skills of
clinical staff)

Quarterly

For at least three or four
patients, a supervisor or peer
auditor attends the SOC visit.
The auditor completes OASIS
items while the care provider
conducts the assessment and
completes SOC paperwork.
OASIS items are compared
for consistency between
auditor and care provider.

QI
coordinator,
clinical
supervisor,
or clinical
staff

Monthly Audit Activities

Clinical Record Audits: Clinical record audits allow an agency to monitor the validity of OASIS data. The quality
check assesses the congruence of OASIS data with other patient status information found in the clinical record. This
audit allows an agency to check for systematic bias in describing patient status. Most often, this will take the form of
exaggerating illness or disability at start of care to enhance the justification for providing services and, under
prospective payment, to maximize payment. There may also be a concomitant bias in the opposite direction for a
discharge assessment, driven by a desire to make patient outcomes appear in a more favorable light or simply as a
justification for discharge (for example, the goal of reaching a certain level of functioning has been met).
To conduct a clinical record audit, an abbreviated record review can be conducted for at least five new admissions
and five patients discharged from the agency (but not due to an inpatient facility admission). Records should be
randomly selected, in order to evaluate data quality for a cross-section of patients and care providers. The selection
process might be as follows:
1.

Choose a standing date for record selection (for example, the first Tuesday of every month). On that day
each month, alphabetically compile a list of all skilled care patients admitted to the agency for the previous
month. For example, if the record selection date for February falls on February 3rd, compile a list of all
patients admitted to the agency from January 3rd to February 2nd.

Count the number of patients on the list. Divide that number by five, rounding down to the nearest whole
number. For example, if there are 42 patients on the list, 42 ÷ 5 = 8.4, which would be rounded to 8. This

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Appendix B-2

Appendix B

OASIS Data Accuracy

number, n, will be used to select records. Divide this number by 2 to obtain the starting point, m, for selecting
records.
th

Count from the first patient alphabetically, select the m patient, and select every n patient after that. Using
th
th
the above example, you would select the 4 person and then every 8 person on the list for record review.

The same procedure should be used to select records for discharged patients. Compile a list of patients
discharged from the agency within the previous month. Divide the number of patients by five, and use that
number (n) to select patients for record review.

In the event that you have fewer than five patients admitted to or discharged from your agency, review all
records. It should be noted that many agencies choose to audit a larger sample and some audit 100% of
records.

Procedure for Clinical Record Audits: For new admissions, review the start of care (SOC) OASIS items and
compare to other admission documentation and two or three subsequent visit notes, if they occur within the first week
after SOC. In addition, if care providers from two disciplines perform assessments on the patient within one week of
SOC (for example, registered nurse conducts comprehensive assessment visit and completes OASIS items; the
physical therapist visits two days later and evaluates the patient), the documentation should be compared. Reviewers
should evaluate whether any discrepancies between the SOC OASIS assessment and the other documentation are
sufficiently significant to indicate a data quality problem. For example, if the SOC OASIS items indicate that the patient
is fully independent in ambulation, but other documentation indicates that the patient needs assistance when walking,
a data quality problem may exist. Assess for any discrepancies between sociodemographic items (for example,
patient ID number or age) in addition to discrepancies in clinical assessments (ICD codes, all clinical assessment
OASIS items).
The records for discharged patients should be reviewed in the same manner. All discharge OASIS patient status
items should be compared to other discharge information as well as to the previous two or three visit notes (if those
visits occur within the same week of discharge). If there are large differences in descriptions of the patient, a potential
data quality problem exists.
If differences are found that cannot be explained by other documentation in the clinical record, the care provider who
completed the OASIS should be contacted to determine if the discrepancies were real (for example, the patient did
change significantly between the SOC visit and a visit the next day) or if an error was made when recording OASIS
data. If data quality problems exist, the problems can be corrected. If clinical documentation must be amended, this
should be done according to agency policy. Any corrections to OASIS data in the clinical record must also be reflected
in the OASIS database maintained by the agency, and if data submission has already occurred, a correction must be
transmitted to CMS.
Data Entry Audits: Data entry audits allow agencies to monitor the accuracy of data entry. Data entry errors in fields
such as birth date or health insurance number are often detected through other agency procedures (for example,
billing—if the data entry software communicates with other agency systems), while patient status data are not typically
subjected to such verification. Such errors, however, can affect outcome analyses and should be monitored. This type
of audit may not be relevant for agencies using electronic health records, as data entry occurs concurrently with the
clinical assessment.
To conduct a data entry audit, a small sample of Medicare and/or Medicaid (skilled care) patient records should be
checked at monthly intervals. In this evaluation, the clinical documentation is compared to the OASIS data that was
entered to assess for data entry errors. This can be done by visual inspection or by double data entry, where the
same record is data entered twice.
Procedure for Data Entry Audits: From the monthly list of Medicare and Medicaid patients admitted to the agency,
select at least five records. The sample records need not be randomly selected, but if more than one person is
responsible for data entry, some records entered by each staff member should be assessed. These may be the same
records you use for the clinical audit. Obtain a printout of the information that was data entered or view the data online
(the procedure for doing this will vary, depending upon the software you choose). Compare the response to each
OASIS item in the clinical documentation with the computer printout or screen display of entered data. An alternative

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Appendix B-3

Appendix B

OASIS Data Accuracy

method is to have two staff conduct data entry of the same records independently and to compare the data records
1
item by item .
If discrepancies exist between the data that were entered and the OASIS items in the clinical record or between the
OASIS items that were data entered twice, it is important to follow up with appropriate personnel. The agency
database should be corrected and if necessary a correction should be transmitted to CMS. If data entry errors appear
to be pervasive, a plan of action to remedy the problems should be developed and implemented.
b.

Quarterly Audit Activities

Clinical Audit Visits: Clinical audit visits provide an opportunity to verify the quality of patient status data collected by
clinicians. It is recommended that each quarter agencies conduct supervisory (or peer) audit visits to at least three to
four patients. These audit visits should occur at the admission comprehensive assessment visit. Within a one-year
period, each clinical staff member of an average-sized agency thus can receive an audit visit. The supervisor or peer
auditor should complete the SOC OASIS items while observing the care provider conducting the SOC visit. The care
provider and auditor should not discuss OASIS items between themselves during the visit. The QI coordinator (or
designated person) then compares each item on the SOC OASIS items completed by the care provider to the OASIS
items completed by the auditor. Discrepancies should be noted. Any differences between OASIS items should be
discussed jointly by the care provider and auditor to determine the reasons for the differences and to ensure that care
providers fully understand the OASIS items. It is not necessary to select a random sample of patients for the audit
visits, but the QI coordinator or QI team should ensure that a variety of patients and care providers are represented.

3.
a.

SUMMARIZING AUDIT ACTIVITIES
Documentation

Agencies should summarize findings from all audit activities as they are completed. Because these audit activities will
be an ongoing quality monitoring activity, it may be helpful to include summaries of findings in quarterly QI reports. If
data quality problems are identified from the audit activities, investigations should be conducted into the cause(s) of
the problems, and action plans developed and implemented to resolve the problems. Approaches to assure that
accurate patient-level data are utilized to describe patient status and to compute outcome measures increase the
likelihood that agency-level outcome reports accurately describe the effectiveness of patient care.
b.

Making Corrections to OASIS Data

For information about making corrections to OASIS data, refer to Survey and Certification Memo # 15-18-HHA,
Outcome and Assessment Information Set (OASIS) transition to the Automated Submission and Processing System
2
3
(ASAP) and OASIS Correction policy and the OASIS Submission User's Guide .

The exact mechanism for accomplishing double data entry will depend on the data entry software your agency uses. For
example, jHAVEN does not directly support double data entry. However, a separate installation of jHAVEN could be used for
the second data entry. The assessments could then be exported from their respective jHAVEN installations, and the exported
data could be compared for consistency.

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-Statesand-Regions-Items/Survey-and-Cert-Letter-15-18.html?DLPage=1&DLFilter=15-18&DLSort=3&DLSortDir=descending

https://www.qtso.com/hhatrain.html

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Appendix B-4

APPENDIX C

OASIS-C2 ITEMS, TIME POINTS, AND USES

This table can be used in identifying the time points and potential uses for each OASIS-C2 data item.
The following key should be used for the Item Uses column:

A
C
Q
PQ
PRA
$

=
=
=
=
=
=

Administrative
Consistency Check
Quality Measure
Potential Quality Measure
Potential Quality Measure Risk Adjustment
Payment

The following key should be used for the Time Points columns:

S
R
FU
TRF
DC
H

=
=
=
=
=
=

Start of Care
Resumption of Care
Follow-Up
Transfer
Discharge
Death at Home
Items

Item #

Item Description

Item

Time Points
SOC

ROC

TRF

DAH

M0010

CMS Certification Number

M0014

Branch State

M0016

Branch ID Number

M0018

National Provider Identifier (NPI)

M0020

Patient ID Number

M0030

Start of Care Date

M0032

Resumption of Care Date

M0040

Patient Name

M0050

Patient State of Residence

M0060

Patient ZIP Code

M0063

Medicare Number

M0064

Social Security Number

M0065

Medicaid Number

M0066

Birth Date

M0069

Gender

M0080

Discipline of Person Completing Assessment

M0090

Date Assessment Completed

C,Q

M0100

This Assessment is Currently Being
Completed for the Following Reason

C,Q

M0102

Date of Physician-ordered Start of
Care (Resumption of Care)

M0104

Date of Referral

M0110

Episode Timing

M0140

Race/Ethnicity

M0150

Current Payment Sources for Home Care

A
A
A
A
A
C,Q
Q
A
A
A
A
A
A
PRA
PRA

Q
C, $, PRA
A
A, PRA

Appendix C

OASIS-C2 Items, Time Points, and Uses
Items

Item #

Item Description

Item

Time Points
SOC

ROC

TRF

DAH

PRA

M0903

Date of Last (Most Recent) Home Visit

M0906

Discharge/Transfer/ Death Date

M1000

Inpatient Facilities

M1005

Inpatient Discharge Date

M1011

List each Inpatient Diagnosis and ICD-10-CM
code at the level of highest specificity for only
those conditions actively treated during an
inpatient stay having a discharge date within
the last 14 days

PRA

M1017

Diagnoses Requiring Medical or
Treatment Regimen Change Within Past
14 Days

PRA

M1018

Conditions Prior to Medical or Treatment
Regimen Change or Inpatient Stay Within
Past 14 Days

PRA

M1021

Primary Diagnosis, ICD-10-CM and
Symptom Control Rating

$, PRA

M1023

Other Diagnoses, ICD-10-CM and
Symptom Control Rating

PRA

M1025

Optional Diagnoses and ICD-10-CM codes

$, PRA

M1028

Active Diagnoses – Comorbidities and Coexisting Conditions

PRA

M1030

Therapies patient receives at home

$, PRA

M1033

Risk for Hospitalization

Overall Status

M1036

Risk Factors

M1041

Influenza Vaccine Data Collection Period

Influenza Vaccine Received

M1051

Pneumococcal Vaccine

M1056

Reason Pneumococcal Vaccine not received

M1046

M1060

Height and Weight

M1100

Patient Living Situation

PRA

M1034

M1200

Vision

M1210

Ability to Hear

Understanding of Verbal Content

PRA

M1220

M1230

Speech and Oral (Verbal) Expression
of Language (in patient's own language)

Q, PRA

M1240

Has this patient had a formal Pain Assessment
using a standardized, validated pain
assessment tool (appropriate to the patient’s
ability to communicate the severity of pain)?

M1242

Frequency of Pain Interfering with
patient's activity or movement:

Q, $, PRA

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PRA
PRA
Q
Q
Q
Q
PRA
Q, PRA
$, PRA
PRA

Appendix C-2

Appendix C

OASIS-C2 Items, Time Points, and Uses
Items

Item #

Item Description

Item

Time Points
SOC

ROC

TRF

DAH

M1300

Pressure Ulcer Assessment: Was this
patient assessed for Risk of Developing
Pressure Ulcers?

M1302

Risk of Developing Pressure Ulcers

Q, PRA

M1306

Does this patient have at least one
Unhealed Pressure Ulcer at Stage 2 or
Higher or designated as Unstageable

C,Q, PRA

M1307

The Oldest Stage 2 Pressure Ulcer that
is present at discharge

Q, PRA

M1311

Current Number of Unhealed Pressure
Ulcers at Each Stage

Q, $, PRA

M1313

Worsening in Pressure Ulcer Status
since SOC/ROC

M1320

Status of Most Problematic Pressure Ulcer
that is Observable

C, PRA

M1322

Current Number of Stage 1 Pressure Ulcers

Stage of Most Problematic Unhealed
Pressure Ulcer that is Stageable

$, PRA

M1324

M1330

Does this patient have a Stasis Ulcer?

M1332

Current Number of Stasis Ulcer(s) that
are Observable

M1334

Status of Most Problematic Stasis Ulcer that
is Observable

M1340

Does this patient have a Surgical Wound?

M1342

Status of Most Problematic Surgical
Wound that is Observable

M1350

Does this patient have a Skin Lesion or Open
Wound, excluding bowel ostomy, other than
those described above that is receiving
intervention by the home health agency?

M1400

When is the patient dyspneic or noticeably
Short of Breath?

M1410

Q, $, PRA
$, PRA

$, PRA

D
D

C,Q, PRA

C, PRA

Q, $, PRA

Respiratory Treatments utilized at home

PRA

M1501

Symptoms in Heart Failure Patients

Heart Failure Follow-up

M1511

M1600

Has this patient been treated for a Urinary
Tract Infection in the past 14 days?

Q, PRA

M1610

Urinary Incontinence or Urinary
Catheter Presence

Q, $, PRA

M1615

When does Urinary Incontinence occur?

Bowel Incontinence Frequency

M1630

Ostomy for Bowel Elimination

M1700

Cognitive Functioning

Q, PRA

M1620

M1710

When Confused (Reported or Observed
Within the Last 14 Days)

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$, PRA

Q, $ PRA

Q, $, PRA
$, PRA
Q, PRA
Q, PRA

Appendix C-3

Appendix C

OASIS-C2 Items, Time Points, and Uses
Items

Item #

Item Description

Item

Time Points
SOC

ROC

TRF

DAH

M1720

When Anxious (Reported or Observed
Within the Last 14 Days)

Q, PRA

M1730

Depression Screening

Q, PRA

M1740

Cognitive, behavioral, and psychiatric
symptoms that are demonstrated at least once
a week (Reported or Observed)

Q, PRA

M1745

Frequency of Disruptive Behavior
Symptoms (Reported or Observed)

Q, PRA

M1750

Psychiatric Nursing Services at home
provided by a qualified psychiatric nurse?

PRA

M1800

Grooming

M1810
M1820

S
S

R
R

F
F

Ability to Dress Upper Body
Ability to Dress Lower Body

D
D

Q, $, PRA
Q, $, PRA

Q, $, PRA

M1840

Bathing: Excludes grooming (washing
face, washing hands, and shampooing
hair).
Toilet Transferring

M1845

Toileting Hygiene

M1850

Transferring

M1830

GG0170C Mobility – Lying to sitting on side of bed

M1860

Ambulation/Locomotion

M1870

Feeding or Eating

M1880

Ability to Plan and Prepare Light Meals

M1890

Ability to Use Telephone

M1900

Prior Functioning ADL/IADL.

M1910

Falls Risk Assessment

M2001

Drug Regimen Review

M2003

Medication Follow-up

M2005

Medication Intervention

M2010

Patient/Caregiver High-Risk Drug Education

M2016

Patient/Caregiver Drug Education Intervention

M2020

Management of Oral Medications: Excludes
injectable and IV medications.

M2030

Management of Injectable
Medications: Excludes IV medications

M2040

D
D

D
D
D
D

Q, PRA

Q, PRA
Q, $, PRA
PRA
Q, $, PRA
Q, PRA
Q, PRA
Q, PRA
PRA
Q

C, Q

Q, PRA

$, PRA

Prior Medication Management

Types and Sources of Assistance

PRA

M2102

M2110

How Often does the patient receive ADL or
IADL assistance from any caregiver(s) (other
than home health agency staff)?

PRA

M2200

Therapy Need

Plan of Care Synopsis

M2301

Emergent Care

$, PRA

M2250

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PRA

Q, PRA
Q

Appendix C-4

Appendix C

OASIS-C2 Items, Time Points, and Uses
Items

Item #

Item Description

Item

Time Points
SOC

ROC

TRF

DAH

M2310

Reason for Emergent Care

M2401

Intervention Synopsis

M2410

To which Inpatient Facility has the patient
been admitted?

M2420

Discharge Disposition

Reason for Hospitalization

M2430

TOTAL

Total items per timepoint

113

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Appendix C-5

APPENDIX D (RESERVED FOR FUTURE USE)

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Appendix D-1

APPENDIX E

DATA REPORTING REGULATIONS

DATA REPORTING REGULATION
The Balanced Budget Act of 1997 authorized the Secretary of the Department of Health and Human Services (HHS)
to require that home health agencies (HHAs) submit any information that the Secretary considers necessary to
develop a reliable case mix system for the purposes of implementing a prospective payment system for HHAs. To
fulfill this mandate, CMS implemented a regulation requiring electronic reporting of OASIS data for Medicare and
Medicaid patients to a centralized data submission system maintained by CMS as a Condition of Participation for
HHAs. This rule provides guidelines for HHAs for the electronic transmission of the OASIS data as well as
responsibilities of the provider in collecting and transmitting this information to CMS. Rules concerning the privacy of
patient identifiable information generated by the OASIS were also set forth.

Condition of Participation: Reporting OASIS Information
•

Encoding OASIS Data
Once the comprehensive assessment has been completed and OASIS data collected, HHAs not already
utilizing electronic capture of their OASIS data would enter the OASIS information into the computer system,
referred to as “encoding.” All the time points of the OASIS assessments have a uniform time frame of thirty
days from the date the assessment is completed (M0090—Date Assessment Completed) for encoding and
submitting the data. Once the OASIS data are encoded (in software available from CMS, or other software
that conforms to the CMS standard data submission specifications), the agency will review each assessment
and edit it for transmission to a centralized data submission system. During this preparation period, the HHA
must run a software application that subjects each patient data set to the CMS edit specifications and makes
it transmission-ready. The agency must correct any information that does not pass the CMS-specified edits
(e.g., data is missing, incorrect, or inconsistent). Staff entering data or preparing for submission may need to
contact the qualified clinician who assessed the patient for assistance in making necessary corrections. The
clinician’s recall of the patient assessment and clinical notes that document the assessment are more
accurate if the review occurs soon after the assessment than if edits and corrections are delayed.
HHAs have flexibility in the method used to encode their data. Data can be encoded directly by the skilled
professional who conducts the assessment into a laptop, hand-held, or tablet computer, by a clerical staff
member from a hard copy of the completed assessment, or by a data entry operator or service with whom
the HHA may contract to enter the data. Any of these are acceptable methods of meeting the regulatory
reporting requirements for OASIS. However, the HHA is ultimately responsible for meeting the reporting
requirements as well as maintaining patient confidentiality.
Once the OASIS data are encoded, HHAs use their software to review and edit the data prior to data
submission. When editing the data prior to transmission, it is important to remember that the edits include an
electronic safety net to preclude the transmission of erroneous or inconsistent information and enforce the
required formatting for the data set items. When transmitted, the patient assessment data are stabilized at
the time point of the assessment, preventing the override of current assessment information with future or
past information.

•

Accuracy of Encoded OASIS Data
The encoded OASIS data must accurately reflect the patient’s status at the time the information is collected.
Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data
that are sent to the centralized data submission system. We expect that once the qualified skilled
professional (specifically, RN, PT, SLP/ST, or OT) completes the assessment, the HHA will develop a
means to ensure that the OASIS data input into the computer and transmitted to a centralized data
submission system exactly reflect the data collected by the skilled professional. Appendix B contains
recommendations for conducting data quality audits on a routine basis and includes information from the
original OASIS Implementation Manual (Chapter 12) (archived but available at the following link:

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Appendix E-1

Appendix E

Data Reporting Regulations

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/HHQIArchives.html).
In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and
transmitted to the State.

•

Transmission of OASIS Data
CMS requires that the HHA electronically transmit the accurate, completed, and encoded OASIS data to a
centralized data submission system within 30 days of the completion of the assessment (M0090 Date
Assessment Completed). As long as the submission time frame is met, HHAs are free to develop schedules
for transmitting the data that best suit their needs. Data must be transmitted in a format that meets the
requirements specified in the data format standard (i.e., conforming to the CMS standard electronic record
layouts, edit specifications, and data dictionary). HHAs that are required to submit OASIS data must do so
using a secure connection to a network maintained by CMS or its contractor. Once transmitted, the data
submission is validated and feedback is provided to the HHA as to whether the submission file(s) has been
accepted or rejected and whether each submitted record meets the data format and edit requirements. An
entire submission or individual records may be rejected for a variety of reasons. The HHA must make
corrections and resubmit the data for any assessments that are rejected. If an assessment record causes
non-fatal warning messages to be generated, the HHA may elect to submit a corrected assessment record
but is not required to do so.
HHAs must use a CMS-assigned branch identification number (where applicable) to identify branch-specific
assessment information in a uniform fashion nationwide. This procedure finalized a process that began in
January 2004, uniquely identifying every branch of every HHA certified to participate in the Medicare home
health program. The system links the parent to the branch HHA and gives CMS the capability of monitoring
the quality of care delivered by agencies down to the HHA branch level.

•

Centers for Medicare & Medicaid Services
For Medicare fee-for-service patients, the transmitted OASIS data also are utilized for billing. The HHA can
submit a Request for Anticipated Payment (RAP) to their Medicare Administrative Contractor (MAC) when
all of the four following conditions are met:
o

After the OASIS assessment is complete, locked or export ready, or there is an agency-wide
internal policy for establishing that the OASIS data is finalized for transmission to the centralized
data submission system,

A physician’s verbal orders for home care have been received and documented,

A plan of care has been established and sent to the physician, and

The first service visit under that plan has been delivered.

An episode will be opened on Common Working File (CWF) with the receipt and processing of the RAP.
RAPs, or in special cases claims, must be submitted for initial HH PPS episodes, subsequent HH PPS
episodes, or in transfer situations to start a new HH PPS episode when another episode is already open at a
different agency. HHAs should submit the RAP as soon as possible after care begins to assure they are
established as the primary HHA for the beneficiary.

•

Data Format
To meet the data format requirements, HHAs may use software developed by CMS (the most recent version
of which is jHAVEN) or other vendor’s software that conforms to CMS standardized electronic record
formats, edit specifications, and data dictionaries. The CMS software can be used for several purposes.
HHAs can use CMS software to encode OASIS data, maintain agency and patient-specific OASIS
information, and create export files to submit OASIS data. The CMS software provides comprehensive online help to users in encoding, editing, and transmitting these data sets. The CMS software can also be used
as a core program by HHAs and software vendors for developing their own software that supports OASIS
reporting requirements, while also supporting or developing programs that meet other agency needs.

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Appendix E-2

Appendix E

Data Reporting Regulations

Additionally, CMS maintains a toll-free help line to support this software product. For questions, please call
the help desk at 877-339-9323 or you can use “[email protected].”
The CMS software alerts the individual who is encoding the data to use the correct screens for the specific
type of assessment record required. HHAs using paper copies of assessment instruments must differentiate
among the various subsets of OASIS data, i.e., specialized forms for particular assessment time points.
HHAs are cautioned that the CMS software provides only the minimum requirements to encode data, apply
mandatory edits, and prepare data files for transmission. CMS will support these functions and applications.
However, CMS does not intend to provide any other applications related to care planning, financial
information, durable medical equipment, medications, personnel, or claims submission. Software developers
are encouraged to use the CMS software to meet minimum requirements until they can ensure that their
own software will accommodate CMS specifications and other applications useful for HHAs. If the HHA uses
software other than software developed by CMS, it must conform to CMS standardized electronic data
submission specifications.

•

The current OASIS Data Set and Manuals can be found https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-ReportingRequirements.html
HHAs can download the required OASIS data set documents by clicking on “OASIS Data Sets”, and then on
“OASIS-C2." There is one document that includes all items in the data set, and additional documents for
each data collection time point: start of care; resumption of care following an inpatient facility stay; follow-up;
discharge (not to an inpatient facility); transfer to inpatient facility (with or without agency discharge); and
death at home. In addition, CMS provides OASIS data entry and data management software. The software
can be downloaded at no charge to HHAs and used to encode OASIS data and create data files ready for
submission to CMS. Data submission specifications, data dictionaries, the HHA data submission manual,
contact information for each state's OASIS Education Coordinator and OASIS Automation Coordinator, and
a link to OASIS Questions and Answers are located at http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/OASIS/HHAQA.html. Other educational materials for HHAs will be posted
on the website. The site is intended to provide direct access for HHAs, State agencies, CMS contractors,
software vendors, professional organizations, and consumers. Vendors and agencies are encouraged to
regularly review the website for information related to the computerization of OASIS and other CMS-related
home health issues. CMS will continue to promote processes for ensuring accuracy in the software. In the
future, as OASIS is revised, HHAs will be directed to the CMS OASIS website for the current version of the
OASIS data set.

Condition of Participation: Release of Patient Identifiable OASIS Information
The HHA or an agent acting on behalf of the HHA must ensure that all protected health (patient-identifiable)
information in the clinical record, including OASIS data, remains confidential and is not released to the public. The
data must be secured and controlled, whether in hard copy or in electronic format. In addition to the provisions of this
Condition of Participation, all HHAs must adhere to the provisions of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) to ensure patient confidentiality and the security of patient information. (Further
information on these requirements is provided on-line at http://www.cms.gov/Regulations-and-Guidance/HIPAAAdministrative-Simplification/HIPAAGenInfo/index.html?redirect=/hipaageninfo/.)
CMS specifies that the HHA who chooses to secure the services of an agent to complete the OASIS regulatory
reporting requirements must secure a written contract between the HHA and the agent to not use or disclose the
information. The agent may only release data to the extent the HHA itself is permitted to do so. It is believed that this
CoP will act as a safeguard against the unauthorized use of a patient’s clinical record information, regardless of the
form or storage method.

•

State Agency Responsibilities for OASIS Collection
Under section 1891(b) of the Social Security Act, the Secretary of the Department of Health and Human
Services must assure that processes are in place to protect the health and safety of individuals under the
care of an HHA and to promote the effective and efficient use of public monies. Section 1864 of the Act

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Appendix E-3

Appendix E

Data Reporting Regulations

authorizes the use of State health agencies to determine a provider’s compliance with the CoPs. State
responsibilities in ensuring compliance with the CoPs are set forth at Part 488, Survey, Certification, and
Enforcement Procedures.
The State Agency must ensure that access to data is restricted (except for the transmission of data and
reports to CMS) to the State Agency component that conducts surveys for purposes related to this function,
and to other entities if authorized by CMS. The State Agency must ensure that patient identifiable OASIS
data are released only to the extent permitted under the Privacy Act of 1974 and the Administrative
Simplification provision of the HIPAA Act of 1996. The System of Records supports the HHA/OASIS
database.
The State Agency provides training and technical support for HHAs. The State Agency or other entity
designated by CMS must instruct each HHA on the administration of and integration of the OASIS data set
into the facility’s own record keeping system; instruct each HHA on the use of software to encode and
transmit OASIS data to the centralized data submission system; monitor each HHA’s ability to transmit
OASIS data; and provide ongoing technical assistance and general support to HHAs in implementing the
OASIS reporting requirements specified in the Conditions of Participation for HHAs.

Privacy Act System of Records Notice
The Privacy Act System of Records (SOR) Notice was first published in the Federal Register, Vol. 64, No. 117, June
18, 1999, and was updated in the Vol. 66, No. 248 Federal Register, published on December 27, 2001 and Vol. 72,
No. 218 Federal Register, published November 13, 2007. The original notice describes the purpose of the new SOR
(a national database) and identifies the statutory authority for creation and maintenance of the system and
appropriate routine uses of the data. Clinical assessment information for all Medicare or Medicaid patients receiving
the services of a Medicare- or Medicaid-approved HHA except for those receiving HHA services for pre- and postpartum conditions, patients less than 18 years of age, and patients receiving exclusively personal care or non-health
care services (i.e., chore or homemaker services) is included in the System of Records (SOR). The assessment
information contained in the SOR is the OASIS data set. These data are obtained through a patient assessment that
is conducted by a registered nurse or qualified therapist. To determine the type of care needed by a patient, HHAs
perform an assessment of each patient's physical and emotional status. HHAs will continue to do these assessments,
but now they will report a portion of that assessment to CMS to perform several critical functions, such as calculating
the appropriate amount to pay for home health services, and to ensure that HHAs are providing the highest quality of
care for the entire agency and for each individual patient. Home health patients are one of the most vulnerable
populations because services are provided in the home where it is difficult to oversee the quality of services provided.
OASIS data allow CMS to measure how well HHAs care for their patients through the development of performance
profiles for each agency.
Consistent with the HIPAA Privacy and Security Rules, the Privacy Act permits CMS to disclose information without
an individual's consent if the information is to be used for a purpose that is compatible with the stated purpose(s) for
which the information was collected. This disclosure is known as "routine use." Several routine use disclosures have
been identified for OASIS data. These data may be disclosed only to:

•

The Department of Justice, court, or adjudicatory body when CMS is involved in litigation or when CMS'
policies or operations could be affected by the outcome of the litigation.

•

A third party with whom CMS has contracted to assist in accomplishing CMS functions relating to purposes
of the System of Records.

•

Another Federal or State Agency, agency of a State Government, or established by State law, for purposes
of evaluating and monitoring the quality of home health care and contributing to the accuracy of CMS' health
insurance operations.

•

A Quality Improvement Organization (QIO), to assist in performing specific functions relating to assessing
and improving HHA quality of care.

•

An individual or organization for research, evaluation, or epidemiological activities related to health.

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Appendix E-4

Appendix E
•

Data Reporting Regulations

A member of Congress or a Congressional staff member in response to an inquiry of the Congressional
Office made at the written request of the constituent about whom the record is maintained.

The December 27, 2001, Federal Register notice added a seventh use disclosure:

•

National accrediting organizations with approval for deeming authority for Medicare requirements for home
health services, allowing these organizations to target potential or identified problems during the
accreditation review process.

The June 18, 1999, Federal Register notice also identified the specific safeguards in place to ensure confidentiality of
patient-level data. Please refer to this announcement for details.

Deficit Reduction Act of 2005 Requirement for Reporting Quality Data and Public
Reporting for Quality Measures
In 2005, the Deficit Reduction Act (DRA) Section 5201(c) (2) was passed by Congress and added section 1895(b) (3)
(ii) (V) to the Social Security Act requiring each HHA to submit to the Secretary such data that the Secretary
determines are appropriate for the measurement of health care quality for 2007 and each subsequent year. Section
5201 (c)(v) requires a payment adjustment if an HHA does not submit data for the reporting year, "the home health
market basket percentage increase applicable for such year shall be reduced by 2 percentage points.” The two
percent reduction would begin to apply to annual payment updates beginning on January 2007 and each year
thereafter.
The law also requires the Secretary to establish procedures for making data submitted available to the public and
ensures the HHA has the opportunity to review the data prior to the data being made public. HHAs currently have
pre-publication access to their own agency's quality data (which the contractor updates periodically). CMS proposes
to continue this process, to enable each agency to know how it is performing before public posting of data on the
Home Health Compare website. CMS also publishes quarterly Preview Reports (available to home health agencies
on the Casper Reporting system and posted the QTSO memorandum in the OASIS State Welcome Page in their
folders to advise agencies of the preview reports and how to access them).
The Secretary of the Department of HHS has determined that the OASIS information collection best meets the
requirements of this statutory mandate. Continuing to use the OASIS instrument ensures that providers will not have
an additional burden of reporting through a separate mechanism and that the costs associated with the development
and testing of a new reporting mechanism can be avoided. Therefore, OASIS assessment submissions are monitored
by CMS to evaluate compliance with the quality reporting requirements. HHAs that meet the reporting requirements
are eligible for the full home health market basket percentage increase. The specific manner in which CMS
determines whether an HHA is in compliance with this requirement is laid out in the yearly Prospective Payment Rule.
HH PPS regulations, including the Final Rules, are available at: https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices.html.

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Appendix E-5

APPENDIX F

OASIS AND QUALITY IMPROVEMENT

Overview
The OASIS instrument was introduced nationally in 1999. Its initial purpose was to provide a standardized home
health item set and standardized quality measures for use in quality improvement activities within individual home
health agencies. The uses for OASIS data quickly expanded beyond quality measurement to also include determining
reimbursement under Medicare Prospective Payment System (PPS). The uses for OASIS data have continued to
evolve over the years with significant quality and payment implications tied to OASIS data. The current uses for
OASIS-based measures include: 1) Home Health Agency Medicare-certification surveys, 2) the measures on the
consumer-focused Home Health Compare website, 3) the measures used in the Home Health Quality of Patient Care
Star Ratings,4) the measures used in the Centers for Medicare & Medicaid Services (CMS) Home Health ValueBased Purchasing (HHVBP) Model, and 5) the Quality Assessment Only (QAO) Metric used in home health pay-forreporting (P4R). The OASIS instrument is also expected to play a pivotal role in post-acute care quality improvement
as advances are made related to the mandates of the IMPACT Act (Improving Medicare Post-Acute Care
Transformation Act of 2014).

History of OASIS and Outcome-Based Quality Improvement (OBQI)
In the early 2000s, CMS developed and began to promote a quality improvement process that used OASIS-based
measures as the foundation for home health quality improvement activities. This process was known as Home Health
Outcome-Based Quality Improvement, or OBQI. CMS, through their contracts with state Quality Improvement
Organizations (QIOs), provided training to home health agencies nationally on OBQI. Agency training and use of
OBQI to improve quality was a preparatory step for the upcoming home health public reporting of quality measures.
In 2002, CMS announced plans for public reporting of home health quality measures. In the fall of 2003, CMS
launched the Home Health Compare website. This website encouraged consumers to use publicly available home
health quality measures when selecting a home health agency. The launch of the Home Health Compare website
was also a catalyst for agency quality-improvement activities as well as the marketing and promotion of quality of
care by individual agencies. The OASIS-based measures created the foundation for these early activities and
advances in home health quality improvement.

Understanding Quality & Quality Improvement
What is quality? The term "quality" in healthcare may have many different meanings. However, standard definitions
are required to be able to measure quality and to then improve quality. The OASIS-based quality measures provide
the home health industry with a framework for defining quality in terms of what matters to a patient and their
caregivers. The home health quality measures have included many measures of activities of daily living (ADLs),
instrumental activities of daily living (IADLs), patient status, and home health agency care processes. These include
the measures of “Improvement in Ambulation-Locomotion” “Stabilization in Grooming,” “Improvement in Pain
Interfering with Activity,” etc. These measures are important to patients as they symbolized quality of life and
independence in a home setting. They are also important measures to home health clinicians as clinicians could
implement best practice interventions to assist patients to improve or to stabilize in the measures that were most
meaningful to the individual patients. The definition of quality for home health also includes measures of agency best
practices that are expected to impact quality of care such as the measures of “Timely Initiation of Care” and
“Depression Assessment Conducted.”
On an agency-wide scale, agencies can then measure their overall progress in each quality measure to determine if
they are improving in the measure, worsening in the measure, or remaining unchanged. Through the Certification and
Survey Provider Enhanced Report (CASPER) system, agencies can compare, or benchmark, their current
performance on the individual quality measures to their prior performance for each individual measure and can also
compare their performance to a risk adjusted national reference rate. A subset of all quality measures is available to
the public on the Home Health Compare website.

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Appendix F-1

Appendix F

OASIS and Quality Improvement

Outcome and Process Measures
The initial OASIS-based quality measures were risk adjusted outcome measures. Shortly after the 2010
implementation of OASIS-C, agencies were introduced to the first standardized process measures which were
derived from OASIS data.

Outcome Measures
An outcome is a health status change that occurs over time, where the change is intrinsic to the patient. Outcome of
care measures are one tool for examining changes in patient status that may be impacted by home health care
services. Thus, a change in the patient's environment, such as the provision of a walker or handrails in the patient's
residence, is not considered an outcome according to this definition—such changes are services or processes of
care. Because the nature of the change can be positive, negative, or neutral, the actual change in patient health
status can correspond to improvement, decline, or stabilization (i.e., no change) in patient condition or functioning.
The definition of an outcome does not include a presumed direction; therefore, any deviation (or non-deviation) in
health status between the initial time point and the follow-up time point constitutes an outcome. For example, did the
patient’s ability to walk and move around improve by the time they finished working with the home health agency? A
rate of 88% for that measure means that 88% of the time, the agency improved their patients’ ability to walk and
move around.
An end-result outcome is a change in patient health status, such as physiologic, functional, cognitive, emotional, or
behavioral health, between two or more time points. Examples of end-result outcomes are: Improvement in
Ambulation/Locomotion and Stabilization in Bathing.
A utilization outcome is a type of health care utilization (or non-utilization) that reflects (typically a substantial)
change in patient health status over time. Examples of utilization outcomes are hospital admission, use of hospital
emergency department services, and discharge to the community. Utilization measures were initially computed using
only OASIS data; however, there are currently utilization measures that are computed using OASIS data and
utilization measures computed using Medicare fee-for-service (FFS) claims data. An overview of the utilization
measures that are derived from OASIS data and the measures that are derived from claims data can be found in the
Home Health Quality Measures Tables found on the CMS Home Health Quality Initiative website at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/index.html

Measure Exclusions for Outcome Measures
Some patients are excluded from the improvement or the stabilization computations. Any patient whose status at start
(or resumption) of care is optimal for the health attribute under consideration is excluded from the improvement
computation. Such a case is excluded because the patient could not possibly show improvement, since he/she is as
"good" as they can possibly be for this attribute. All the patients included in the improvement computation had the
potential to show improvement; the percentage (and the actual number of cases) listed at the end of the bar actually
did improve.
Similar to exclusions from the improvement measures, some cases are excluded from the stabilization computation.
Any patient whose status at start (or resumption) of care is at the most severely impaired level for the health attribute
under consideration is excluded from the stabilization computation. This patient could not possibly show worsening,
so is excluded.

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Appendix F-2

Appendix F

OASIS and Quality Improvement

Examples – Outcome Measures

Measure Name
Improvement in
AmbulationLocomotion

Consumer
Language
(on Home Health
Compare)
How often patients
got better at
walking or moving
around.

Measure
Description

Measure Focus
(Numerator)

OASIS Items Used in
Measure Calculation

Percentage of
home health
episodes of care
during which the
patient improved in
ability to ambulate.

Number of home
health episodes of
care where the value
recorded on the
discharge assessment
indicates less
impairment in
ambulation/locomotion
at discharge than at
start (or resumption)
of care

Items Used to Compute
Change:
(M1860) Ambulation/
Locomotion
Items Used to Compute
Exclusions:
(M1700) Cognitive
Functioning
(M1710) When
Confused
(M1720) When Anxious

Stabilization in
Grooming

NA – This
measure is not
publicly reported.

Percentage of
home health
episodes of care
during which
patients improved
or stayed the same
in ability to groom
self.

Number of home
health episodes of
care where the value
recorded on the
discharge assessment
indicates the same or
less impairment in
grooming themselves
at discharge than at
start (or resumption)
of care.

Items Used to Compute
Change: (M1800)
Grooming.
Items Used to Compute
Exclusions:
(M1700) Cognitive
Functioning
(M1710) When
Confused
(M1720) When Anxious

Re-hospitalization
During the First 30
Days of Home
Health (Claims
based)

How often home
health patients,
who have had a
recent hospital
stay, had to be
readmitted to the
hospital.

Percentage of
home health stays
in which patients
who had an acute
inpatient
hospitalization
discharge within 5
days before the
start of their home
health stay and
were admitted to
an acute care
hospital during the
30 days following
the start of the
home health stay.

Number of home
health stays for
patients who have a
Medicare claim for an
admission to an acute
care hospital in the 30
days following the
start of the home
health stay

None – based on
Medicare FFS claims.

A home health stay is
a sequence of home
health payment
episodes separated
from other home
health payment
episodes by at least
60 days.

The complete list of home health quality measures can be in the Home Health Quality Measures Tables found on the
CMS Home Health Quality Initiative website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/index.html.

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Appendix F-3

Appendix F

OASIS and Quality Improvement

Process Measures
Process quality measures evaluate the rate of home health agency use of specific evidence-based processes of care.
The standardized home health quality process measures focus on high-risk, high-volume, problem-prone areas for
home health care. These include measures pertaining to all or most home care patients, such as timeliness of home
care admission, immunizations, and use of risk assessment tools (e.g. for falls, depression). As well, there are
measures for specific diagnoses (e.g. diabetes).
Process items represent actions taken by home health care providers that are designed to improve patient outcomes.
An example of a process measure is the percentage of patients for whom drug education on all medications was
provided during the episode. An agency rate of 72% for that measure means that the agency’s process of caring for
patients included the recommended practice in 72% of the time.
The process items in OASIS have been carefully chosen to represent “evidence-based” practice. However, not every
process item will apply to every patient.

Measure Exclusions for Process Measures
The majority of the OASIS-based process measures have measure-specific exclusions. Exclusions are specific to
each measure. For example, the process measure of “Influenza Immunization Received for Current Flu Season”
excludes quality episodes in which no care was provided during October 1–March 31, or the patient died, or the
patient does not meet age/condition guidelines for influenza vaccine. The process measure of “Depression
Assessment Conducted” excludes quality episodes for which the patient is nonresponsive. However, the process
measure of “Timely Initiation of Care” has no exclusions. Quality episodes that are excluded are not counted
favorably or unfavorably toward the measure calculation.
Examples – Process Measures

Measure Name
Timely Initiation of
Care

Consumer
Language
(on Home Health
Compare)
How often the
home health team
began their
patients’ care in a
timely manner.

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Measure
Description

Measure Focus
(Numerator)

OASIS Items Used in
Measure Calculation

Percentage of
home health
episodes of care in
which the start or
resumption of care
date was either on
the physicianspecified date or
within 2 days of the
referral date or
inpatient discharge
date, whichever is
later.

Number of home
health episodes of
care in which the
start or resumption
of care date was
either on the
physician-specified
date or within 2
days of the referral
date or inpatient
discharge date,
whichever is later.
For a resumption of
care, per the
Medicare
Conditions of
Participation, the
patient must be
seen within two
days of inpatient
discharge, even if
the physician
specifies a later
date.

Items Used to Compute
Care Processes:
(M0102) Date of
Physician-ordered Start
of Care
(M0104) Date of Referral
(M0030) Start of Care
Date
(M0032) Resumption of
Care Date
(M1000) Inpatient Facility
discharge
(M1005) Inpatient
Discharge Date

Appendix F-4

Appendix F

Measure Name
Influenza
Immunization
Received for
Current Flu Season

OASIS and Quality Improvement
Consumer
Language
(on Home Health
Compare)
How often the
home health team
made sure that
their patients have
received a flu shot
for the current flu
season.

Measure
Description

Measure Focus
(Numerator)

OASIS Items Used in
Measure Calculation

Percentage of
home health
episodes of care
during which
patients received
influenza
immunization for
the current flu
season.

Number of home
health episodes of
care during which
the patient a)
received
vaccination from
the HHA or b) had
received
vaccination from
HHA during earlier
episode of care, or
c) was determined
to have received
vaccination from
another provider.

Items Used to Compute
Care Processes:
(M0030) Start of Care
Date
(M0032) Resumption of
Care Date
(M0906)
Discharge/Transfer/Death
Date
(M1046) Influenza
Vaccine Received
Items Used Compute
Exclusions:
(M1041) Influenza
Vaccine Data Collection
Period
(M1046) Influenza
Vaccine Received
(M0906)
Discharge/Transfer/Death
Date

Home Health Quality Improvement
Soon after the introduction of OASIS-based quality reports, CMS provided home health agencies with a quality
improvement model: Outcome-Based Quality Improvement (OBQI). As home health quality initiatives have evolved
over the years, the OBQI process has also evolved. Today, agencies may select to use other quality improvement
methodologies in addition to or in place of OBQI. These may include Six Sigma, Lean Methodology, PDSA (Plan, Do,
Study, Act), etc., or agencies may choose to use a combination or variation of methodologies to meet their individual
quality improvement needs.
Although agencies may not choose to use the original OBQI process, many of the steps within OBQI are relevant to
home health quality improvement today. A cyclical and ongoing quality improvement process may include the
following steps:
1.
2.
3.
4.
5.
6.
7.

Review Quality Measure Reports
Select Quality Measures—for focused quality improvement activities
Investigate Care Processes (related to measures selected for quality improvement)
Develop a Plan of Action (a.k.a. Quality Improvement Plan)
Implement the Plan
Monitor the Plan
Revise/Update the Plan - as needed

OASIS items provide the basis for the majority of home health quality measures today. In addition to the OASISbased quality measures, there are also home health quality measures that are derived from claims data and Home
Health CAHPS® (Consumer Assessment of Healthcare Providers and Systems) data. Some agencies may have
access to additional quality measures through their health system or payer affiliations, through other programs, or
quality reports generated from their health records. Home health agencies are encouraged to use any of these
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Appendix F-5

Appendix F

OASIS and Quality Improvement

information sources in systematic efforts to continuously monitor and improve the care provided to their patients.
However, CMS cannot provide guidance on data, analysis, or reports from software or data benchmarking from other
sources such as software vendors or data benchmarking companies.

Quality Episodes
Quality episodes are used in the calculation of the quality measures. Quality episodes are not the same as payment,
or Prospective Payment System (PPS) episodes. A quality episode begins with either a start of care or resumption of
care assessment and ends with a transfer or discharge assessment. A quality episode does not include
recertification(follow-up) assessments and may span payment episodes.
A quality episode is measured from:
Start of Care to the Transfer OR
Start of Care to the Discharge/Death OR
Resumption of Care to the Transfer OR
Resumption of Care to the Discharge/Death.
For example, let’s look at a patient who was admitted on 1/1/15 and transferred to an inpatient facility on 1/15/15,
then had a resumption of care on 1/20/15 and was discharged from the agency on 2/1/15. In this example, this
patient had two quality episodes. The first quality episode began with the start of care on 1/1/15 and ended with the
transfer to an inpatient facility on 1/15/15. The second quality episode began with the resumption of care on 1/20/15
and ended with the discharge on 1/31/15.

Calculating Quality Measures
Measuring quality first begins at the patient-level. Outcome measures indicate the change in patient status from one
point in time to another point in time. For this OASIS-based measures, we use the OASIS items for this calculation.
To calculate quality measures, we also need to understand the measure definition (as found in the Home Health
Measures Tables) including the numerator, denominator, and measure exclusions.

Example: Improvement in Dyspnea
Measure Definition: Per the Home Health Measures Tables, the “Improvement in Dyspnea” measure is the
“Percentage of home health episodes of care during which the patient became less short of breath or dyspneic.”
OASIS Item(s) Used in Measure Calculation: The measure is calculated using the OASIS item: (M1400) When is
the patient dyspneic?
(M1400) When is the patient dyspneic or noticeably Short of Breath?
0 – Patient is not short of breath
1 – When walking more than 20 feet, climbing stairs
2 – With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than
20 feet)
3 – With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation
4 – At rest (during day or night)
Measure Exclusions: The first step in calculating measures is to determine the patients that are eligible for the
measure. In this example, this measure excludes home health quality episodes of care for which the patient, at
start/resumption of care, was not short of breath at any time, and also excludes quality episodes that end with
inpatient facility transfer or death. Therefore, for this measure, all patients who at start of care or resumption of care
are scored a “0 – Patient is not short of breath” on OASIS are excluded from this measure because the patient cannot
improve. If the patient cannot improve, then Improvement in Dyspnea is not computed. Quality episodes that end with
death are also excluded and quality episodes that end with a transfer to an inpatient facility are excluded. Quality
episodes that are excluded are not counted favorably or unfavorably toward the measure calculation.
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Appendix F-6

Appendix F

OASIS and Quality Improvement

Improvement: To improve in this measure, a patient must move from a higher numeric score on the OASIS
response scale at start of care or resumption of care to a lower numeric score at discharge (e.g. M1400 start of care
score of “3” and discharge score of “2” would be an improvement). The following table depicts how an individual
patient’s score at the beginning of a quality episode (start of care or resumption of care) and at the end of a quality
episode (discharge for this measure) would be calculated for the Improvement in Dyspnea measure:
OASIS Responses & Measure Calculation for Improvement in Dyspnea Measure:
Start of Care OR
Resumption of Care
0
1
1
2
2
3
3
4
4

Discharge
0–4
0
1–4
0–1
2–4
0–2
3–4
0–3
4

Calculation
Excluded
Improved
Did Not Improve
Improved
Did Not Improve
Improved
Did Not Improve
Improved
Did Not Improve

Agency “Improvement in Dyspnea” Observed Rate: In determining the agency rate for each outcome measure,
we also need to understand the definitions for the measure numerator and denominator.
The numerator for this measure is the number of cases where improvement occurred. In the “Improvement in
Dyspnea” measure, the numerator is number of home health quality episodes of care where the discharge
assessment indicates less dyspnea at discharge than at start (or resumption) of care.
The denominator is the entire population who improved (i.e. patients who improved and who did not improve) for the
measure. Therefore, the denominator is every patient in the reporting period that is not excluded from the measure. In
the “Improvement in Dyspnea” measure, the denominator is the number of home health quality episodes of care
ending with a discharge during the reporting period, other than those covered by generic or measure-specific
exclusions. (Remember that for the “Improvement in Dyspnea” measure, home health quality episodes of care for
which the patient, at start/resumption of care, was not short of breath at any time, are excluded from this measure as
are quality episodes that end in transfer to an inpatient facility or death.
Sample Agency Calculation: If an agency had 100 patients during the reporting period that were discharged from
the agency, and 10 of these patients scored “0” at start of care/resumption of care on M1400 (and therefore were
excluded) and 70 of the remaining 90 patients improved in dyspnea (moved from a higher numeric score on M1400 to
a lower numeric score), then 70/90 (or 0.777) which equals 77.77% scored favorably or improved in dyspnea.

Measuring Stabilization
In our example, we noted that with improvement in OASIS-based measures, the patient’s status moved from a higher
numeric score (at start of care or resumption of care) on the OASIS response scale to a lower numeric score (at
discharge). A number of OASIS-based measures are calculated for “improvement” and are also calculated for
“stabilization.” For example, there is a measure for “Improvement in Bathing” and there is also a measure for
“Stabilization in Bathing.” How then is “stabilization” measured? For the OASIS-based measures, stabilization is
calculated as all patients who did not worsen for the measure. Stabilization includes all patients who remain
numerically the same on the OASIS response scale (i.e., “stabilized”) from start of care or resumption of care to
discharge AND all patients who improved (moved from a higher numeric score to a lower numeric score).
As the stabilization measures include all patients who have stabilized AND all patients who have improved, the
measure rates for the stabilization measures are much higher than the corresponding improvement measure rates.
For example, the current “Improvement in Bathing” national reference rate is approximately 76%. However, the
current “Stabilization in Bathing” national reference rate is approximately 98% as the stabilization rate includes
patients who numerically stay the same for OASIS M1830 AND patients who numerically improve in the OASIS
M1830 score.
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Appendix F-7

Appendix F

OASIS and Quality Improvement

OASIS & Quality Measure Reports
CMS provides several quality measure reports that are generated from OASIS data. Home health agencies can
obtain their OASIS-based quality measure reports from CASPER reports. Information on obtaining OASIS-based
quality reports can be found at https://www.qtso.com/hhatrain.html.
Report Title

Report Description

Agency Patient-Related
Characteristics Report (*)
(**)

Agency Patient-Related
Characteristics Analysis
Summary Report

Home Health Agency (HHA)
Trend Analysis Report

Home Health Hospitalization
by Reason Report

Risk Adjusted Outcome
Report (*) (**)

The average value of each OASIS
patient-related characteristics (patient
attributes or circumstances) measure for
episodes of care that ended during a
specified period for the agency, along
with national reference mean values for
the same period.
The average value of each case mix
attribute, by outcome measure, for a
specified time frame, for patients who
have achieved the outcome, the average
value of each case mix attribute for
patients who have not achieved the
outcome, and the difference between the
two calculations.
The actual OBQI measure rates versus
risk adjusted rates and state and
national percentile rankings by measure
including a 12-month graph.
This is a companion report to the HHA
Trend Analysis Report and is depicted
when the measure of Acute Care
Hospitalization is selected.
Thirty-three End Results Outcome
measures, three Utilization Outcome
measures, and four Claims Based
Outcome measures are reported;
End Results Outcomes are computed
only for episodes of care ending with a
discharge to the community (RFA = 09);
Utilization Outcomes are computed for
episodes of care ending with a transfer
to an inpatient facility (RFA = 06 or 07)
or a discharge to the community (RFA =
09);
Claims Based Outcomes are calculated
based upon the Episode Begin Date;

Report Uses
Agencies can use this report as a
companion to their Risk Adjusted
Outcome Report and their Process
Measures Report.

Agencies can use this report to
assist in investigating unfavorable
OASIS-based outcome measures.

Agencies can use this report for
trending their OASIS-based outcome
measures.
Agencies can use this report to
identify the reason for hospitalization
trends as identified on their agency’s
OASIS.
Agencies can use this report to
monitor their outcome measures.
Agencies are encouraged to review
this report no less frequently than
quarterly and may choose to review
monthly for optimal monitoring of
quality measures.
This report is used in the CMS Home
Health Agency Survey Process.

Significance levels are presented for
each measure when the sample size
corresponding to the measure is at least
10. If the agency had nine or fewer
patients on whom the outcome measure
could be computed validly, statistical
significance is not provided.

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Appendix F-8

Appendix F

OASIS and Quality Improvement

Report Title
6.

Risk Adjusted Potentially
Avoidable Event Report (*)

Potentially Avoidable Event Patient Listing Report (*)

All Patients’ Process Quality
Measures Report (*) (**)

Report Description
Lists each of the twelve Potentially
Avoidable Event Measures and statistics
for each measure; Significance levels
are presented for each measure when
the sample size; corresponding to the
measure is at least 10. If the agency had
nine or fewer patients on whom the
outcome measure could be computed
validly, statistical significance is not
provided.

Agencies are encouraged to review
this report no less frequently than
quarterly and may choose to review
monthly for optimal monitoring of
quality measures.

Lists each of the twelve Potentially
Avoidable Event Measures, statistics for
each, and the patients who experienced
those events for a select agency during
a specified period.

Agencies are encouraged to review
this report no less frequently than
quarterly and may choose to review
monthly for optimal monitoring of
quality measures.

Provides the number and percentage of
each OASIS process quality measure
followed for episodes of care that ended
during a specified period for the agency,
along with national reference
percentages for the same period:
Significance levels are presented for
each measure when the sample size;

Tally – Agency PatientRelated Characteristics
Report

Report Uses

Corresponding to the measure is at least
10. If the agency had nine or fewer
patients on whom the outcome measure
could be computed validly, statistical
significance is not provided.
Details the patient-related characteristics
of each episode of care that ended
during a specified period for the agency.

10. Tally Outcome Report (*)

Details the episodes of care that ended
during a specified period for a select
agency and were used to calculate the
Outcome: Risk Adjusted reports.

11. Tally Process Report (*)

Details the episodes of care that ended
during a specified period for a select
agency and were used to calculate the
Process Measures reports.

12. Home Health Compare
Provider Preview Report

This report is a preview of the agency’s
Home Health Compare data.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

This report is used in the CMS Home
Health Agency Survey Process.

This report is used in the CMS Home
Health Agency Survey Process.
Agencies can use this report to
monitor their OASIS-based process
measures. Agencies are encouraged
to review this report no less
frequently than quarterly and may
choose to review monthly for optimal
monitoring of quality measures.

Agencies can use this report to drilldown to the individual patient-level to
identify cases that triggered for each
of the indicators on the AgencyRelated Characteristics Report.
Agencies can use this report to drilldown to the individual patient-level to
identify cases that triggered for each
of the measures on the Risk
Adjusted Outcome Report. Agencies
may find this report useful in
investigating unfavorable OASISbased outcome measures.
Agencies can use this report to drilldown to the individual patient-level to
identify cases that triggered for each
of the measures on the All Patients’
Process Quality Measures Report.
Agencies may find this report useful
in investigating unfavorable OASISbased process measures.
This report is placed in the agency’s
CASPER folders 3 months prior to
the Home Health Compare update to
allow the agency to preview their
report and contact CMS with any
potential data issues.

Appendix F-9

Appendix F

OASIS and Quality Improvement

Report Title

Report Description

13. Quality of Patient Care Star
Ratings Provider Preview
Report

This report is a preview of the agency’s
Quality of Patient Care Star Rating and
includes a score-card for each of the
measures used to compute the Quality
of Patient Care Star Rating.

14. Quality Assessment Only
(QAO) Metric

This report provides agencies with an
indication of their pay-for-reporting
compliance and is used for informational
purposes only.

Report Uses
This report is placed in the agency’s
CASPER folders 3 months prior to
the Home Health Compare update to
allow the agency to preview their
report and contact CMS with any
potential data issues.
Agencies can use this report to
monitor their compliance with Home
Health pay-for-reporting
requirements.

(*) Sample reports are provided in Figures 1-7 (p.x-x).
(**) Agencies may select this report as either a 2-bar report (comparing their current performance to a risk adjusted
national reference rate) or a 3-bar report (comparing their current performance to their prior performance and to a risk
adjusted national reference rate).

Risk Adjustment of Quality Measures
Change in health status over a time interval during which care is provided (e.g., a quality episode) can occur either as
a result of the care provided or the natural progression of disease and disability. The challenge in outcome analysis is
to attempt to somehow separate changes due to care from those due to natural progression. Statistical risk
adjustment refers to a collection of analytic methods designed to separate the relationships of outcomes with care
provided from the relationship of outcomes with natural progression of disease and disability, which is critical to
accurate outcome analysis. One of the major purposes of OASIS is to provide data items needed for risk adjustment.
In essence, the general intent of risk adjustment is to compensate or adjust for differences in case mix or risk factors
(between agency and a comparison sample) that should be taken into consideration if outcomes are to be compared
validly. Risk adjustment compensates or controls for the potential influence of case mix variables (i.e., risk factors)
that can affect outcomes.
The OASIS-based quality measures are calculated using assessments from the OASIS assessments from Medicare
FFS, Medicare Advantage, Medicaid and Medicaid Managed care. For each of these quality measures a logistic
regression prediction model is created. Each prediction model has on average approximate 100 risk factors selected
from among more than 400 possible risk factors using a rigorous, multi-step process that includes clinical review of
the scientifically identified risk factors. Hence, the result of applying this prediction model for any episode of care is, in
fact, the predicted value based on this logistic regression equation. This value could be described as the probably of
obtaining a positive outcome (expected value) given the patient’s clinical and functional status at the start of care. For
more details regarding the methodology used to construct these prediction models, please review the materials
available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
Risk adjustment for home health agencies takes two forms depending upon whether the results are presented to the
agency via their private CASPER reports or the results are publicly reported via the CMS Website: Home Health
Compare. Risk adjustment of an agency’s observed outcome scores was first tested in the mid-1990’s. These risk
adjusted values have been reported to HHAs via their CASPER reports beginning in the late 1990’s. Public reporting
of home health quality outcomes on Home Health Compare (HHC) began in August 2003. Because the purpose of
these publicly reported results is to provide the public with the ability to compare performance across HHAs rather
than within a particular HHA, the HHA’s observed value for an outcome measure is adjusted by the difference
between the national and the agency’s predicted values. There are no plans to change the methodology of applying
the results from the prediction models for each quality measure to risk adjust the outcome measures for HHAs.
Risk adjusted outcome and utilization measures are reported on the CASPER Risk Adjusted Outcome Reports and
on Home Health Compare. Risk adjustment is based on statistical prediction models estimated on a national sample
of home health agency patients to predict the likelihood of individual patient outcomes based on patient health status
and other attributes at admission to home health care. The method used to risk adjust home health agency outcome
measures is as follows:

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Appendix F-10

Appendix F

OASIS and Quality Improvement

•

The observed outcome rate for the agency is calculated for all eligible patients receiving care from the
agency during the most recent 12 month period: Agencyobs= (# of patients achieving outcome)/(# of
patients eligible for outcome).

•

For each of the same patients, a predicted outcome probability is calculated based on the statistical risk
model and the patient’s condition at admission to home health care.

•

Predicted outcome probabilities are averaged across all of the patients served over a 12 month period,
to yield a predicted outcome rate for the agency: Agencypred= (sum of predicted probability)/(# of
patients eligible for outcome).

•

National observed and predicted rates are calculated in the same manner for the same 12 month
period, by aggregating across all patients served by any home health agency in the United States.

•

The agency rate is risk adjusted by adding to the observed agency rate the difference between the
national predicted rate and the agency predicted rate, using the following formula: Agencyra =
Agencyobs + (National¬pred – Agencypred).

If applying the risk adjustment formula results in a number less than zero the risk adjusted rate is set to zero.
Similarly, if the result is greater than 100%, it is set to 100%.
On the CASPER reports that home health agencies receive, the observed agency outcome rate is reported and the
national reference rate is risk adjusted. This is done using the same method as for Home Health Compare, but the
following formula is used: National¬ra = National¬obs + (Agencypred – National¬pred).
The OASIS-based outcome measures are all risk adjusted. This is indicated on the report titles: Risk Adjusted
Outcome Report and the Risk Adjusted Potentially Avoidable Event Report. The OASIS-based process measures are
not risk adjusted.

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Appendix F-11

Appendix F

OASIS and Quality Improvement

Sample Reports
Sample Report 1: Agency Patient-Related Characteristics Report

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Appendix F-12

Appendix F

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OASIS and Quality Improvement

Appendix F-13

Appendix F

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OASIS and Quality Improvement

Appendix F-14

Appendix F

OASIS and Quality Improvement

Sample Report 2: Risk Adjusted Outcome Report

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Appendix F-15

Appendix F

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Centers for Medicare & Medicaid Services

OASIS and Quality Improvement

Appendix F-16

Appendix F

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Centers for Medicare & Medicaid Services

OASIS and Quality Improvement

Appendix F-17

Appendix F

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Centers for Medicare & Medicaid Services

OASIS and Quality Improvement

Appendix F-18

Appendix F

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Centers for Medicare & Medicaid Services

OASIS and Quality Improvement

Appendix F-19

Appendix F

OASIS and Quality Improvement

Sample Report 3: Risk Adjusted Potentially Avoidable Event Report

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Centers for Medicare & Medicaid Services

Appendix F-20

Appendix F

OASIS-C2 Guidance Manual
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Centers for Medicare & Medicaid Services

OASIS and Quality Improvement

Appendix F-21

Appendix F

OASIS and Quality Improvement

Sample Report 4: Potentially Avoidable Event Report: Patient Listing

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Appendix F-22

Appendix F

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OASIS and Quality Improvement

Appendix F-23

Appendix F

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OASIS and Quality Improvement

Appendix F-24

Appendix F

OASIS and Quality Improvement

Sample Report 5: All Patients’ Process Quality Measures Report

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Appendix F-25

Appendix F

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OASIS and Quality Improvement

Appendix F-26

Appendix F

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OASIS and Quality Improvement

Appendix F-27

Appendix F

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OASIS and Quality Improvement

Appendix F-28

Appendix F

OASIS and Quality Improvement

Sample Report 6: Outcome Tally Report

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Appendix F-29

Appendix F

OASIS and Quality Improvement

Sample Report 7: Process Tally Report

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Appendix F-30

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2

Table G.1 presents an overview of changes made to the OASIS items and Guidance Manual for the transition from OASIS-C1/ICD-10 to OASIS-C2. The table columns and
headings are explained below.
1.

OASIS-C1/ICD-10 item number: Item number in the OASIS-C1/ICD-10.

OASIS-C2 item number: Item number in the OASIS-C2.

Item Description: A brief description of the item.

Item Change: Provides an at a glance categorization of the changes in 7 categories explained below.

•

Convert response spaces to box(es) – if the item response entry format has changed from lines to boxes, or from multiple check boxes to a single box for
response entry, “X” will appear in this column

•

Item text – if the item text is changed, “X” will appear in this column

•

Item number – If the item number is changed, “X” will appear in this column. If item text, response options or guidance is significantly changed, a new
number will be assigned to the item in OASIS-C2.

•

Response option(s) – if the text for the response option(s) is changed, “X” will appear in this column

•

New Item/IMPACT Act Item – if a new item is added to satisfy requirements of the IMPACT Act of 2014, “X” will appear in this column

•

(-) dash is a valid response – if the dash (-) value is a valid response for this item; “X” will appear in this column.

•

Skip Directions - If the skip instructions (for example, [Go to M2401]) have changed, “X” will appear in this column.

Change Description: This column contains a brief description of the changes that have been made to each item.

Guidance Manual Change: provides an at a glance categorization of the changes in the Guidance Manual using the 4 categories explained below.

•

Item Intent- if the Guidance Manual text includes wording changes to the item intent, “X” will appear in this column.

•

Time Points Collected – if the specific time point at which this item is collected has changed (either it is collected at a new time point or it is no longer collected
at a specific time point) “X” will appear in this column.

•

Response Specific Instructions – if the Guidance Manual text for the item includes changing the instructions for how to select a response, “X” will appear in
this column.

•

Data sources and resources – if the Guidance Manual text for the item includes changes to data sources and resources the clinician can use to answer the
item “X” will appear in this column.

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Effective 1/1/2017
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Appendix G-1

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2

Table G.1: Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

M0010
M0014
M0016
M0018

M0020
M0030
M0032
M0040
M0050
M0060
M0063
M0064
M0065
M0066
M0069
M0080

OASISC2
Item #

M0010
M0014
M0016
M0018

M0020
M0030
M0032
M0040
M0050
M0060
M0063
M0064
M0065
M0066
M0069
M0080

M0090 M0090
M0100 M0100

Item Description

CMS Certification Number
Branch State
Branch ID Number
National Provider Identifier (NPI)
physician who signed plan of
care
Patient ID Number
Start of Care Date
Resumption of Care Date
Patient Name
Patient State of Residence
Patient Zip Code
Medicare Number
Social Security Number
Medicaid Number
Birth Date
Gender
Discipline of Person Completing
Assessment
Date Assessment Completed
This Assessment is Currently
Being Completed for the
Following Reason:

OASIS-C2 Guidance Manual
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Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

X
X
X

X
X
X
X
X
X
X
X
X
X
X

X
-

Appendix G-2

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

M0102

OASISC2
Item #

M0102

M0104 M0104

M0110 M0110
M0140 M0140
M0150 M0150
M0903 M0903
M0906 M0906
M1000 M1000

M1005 M1005
M1011 M1011

Item Description

Date of Physician-ordered Start
of Care (Resumption of Care): If
the physician indicated a specific
start of care (resumption of care)
date when the patient was
referred for home health
services, record the date
specified.
Date of Referral: Indicate the
date that the written or verbal
referral for initiation or
resumption of care was received
by the HHA.
Episode Timing
Race/Ethnicity
Current Payment Sources for
Home Care
Date of Last (Most Recent) Home
Visit
Discharge/Transfer/Death Date
From which of the following
Inpatient Facilities was the
patient discharged within the past
14 days? (Mark all that apply.)
Inpatient Discharge Date (most
recent)
List each Inpatient Diagnosis and
ICD-10-C M code at the level of
highest specificity for only those
conditions actively treated during
an inpatient stay within the last
14 days

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Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Appendix G-3

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1017 M1017 Diagnoses Requiring Medical or
Treatment Regimen Change
Within Past 14 Days: List the
patient's Medical Diagnoses and
ICD-10-CM codes at the level of
highest specificity for those
conditions requiring changed
medical or treatment regimen
within the past 14 days
M1018 M1018 Conditions Prior to Regimen
Change or Inpatient Stay Within
Past 14 Days
M1021 M1021 Primary Diagnosis & Degree of
Symptom Control
M1023 M1023 Other Diagnoses & Degree of
Symptom Control
M1025 M1025 Optional Diagnoses (OPTIONAL)
(not used for payment)
M1028
Active Diagnoses- Comorbidities
and Co-existing Conditions –
Check all that apply. See OASIS
Guidance Manual for a complete
list of relevant ICD-10 codes.
M1030 M1030 Therapies the patient receives at
home
M1033 M1033 Risk for Hospitalization: Which of
the following signs or symptoms
characterize this patient as at risk
for hospitalization? (Mark all that
apply.)
M1034 M1034 Overall Status
M1036 M1036 Risk Factors

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Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

New guidance content and format for
new item.

Appendix G-4

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1041 M1041 Influenza Vaccine Data
Collection Period: Does this
episode of care (SOC/ROC to
Transfer/Discharge) include any
dates on or between October 1
and March 31?
M1046 M1046 Influenza Vaccine Received: did
the patient receive the influenza
vaccine for this year’s flu
season?
M1051 M1051 Pneumococcal Vaccine: Has the
patient ever received the
pneumococcal vaccination (for
example, Pneumovax)?
M1056 M1056 Reason PPV not received: If
patient has never received the
pneumococcal vaccination (for
example, Pneumovax), state
reason.
M1060 Height and Weight – While
measuring, if the number is X.1 –
X.4 round down; X.5 or greater
round up
M1100 M1100 Patient Living Situation Which of
the following best describes the
patient's residential circumstance
and availability of assistance?
(Check one box only.)
M1200 M1200 Vision (with corrective lenses if
the patient usually wears them)
M1210 M1210 Ability to Hear (with hearing aid
or hearing appliance if normally
used):
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Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Appendix G-5

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1220 M1220 Understanding of Verbal
Content in patient's own
language (with hearing aid or
device if used):
M1230 M1230 Speech and Oral (Verbal)
Expression of Language (in
patient's own language):
M1240 M1240 Has this patient had a formal
Pain Assessment using a
standardized, validated pain
assessment tool (appropriate to
the patient’s ability to
communicate the severity of
pain)?
M1242 M1242 Frequency of Pain Interfering
with patient's activity or
movement:
M1300 M1300 Pressure Ulcer Assessment: Was
this patient assessed for Risk of
Developing Pressure Ulcers?
M1302 M1302 Does this patient have a Risk of
Developing Pressure Ulcers
M1306 M1306 Does this patient have at least
one Unhealed Pressure Ulcer at
Stage 2 or Higher or designated
as "unstageable"? (Excludes
Stage 1 pressure ulcers and
healed Stage 2 pressure ulcers)
M1307 M1307 The Oldest Non-epithelialized
Stage 2 Pressure Ulcer that is
present at discharge (Excludes
healed Stage 2 pressure ulcers)

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Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Changed
Roman
numerals to
Arabic
numerals
Changed
Roman
numerals to
Arabic
numerals

Appendix G-6

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

M1308 M1311 Current Number of Unhealed
Pressure Ulcers at Each Stage

M1309 M1313 Worsening in Pressure Ulcer
Status since SOC/ROC: Indicate
the number of current pressure
ulcers that were not present or
were at a lesser stage at the
most recent SOC/ROC. If no
current pressure ulcer at a given
stage, enter 0.

OASIS-C2 Guidance Manual
Effective 1/1/2017
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Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Changed
Roman
numerals to
Arabic
numerals;
response
options
relabeled for
clarity; each
response
has two parts
(except for
SOC/ROC)
Item
description
clarified;
Changed
Roman
numerals to
Arabic
numerals;
added
responses
for all types
unstageable
ulcers

Appendix G-7

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1320 M1320 Status of Most Problematic
Pressure Ulcer that is
Observable
M1322 M1322 Current Number of Stage 1
Pressure Ulcers: Intact skin with
non-blanchable redness of a
localized area usually over a
bony prominence. The area may
be painful, firm, soft, warmer or
cooler as compared to adjacent
tissue. Darkly pigmented skin
may not have a visible blanching;
in dark skin tones only it may
appear with persistent blue or
purple hues.
M1324 M1324 Stage of Most Problematic
Unhealed Pressure Ulcer that is
Stageable

M1330 M1330 Does this patient have a Stasis
Ulcer?
M1332 M1332 Current Number of (Observable)
Stasis Ulcer(s)
M1334 M1334 Status of Most Problematic
Stasis Ulcer that is Observable
M1340 M1340 Does this patient have a Surgical
Wound?
M1342 M1342 Status of Most Problematic
Surgical Wound that is
Observable

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Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Sentence
added to
description to
address dark
skin tones;
Changed
Roman
numerals to
Arabic
numerals

Changed
Roman
numerals to
Arabic
numerals for
ulcer stages

Appendix G-8

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1350 M1350 Does this patient have a Skin
Lesion or Open Wound (excluding
bowel ostomy), other than those
described above, that is receiving
intervention by the home health
agency?
M1400 M1400 When is the patient dyspneic or
noticeably Short of Breath?
M1410 M1410 Respiratory Treatments utilized at
home: (Mark all that apply.)
M1500 M1501 Symptoms in Heart Failure
Patients: If patient has been
diagnosed with heart failure, did
the patient exhibit symptoms
indicated by clinical heart failure
guidelines (including dyspnea,
orthopnea, edema, or weight gain)
at the time of or at any time since
the most recent SOC/ROC
assessment?
M1510 M1511 Heart Failure Follow-up: If patient
has been diagnosed with heart
failure and has exhibited
symptoms indicative of heart
failure at the time of or at any
time since the most recent
SOC/ROC assessment, what
action(s) has (have) been taken
to respond? (Mark all that apply.)
M1600 M1600 Has this patient been treated for
a Urinary Tract Infection in the
past 14 days?
OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Change
wording in
the item from
“previous
OASIS
assessment”
to “most
recent
SOC/ROC
assessment”
Change
wording in
the item from
“previous
OASIS
assessment”
to “most
recent
SOC/ROC
assessment”
-

Appendix G-9

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1610 M1610 Urinary Incontinence or Urinary
Catheter Presence
M1615 M1615 When does Urinary Incontinence
occur?
M1620 M1620 Bowel Incontinence Frequency
M1630 M1630 Ostomy for Bowel Elimination:
Does this patient have an ostomy
for bowel elimination that (within
the last 14 days): a) was related
to an inpatient facility stay, or b)
necessitated a change in medical
or treatment regimen?
M1700 M1700 Cognitive Functioning: Patient's
current (day of assessment) level
of alertness, orientation,
comprehension, concentration,
and immediate memory for simple
commands.
M1710 M1710 When Confused (Reported or
Observed Within the Last 14
Days)
M1720 M1720 When Anxious (Reported or
Observed Within the Last 14
Days)
M1730 M1730 Depression Screening: Has the
patient been screened for
depression, using a
standardized, validated
depression screening tool?
M1740 M1740 Cognitive, behavioral, and
psychiatric symptoms that are
demonstrated at least once a
week (Reported or Observed):
(Mark all that apply.)
OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
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Item
Response Impact a valid
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box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Appendix G-10

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1745 M1745 Frequency of Disruptive Behavior
Symptoms (Reported or
Observed) Any physical, verbal,
or other disruptive/dangerous
symptoms that are injurious to
self or others or jeopardize
personal safety.
M1750 M1750 Is this patient receiving
Psychiatric Nursing Services at
home provided by a qualified
psychiatric nurse?
M1800 M1800 Grooming: Current ability to tend
safely to personal hygiene needs
(specifically: washing face and
hands, hair care, shaving or
make up, teeth or denture care,
or fingernail care).
M1810 M1810 Current Ability to Dress Upper
Body safely (with or without
dressing aids) including
undergarments, pullovers, frontopening shirts and blouses,
managing zippers, buttons, and
snaps:
M1820 M1820 Current Ability to Dress Lower
Body safely (with or without
dressing aids) including
undergarments, slacks, socks or
nylons, shoes:
M1830 M1830 Bathing: Current ability to wash
entire body safely. Excludes
grooming (washing face, washing
hands, and shampooing hair).
OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Appendix G-11

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1840 M1840 Toilet Transferring: Current ability
to get to and from the toilet or
bedside commode safely and
transfer on and off
toilet/commode.
M1845 M1845 Toileting Hygiene: Current ability
to maintain perineal hygiene
safely, adjust clothes and/or
incontinence pads before and
after using toilet, commode,
bedpan, urinal. If managing
ostomy, includes cleaning area
around stoma, but not managing
equipment.
M1850 M1850 Transferring: Current ability to
move safely from bed to chair, or
ability to turn and position self in
bed if patient is bedfast.
M1860 M1860 Ambulation/Locomotion: Current
ability to walk safely, once in a
standing position, or use a
wheelchair, once in a seated
position, on a variety of surfaces.
M1870 M1870 Feeding or Eating: Current ability
to feed self meals and snacks
safely. Note: This refers only to
the process of eating, chewing,
and swallowing, not preparing the
food to be eaten.
M1880 M1880 Current Ability to Plan and
Prepare Light Meals (for example,
cereal, sandwich) or reheat
delivered meals safely:
OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Appendix G-12

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M1890 M1890 Ability to Use Telephone: Current
ability to answer the phone safely,
including dialing numbers, and
effectively using the telephone to
communicate.
M1900 M1900 Prior Functioning ADL/IADL:
Indicate the patient’s usual ability
with everyday activities prior to
this current illness, exacerbation,
or injury.
M1910 M1910 Has this patient had a multi-factor
Falls Risk Assessment using a
standardized, validated
assessment tool?
M2000 M2001 Drug Regimen Review: Did a
complete drug regimen review
identify potential clinically
significant medication issues?

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Format of
response
options are
changed, but
text is the
same

Examples
taken out of
item stem;
Not
assessed/not
reviewed is no
longer an
option for
response;
slight changes
to wording in
response
options –
“problems” to
“issues”;
response N/A
is now
response 9 –
N/A.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Change
Description

Appendix G-13

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

M2002 M2003 Medication Follow-up: Did the
agency contact a physician (or
physician-designee) by midnight
of the next calendar day and
complete
prescribed/recommended actions
in response to the identified
potential clinically significant
medication issues?

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Within one
calendar day
clarified as
by midnight
of the next
calendar day;
all issues are
labeled
“potential
clinically
significant
medication
issues” for
consistency;
contact
physician
AND
complete
interventions
required

Appendix G-14

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

M2004 M2005 Medication Intervention: Did the
agency contact and complete
physician (or physician-designee)
prescribed/recommended actions
by midnight of the next calendar
day each time potential clinically
significant medication issues
were identified since the
SOC/ROC?

M2010 M2010 Patient/Caregiver High Risk Drug
Education: Has the
patient/caregiver received
instruction on special precautions
for all high-risk medications (such
as hypoglycemics, anticoagulants,
etc.) and how and when to report
problems that may occur?

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Contact
physician
AND
complete
interventions;
each time
issues
identified; in
one calendar
day changed
to by
midnight of
next calendar
day; since
previous
OASIS
changed to
since the
SOC/ROC;
includes
response for
patient not
taking
medications

Appendix G-15

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M2015 M2016 Patient/Caregiver Drug Education
Intervention: At the time of, or at
any time since the most recent
SOC/ROC assessment, was the
patient/caregiver instructed by
agency staff or other health care
provider to monitor the
effectiveness of drug therapy,
adverse drug reactions, and
significant side effects, and how
and when to report problems that
may occur?
M2020 M2020 Management of Oral
Medications: Patient's current
ability to prepare and take all oral
medications reliably and safely,
including administration of the
correct dosage at the appropriate
times/intervals. Excludes
injectable and IV medications.
(NOTE: This refers to ability, not
compliance or willingness.)
M2030 M2030 Management of Injectable
Medications: Patient's current
ability to prepare and take all
prescribed injectable medications
reliably and safely, including
administration of correct dosage
at the appropriate times/intervals.
Excludes IV medications.

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Change
wording in
the item from
“previous
OASIS
assessment”
to “most
recent
SOC/ROC
assessment”

Appendix G-16

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M2040 M2040 Prior Medication Management:
Indicate the patient’s usual ability
with managing oral and injectable
medications prior to his/her most
recent illness, exacerbation or
injury.
M2102 M2102 Types and Sources of
Assistance: Determine the ability
and willingness of non-agency
caregivers (such as family
members, friends, or privately paid
caregivers) to provide assistance
for the following activities, if
assistance is needed. Excludes all
care by your agency staff.
M2110 M2110 How Often does the patient
receive ADL or IADL assistance
from any caregiver(s) (other than
home health agency staff)?
M2200 M2200 Therapy Need: In the home health
plan of care for the Medicare
payment episode for which this
assessment will define a case mix
group, what is the indicated need
for therapy visits (total of
reasonable and necessary
physical, occupational, and
speech-language pathology visits
combined)? (Enter zero [“000”] if
no therapy visits indicated.)
M2250 M2250 Plan of Care Synopsis: (Check
only one box in each row.) Does
the physician-ordered plan of
care include the following:
OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Response
options
reformatted
but text has
not changed

Appendix G-17

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M2300 M2301 Emergent Care: At the time of or
at any time since the most recent
SOC/ROC assessment has the
patient utilized a hospital
emergency department (includes
holding/observation status)?

M2310

M2310 Reason for Emergent Care: For
what reason(s) did the patient
seek and/or receive emergent
care (with or without
hospitalization)?

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Change
wording in
the stem
from
“previous
OASIS
assessment”
to “most
recent
SOC/ROC
assessment”

Appendix G-18

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

M2400 M2401 Intervention Synopsis: (Check
only one box in each row.) At the
time of or at any time since the
most recent SOC/ROC
assessment, were the following
interventions BOTH included in
the physician-ordered plan of
care AND implemented?

M2410 M2410 To which Inpatient Facility has
the patient been admitted?
M2420 M2420 Discharge Disposition: Where is
the patient after discharge from
your agency? (Choose only one
answer.)

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

Change
wording in
the stem
from
“previous
OASIS
assessment”
to “most
recent
SOC/ROC
assessment”;
Change
wording in
NA response
column for
rows b, c, d,
& e from “last
OASIS
assessment”
to “most
recent
SOC/ROC
assessment”

Appendix G-19

Appendix G

Description of Changes from OASIS-C1/ICD-10 to OASIS-C2
Item Change
Guidance Change

Item Information
OASISC1/
ICD-10
Item #

OASISC2
Item #

Item Description

M2430 M2430 Reason for Hospitalization: For
what reason(s) did the patient
require hospitalization? (Mark all
that apply.)
GG
Mobility – Lying to sitting on side
0170C of bed: Admission performance
and discharge goal

OASIS-C2 Guidance Manual
Effective 1/1/2017
Centers for Medicare & Medicaid Services

Converted
New
response
item/ (-) dash is
spaces to Item
Item
Response Impact a valid
Skip
box(es)
text number option(s) Act Item response Directions

Change
Description

Guidance Manual
Change

Change(s)

Data
Time
Response sources
Item
Point
Specific
and
intent Collected instructions resources

New guidance content and format for new
item.

Appendix G-20

File Type	application/pdf
File Title	Outcome and Assessment Information Set OASIS-C2 Guidance Manual
Subject	OASIS, OASIS Guidance, OASIS tips, OASIS Item-by-item tips, Home Health Guidance, Home Health Guidance Manual, Home Health User
Author	CMIS
File Modified	2016-06-17
File Created	2016-06-16