OASIS-D Guidance Manual

CMS-10545 - OASIS-D Guidance Manual-7-2-2018 Final.pdf

Outcome and Assessment Information Set (OASIS-D) (CMS-10545)

OASIS-D Guidance Manual

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Outcome and Assessment
Information Set

OASIS-D
Guidance Manual
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Centers for Medicare & Medicaid Services

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Table of Contents
Page

CHAPTER 1 — INTRODUCTION

1-1

Preface ....................................................................................................................................................... 1-1

Introduction................................................................................................................................................. 1-1

Revision History ......................................................................................................................................... 1-1

Manual Overview ....................................................................................................................................... 1-2

Why is OASIS Being Revised Now?.......................................................................................................... 1-3

What’s New with the OASIS-D Assessment Instrument?.......................................................................... 1-3

What’s New with the OASIS-D Guidance? ................................................................................................ 1-3

Collecting OASIS Data............................................................................................................................... 1-3

Eligible Patients............................................................................................................................. 1-3

Time Points ................................................................................................................................... 1-3

Who Completes OASIS?............................................................................................................... 1-4

Comprehensive Assessment and Plan of Care ............................................................................ 1-5

Process of Care Data Items .......................................................................................................... 1-5

Conventions for Completing OASIS.............................................................................................. 1-6

OASIS Data Accuracy................................................................................................................................ 1-7

OASIS Data Encoding and Transmission .................................................................................................. 1-8


CHAPTER 2 — OASIS-D: ALL ITEMS AND TIME POINTS VERSIONS

2-1


Introduction................................................................................................................................................. 2-1

All Items...................................................................................................................................................... 2-2

Patient Tracking ...................................................................................................................................... 2-33

Start of Care (SOC) - Admission to Home Health Care........................................................................... 2-34

Resumption of Care (ROC) after Inpatient Facility Stay .......................................................................... 2-53

Follow-up (FU) – Recertification or Other Follow-up ............................................................................... 2-71

Transfer to Inpatient Facility (TRN).......................................................................................................... 2-80

Discharge (DC) from Home Health Care, not to an Inpatient Facility...................................................... 2-85

Death at Home (DAH) .............................................................................................................................. 2-98


CHAPTER 3 — OASIS ITEM GUIDANCE

3-1


Introduction................................................................................................................................................. 3-1

Patient Tracking ........................................................................................................................................3-A

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Clinical Record Items ................................................................................................................................3-B

Patient History and Diagnoses ................................................................................................................ 3-C

Living Arrangements ................................................................................................................................ 3-D

Sensory Status..........................................................................................................................................3-E

Integumentary ...........................................................................................................................................3-F

Respiratory Status ................................................................................................................................... 3-G

[Intentionally Left Blank]........................................................................................................................... 3-H

Elimination Status ...................................................................................................................................... 3-I

Neuro, Emotional, and Behavioral Status................................................................................................. 3-J

ADLs / IADLs ............................................................................................................................................3-K

Medications............................................................................................................................................... 3-L

Care Management ................................................................................................................................... 3-M

Therapy Need .......................................................................................................................................... 3-N

Emergent Care......................................................................................................................................... 3-O

Discharge..................................................................................................................................................3-P

Functional Abilities and Goals .............................................................................................................. 3-GG

Health Conditions...................................................................................................................................... 3-J


CHAPTER 4 — [Intentionally Left Blank]

4-1

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-D Items, Time Points, and Uses .............................................................................. C-1

Appendix D: [Intentionally Left Blank] ....................................................................................................... D-1

Appendix E: Data Reporting Regulations ..................................................................................................E-1

Appendix F: OASIS and Quality Improvement...........................................................................................F-1

Appendix G: Description of Changes from OASIS-C2 to OASIS D .......................................................... G-1


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CHAPTER 1

Chapter 1

OASIS GUIDANCE MANUAL INTRODUCTION

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 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 many 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.

INTRODUCTION
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements developed, tested, and
refined over the course of 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.
OASIS-based quality measures can be used for quality improvement efforts that home health agencies (HHAs) can
employ to assess and improve the quality of care they provide to patients. CMS provides HHAs with numerous quality
measure reports including outcome, process, potentially avoidable event, patient-related characteristic, 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 to improve patient outcomes.
Outcome measures include end-result functional and physical health improvement/stabilization, health care utilization
measures, 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, certain OASIS data elements are used to adjust per-episode
payment rates for patient conditions that affect care needs.

REVISION HISTORY
1.

OASIS C Guidance Manual Original Publication: September 2009

2.

Revision 1: December 2009

3.

Revision 2: January 2011

4.

Revision 3: January 2012

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5.

Revision 4: December 2012

6.

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

Chapter 1

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-10CM.

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.

10. OASIS-C2 Guidance Manual: Effective January 1, 2018
This version of the manual replaces the previous version in its entirety. This version includes corrections and
updates, including but not limited to errors listed in the September OASIS-C2 Guidance Manual Errata, and
new guidance made available in October 2016 and February 2017 CMS National Provider Training Q&A
documents.
11. OASIS D Guidance Manual: Effective January 1, 2019
This version of the manual introduces new and modified items. Some are standardized patient assessment
data elements (SPADEs), added to meet the requirements of the Improving Medicare Post-Acute Care
Transformation Act of 2014 (IMPACT Act). Standardized guidance for the new items is included. The
manual also includes revisions to correct, update or clarify guidance. (See Appendix G for a summary of
changes from OASIS-C2 to OASIS-D).

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

–

Illustrative Examples are retired. Page intentionally left blank.

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Chapter 5

–

Appendices –

Chapter 1

Includes relevant resources for HHAs, with hyperlinks when available.
Include additional contextual information, including sections on OASIS and the comprehensive
assessment, 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 across post-acute care (PAC)
settings to enable calculation of standardized, cross-setting QMs, pursuant to the provisions of the IMPACT
Act. Standardized patient assessment data elements (SPADEs) are questions and response options that are
identical in all four PAC assessment instruments, and to which identical standards and definitions apply.

WHAT’S NEW WITH THE OASIS-D ASSESSMENT INSTRUMENT?
•
•
•
•
•

New items are added
Different time point versions of some items
Removal of items
Revision of some items
Updated Skip Patterns

WHAT’S NEW WITH THE OASIS-D GUIDANCE?
•

•
•
•
•

Chapter 3, two new sections of standard guidance added:

‒
‒

Section J – Health Conditions

Section GG – Functional Abilities and Goals
Chapter 4, Illustrative Examples are retired
Removal of many items and their corresponding guidance
Revisions to existing Guidance for some OASIS items to update or clarify information
Appendix F - sample reports are not included in this version. Users may refer to the Casper Reporting User
Manual, Section 6, OASIS Quality Improvement Reports, located at: https://qtso.cms.gov/hhatrain.html

COLLECTING OASIS DATA
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.

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:

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•
•
•
•
•
•

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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 an inpatient facility
Death at home
Discharge from agency

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 (or its selected medical record vendor) 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, or within 48 hours of knowledge of a qualifying stay in an inpatient facility. A physicianordered resumption of care (ROC) must be conducted on or within 2 calendar days of the physician-ordered ROC
date.
For the transfer to inpatient facility, discharge from home care, death at home, and other follow-up, the assessments
must be completed on, or within 48 hours of becoming aware of the significant change in condition, transfer,
discharge, or death date.

WHO COMPLETES OASIS?
As identified in (M0080) Discipline of Person Completing Assessment, the comprehensive assessment and OASIS
data collection are the responsibility of 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 be responsible for completing OASIS assessments.
In cases involving nursing, the RN is responsible for completing the comprehensive assessment document at the
SOC, and may elicit input from the patient, caregivers, and other health care personnel, including the physician, the
pharmacist and/or other agency staff to assist in completion of any or all OASIS items. 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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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 when allowed (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). Although one clinician must
take responsibility for the comprehensive assessment, collaboration with the patient, caregivers, and other health
care personnel, including the physician, pharmacist, and/or other agency staff is appropriate. For items requiring
patient assessment, the collaborating healthcare providers must have had direct contact with the patient. 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 congruence between documentation of findings from the comprehensive assessment and the Plan of Care.
Agencies may have the comprehensive assessment completed by one clinician. If collaboration with other health care
personnel and/or agency staff is utilized, the agency is responsible for establishing policies and practices related to
collaborative efforts, including how assessment information from multiple clinicians will be documented within the
clinical record, ensuring compliance with applicable requirements, and accepted standards of practice.

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 such as whether the patient was assessed to be at risk
for certain conditions like falls. These items refer to assessments that were completed 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. Specific instructions
about review periods are included in item guidance for the relevant OASIS items.
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.

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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
based on “Frequently Asked Questions” sent to CMS. (A link to Frequently Asked Questions is provided in Chapter
5). It is not 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.

2.

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

3.

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.

4.

Minimize the use of NA and Unknown responses.

5.

Some items allow a dash response. A dash (–) value indicates that no information is available. CMS expects
dash use to be a rare occurrence.

6.

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

7.

Combine observation, interview, collaboration with other agency staff and other relevant strategies to
complete any and all OASIS items as needed, unless otherwise noted in guidance. For example, it is
acceptable to review the hospital discharge summary for information on a patient’s episodes of confusion, or
to interview the caregiver regarding the patient’s incontinence. However, when assessing physiologic or
functional health status, direct observation is the preferred strategy.

8.

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

9.

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 via updates to the guidance manual and posted Q&A
documents.

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13. The comprehensive assessment includes the OASIS items and is part of the patient’s legal home health
agency clinical record. While only the assessing clinician is responsible for accurately completing and
signing a comprehensive assessment, s/he may collaborate to collect data for all OASIS items, if agency
policy allows. Collaboration may consider information from others such as the patient, caregivers, and other
health care personnel, including the physician, pharmacist, and/or other agency staff who have had direct
contact with the patient or had some other means of gathering information to contribute to the OASIS data
collection. When collaboration is utilized, the M0090 Date assessment completed should reflect the last date
the assessing clinician gathered or received any input used to complete the comprehensive assessment,
including the OASIS items. When used, collaboration must occur within the appropriate timeframe and
consistent with data collection guidance. Any exception to this general convention concerning collaboration
is identified in 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.

CONVENTIONS SPECIFIC TO OASIS 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.

2.

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

3.

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.

4.

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

5.

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.

6.

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 for multiple purposes, including production of 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
2
Medicare Conditions of 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.

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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 related to
Encoding OASIS Data, Transmittal of OASIS Data, and Data Format, as 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
4
User Guides and Training).

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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-AssessmentInstruments/OASIS/DataSpecifications.html.

•

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.

OASIS-D Guidance Manual
Effective 1/1/2019
Centers for Medicare & Medicaid Services

Chapter 2-1

OMB #XXXX-XXXX Expiration date xx/xx/xxxx

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

day

year

(M0040) Patient Name:

(First)

(M I)

(Last)

⃞ NA – Not Applicable

(Suffix)

(M0050) Patient State of Residence:
─

(M0060) Patient ZIP Code:
(M0063) Medicare Number:
(including suffix)
(M0064) Social Security Number:
-

-

/
month

OASIS-D – All Item Set
Effective 1/1/2019
Centers for Medicare & Medicaid Services

/
day

⃞ UK – Unknown or Not Available
⃞ NA – No Medicaid

(M0065) Medicaid Number:
(M0066) Birth Date:

⃞ NA – No Medicare

year

Page 1 of 31

(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

(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

OASIS-D – All Item Set
Effective 1/1/2019
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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-M1033,
M1060-M1306, M1311-M2003, M2010, M2020M2200, GG0100-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-M1033, M1060M1306, M1311-M2003, M2010, M2020-M2200,
GG0100-GG0170
M0080-M0100, M0110, M1021- M1023, M1030,
M1200-M1306, M1311-M1400, M1610-M1630,
M1810-M1840, M1850-M1860, M2030, M2200,
GG0130-GG0170
M0080-M0100, M1041-M1056, M2005, M2016,
M2301-M2410, M0906, J1800-J1900

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

M0080-M0100, M2005, M0906, J1800-J1900

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

M0080-M0100, M1041-M1056, M1242-M1311,
M1324-M1330, M1334-M1600, M1620, M1700M1720, M1740-M1870, M2005, M2016-M2020,
M2102, M2301-M2420, M0906, GG0130-J1900

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]
9
Discharge from agency [Go to M1041]

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Effective 1/1/2019
Centers for Medicare & Medicaid Services

Page 3 of 31

CLINICAL RECORD ITEMS, continued
(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

[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?

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
(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 M1021]
(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown

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Effective 1/1/2019
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PATIENT HISTORY AND DIAGNOSES, continued
(M1021/1023) Diagnoses and Symptom Control: 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.
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.

(Form on next page)

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Effective 1/1/2019
Centers for Medicare & Medicaid Services

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

Column 2
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

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

ICD-10-CM / Symptom Control Rating

(M1021) Primary Diagnosis

V, W, X, Y codes NOT allowed

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
a.
(M1023) Other Diagnoses

All ICD-10–CM codes allowed
b.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

c.

c.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

d.

d.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

e.

e.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

f.

f.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

b.

(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)

⃞

3 -

None of the above

(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)

⃞

4 -

None of the above

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Effective 1/1/2019
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PATIENT HISTORY AND DIAGNOSES, continued
(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

(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
1

(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

No [Go to M1051]
Yes

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.

(M1051)

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

Enter Code

0
1

(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

No
Yes [Go to M2005 at TRN; Go to M1242 at DC]

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

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Effective 1/1/2019
Centers for Medicare & Medicaid Services

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(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

pounds

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.)

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

Living Arrangement

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

SENSORY STATUS
(M1200)

Vision (with corrective lenses if the patient usually wears them):

Enter Code

0
1
2

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.

(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

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INTEGUMENTARY STATUS
(M1306)

Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or
designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure
ulcers/injuries)

Enter Code

0
1

(M1307)

The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2
pressure ulcers)

Enter Code

1
2

No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]
Yes

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

SOC/ROC
(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries 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/injuries due to coverage of wound bed by slough
and/or eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

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Effective 1/1/2019
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Follow-Up
Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries 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/injuries due to coverage of wound bed by slough
and/or eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

OASIS-D – All Item Set
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Page 10 of 31

INTEGUMENTARY STATUS, continued
Discharge
Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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, Stage 3]
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, Stage 4]
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, Unstageable: Non-removable dressing/device]
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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
[If 0 – Go to M1311E1, Unstageable: Slough and/or eschar]
D2. Number of these unstageable pressure ulcers/injuries 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, Unstageable: Deep tissue injury]
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
Number of unstageable pressure injuries presenting as deep tissue injury
[If 0 – Go to M1324]
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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(M1322)

Current Number of Stage 1 Pressure Injuries: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. 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/Injury that is Stageable: (Excludes
pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of
wound bed by slough and/or eschar, or deep tissue injury.)

Enter Code

1
2
3
4
NA

(M1330)

Does this patient have a Stasis Ulcer?

Enter Code

0
1
2
3

(M1332)

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

Enter Code

1
2
3
4

(M1334)

Status of Most Problematic Stasis Ulcer that is Observable:

Enter Code

1
2
3

(M1340)

Does this patient have a Surgical Wound?

Enter Code

0
1
2

(M1342)

Status of Most Problematic Surgical Wound that is Observable

Enter Code

0
1
2
3

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries
No [Go to M1340]
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]
One
Two
Three
Four or more
Fully granulating
Early/partial granulation
Not healing
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]
Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

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Effective 1/1/2019
Centers for Medicare & Medicaid Services

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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)

ELIMINATION STATUS
(M1600)

Has this patient been treated for a Urinary Tract Infection in the past 14 days?

Enter Code

0
1
NA
UK

(M1610)

Urinary Incontinence or Urinary Catheter Presence:

Enter Code

0
1
2

(M1620)

Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

(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

0
1
2

No
Yes
Patient on prophylactic treatment
Unknown [Omit “UK” option on DC]
No incontinence or catheter (includes anuria or ostomy for urinary drainage)
Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic)
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]

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.

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NEURO/EMOTIONAL/BEHAVIORAL STATUS
(M1700)
Enter Code

Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
1
2

3
4
(M1710)
Enter Code

(M1720)
Enter Code

(M1730)
Enter Code

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.

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

When Anxious (Reported or Observed Within the Last 14 Days):
0
1
2
3
NA

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

Depression Screening: Has the patient been screened for depression, using a standardized,
validated depression screening tool?
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?”

PHQ-2©*

2
3

a)

Little interest or pleasure
in doing things

b)

Feeling down,
depressed, or hopeless?

Not at all
0-1 day

Several
days
2-6 days

More than
half of the
days
7-11 days

⃞0

⃞1

⃞2

⃞0

⃞1

⃞2

Nearly
NA
every day Unable to
12-14 days respond
⃞3
⃞3

⃞ NA
⃞ 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.

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Effective 1/1/2019
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Page 14 of 31

(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

⃞

2 -

Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop

hours, significant memory loss so that supervision is required
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

(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

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

(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 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.

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.

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ADL/IADLs, continued
(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.

Enter Code

0
1
2
3

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.

(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
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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ADL/IADLs, continued
(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.

(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.

(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.

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MEDICATIONS
(M2001)

Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?

Enter Code

0
1
9

(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

(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

(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

(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

(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

2
3
NA

No – No issues found during review [Go to M2010]
Yes – Issues found during review
NA – Patient is not taking any medications [Go to M2102]

No
Yes

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

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

No
Yes
Patient not taking any drugs

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

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(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.

CARE MANAGEMENT
SOC/ROC
(M2102)

Enter Code

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.
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

Discharge
(M2102)

Enter Code

Enter Code

Enter Code

Enter Code

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.
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
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
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
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

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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.
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

0
1
2
UK

No [Go to M2401]
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 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis

⃞ 10 - Hypo/Hyperglycemia, diabetes out of control
⃞ 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?
Plan / Intervention

No

Yes

Not Applicable

a.

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).

b.

Falls prevention interventions

⃞0

⃞1

⃞NA

Every standardized, validated multi-factor
fall risk assessment conducted at or since
the most recent SOC/ROC assessment
indicates the patient has no risk for falls.

c.

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

⃞0

⃞1

⃞NA

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.

d.

Intervention(s) to monitor and mitigate
pain

⃞0

⃞1

⃞NA

Every standardized, validated pain
assessment conducted at or since the
most recent SOC/ROC assessment
indicates the patient has no pain.

e.

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞NA

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.

f.

Pressure ulcer treatment based on
principles of moist wound healing

⃞0

⃞1

⃞NA

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

1
2
3
4
NA

(M2420)

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

Enter Code

1
2
3
4
UK

Hospital
Rehabilitation facility
Nursing home
Hospice
No inpatient facility admission [Omit “NA” option on TRN]

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

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

/
month

/
day

year

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Section GG

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities: Indicate the patient’s usual ability with everyday activities prior
to the current illness, exacerbation, or injury.
Coding:
3. Independent – Patient completed the
activities by him/herself, with or without
an assistive device, with no assistance
from a helper.
2. Needed Some Help – Patient needed
partial assistance from another person to
complete activities.
1. Dependent – A helper completed the
activities for the patient.
8. Unknown
9. Not Applicable

↓ Enter Codes in Boxes
A.

Self Care: Code the patient’s need for assistance with
bathing, dressing, using the toilet, or eating prior to the
current illnesss, exacerbation, or injury.

B.

Indoor Mobility (Ambulation): Code the patient’s need
for assistance with walking from room to room (with or
without a device such as cane, crutch or walker) prior to
the current illness, exacerbation, or injury.

C.

Stairs: Code the patient’s need for assistance with
internal or external stairs (with or without a device such
as cane, crutch, or walker) prior to the current illness,
exacerbation or injury.

D.

Functional Cognition: Code the patient’s need for
assistance with planning regular tasks, such as shopping
or remembering to take medication prior to the current
illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,
exacerbation, or injury.

↓ Check all that apply
A.

Manual wheelchair

B.

Motorized wheelchair and/or scooter

C.

Mechanical lift

D.

Walker

E.

Orthotics/Prosthetics

Z.

None of the above

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Section GG: Self-Care
SOC/ROC
GG0130. Self-Care
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the
mouth and swallow food and/or liquid once the meal is placed before the
patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if
applicable): The ability to remove and replace dentures from and to the mouth,
and manage equipment for soaking and rinsing them.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes
before and after voiding or having a bowel movement. If managing an ostomy,
include wiping the opening but not managing equipment.

E.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and
drying self (excludes washing of back and hair). Does not include transferring
in/out of tub/shower

F.

Upper body dressing: The ability to dress and undress above the waist;
including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist,
including fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and
shoes or other footwear that is appropriate for safe mobility; including
fasteners, if applicable.

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Follow-Up
GG0130. Self-Care
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal is placed before the patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The
ability to insert and remove dentures into and from the mouth, and manage denture
soaking and rinsing with use of equipment.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

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Discharge
GG0130. Self-Care
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal placed before the patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The
ability to insert and remove dentures into and from the mouth, and manage denture
soaking and rinsing with use of equipment.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

E.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self
(excludes washing of back and hair). Does not include transferring in/out of tub/shower.

F.

Upper body dressing: The ability to dress and undress above the waist; including
fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including
fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and shoes or
other footwear that is appropriate for safe mobility; including fasteners, if applicable.

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Section GG: Mobility
SOC/ROC
GG0170. Mobility
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or
contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Roll left and right: The ability to roll from lying on back to left and right side,
and return to lying on back on the bed.

B.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the
bed.

C.

Lying to sitting on side of bed: The ability to 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.

D.

Sit to stand: The ability to come to a standing position from sitting in a chair,
wheelchair, or on the side of the bed.

E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a
chair (or wheelchair).

F.

Toilet tranfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the
passenger side. Does not include the ability to open/close door or fasten seat
belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room,
corridor, or similar space.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step
(curb)

J.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and
make two turns.

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Page 26 of 31

K.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor
or similar space.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven
or sloping surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one
step.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.
N.

4 steps: The ability to go up and down four steps with or without a rail.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick
up a small object, such as a spoon, from the floor.
Q.

Does patient use wheelchair and/or scooter?
0. No → Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability
to wheel at least 50 feet and make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at
least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Page 27 of 31

Follow-Up
GG0170. Mobility
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C.
D.
E.
F.
I.

J.

Lying to sitting on side of bed: The ability to 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.
Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.
Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).
Toilet tranfer: The ability to get on and off a toilet or commode.
Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Follow-Up performance is coded 07, 09, 10 or 88 → skip to GG0170M, 1 step (curb).
Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Follow-up performance is coded 07, 09, 10 or 88, skip to GG0170Q, Does patient use
wheelchair and/or scooter?
N. 4 steps: The ability to go up and down four steps with or without a rail.

R.

Q. Does patient use wheelchair and/or scooter?
0. No →Skip GG0170R
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.
Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.

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Page 28 of 31

Discharge
GG0170. Mobility
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.

B.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

C.

Lying to sitting on side of bed: The ability to 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.

D.

Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.

E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).

F.

Toilet tranfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the passenger side. Does
not include the ability to open/close door or fasten seat belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb).

J.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two
turns.

K.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar
space.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.
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N.

4 steps: The ability to go up and down four steps with or without a rail.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick up a small
object, such as a spoon, from the floor.
Q. Does patient use wheelchair and/or scooter?
0. No → Skip to J1800 Any falls since SOC/ROC, whichever is more recent.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R.

Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in
a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Section J: Health Conditions
J1800.

Any Falls Since SOC/ROC, whichever is more recent

Enter Code

Has the patient had any falls since SOC/ROC, whichever is more recent?
0. No → Skip J1900
1. Yes → Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent

J1900.

Number of Falls Since SOC/ROC, whichever is more recent

CODING:
0. None
1. One
2. Two or
more

↓ Enter Codes in Boxes.
A.

No injury: No evidence of any injury is noted on physical assessment by the nurse or
primary care clinician; no complaints of pain or injury by the patient; no change in the
patient's behavior is noted after the fall

B.

Injury (except major): Skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains; or any fall-related injury that causes the patient to complain
of pain

C.

Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma

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OMB #XXXX-XXXX Expiration date xx/xx/xxxx

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

day

year

(M0040) Patient Name:

(First)

(M I)

(Last)

⃞ NA – Not Applicable

(Suffix)

(M0050) Patient State of Residence:
─

(M0060) Patient ZIP Code:
(M0063) Medicare Number:
(including suffix)
(M0064) Social Security Number:
-

-

/
month

/
day

⃞ UK – Unknown or Not Available
⃞ NA – No Medicaid

(M0065) Medicaid Number:
(M0066) Birth Date:

⃞ NA – No Medicare

year

(M0069) Gender
Enter Code

1
2

Male
Female

OASIS-D – Patient Tracking Sheet
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Page 1 of 2

(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.)

⃞

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

OASIS-D – Patient Tracking Sheet
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Page 2 of 2

OMB #XXXX-XXXX Expiration date xx/xx/xxxx

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

year

(M0040) Patient Name:

(First)

(M I)

(Last)

(Suffix)

(M0050) Patient State of Residence:
─

(M0060) Patient ZIP Code:
(M0063) Medicare Number:
(including suffix)
(M0064) Social Security Number:
-

-

/
month

OASIS-D – Start of Care
Effective 1/1/2019
Centers for Medicare & Medicaid Services

/
day

⃞ UK – Unknown or Not Available
⃞ NA – No Medicaid

(M0065) Medicaid Number:
(M0066) Birth Date:

⃞ NA – No Medicare

year

Page 1 of 19

(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

(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

OASIS-D – Start of Care
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Centers for Medicare & Medicaid Services

Page 2 of 19

Items to be Used at Specific Time Points
Time Point

Items Used

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

M0010-M0030, M0040-M0150, M1000-M1033,
M1060-M1306, M1311-M2003, M2010, M2020M2200, GG0100-GG0170

Start of care – further visits planned

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]
9
Discharge from agency [Go to M1041]

(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

[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?

Enter Code

1
2
UK
NA

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

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Page 3 of 19

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 -

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 M1021]
(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown
(M1021/1023) Diagnoses and Symptom Control: 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.
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.

(Form on next page)

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Page 4 of 19

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

Column 2
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

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

ICD-10-CM / Symptom Control Rating

(M1021) Primary Diagnosis

V, W, X, Y codes NOT allowed

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
a.
(M1023) Other Diagnoses

All ICD-10–CM codes allowed
b.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

c.

c.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

d.

d.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

e.

e.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

f.

f.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

b.

(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)

⃞

3 -

None of the above

(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)

⃞

4 -

None of the above

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Effective 1/1/2019
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Page 5 of 19

PATIENT HISTORY AND DIAGNOSES, continued
(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

(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

pounds

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.)

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

Living Arrangement

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

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SENSORY STATUS
(M1200)

Vision (with corrective lenses if the patient usually wears them):

Enter Code

0
1
2

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.

(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/Injury at Stage 2 or Higher or
designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure
ulcers/injuries)

Enter Code

0
1

No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]
Yes

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

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries 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/injuries due to coverage of wound bed by slough
and/or eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

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(M1322)

Current Number of Stage 1 Pressure Injuries: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. 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/Injury that is Stageable: (Excludes
pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of
wound bed by slough and/or eschar, or deep tissue injury.)

Enter Code

1
2
3
4
NA

(M1330)

Does this patient have a Stasis Ulcer?

Enter Code

0
1
2
3

(M1332)

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

Enter Code

1
2
3
4

(M1334)

Status of Most Problematic Stasis Ulcer that is Observable:

Enter Code

1
2
3

(M1340)

Does this patient have a Surgical Wound?

Enter Code

0
1
2

(M1342)

Status of Most Problematic Surgical Wound that is Observable

Enter Code

0
1
2
3

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries
No [Go to M1340]
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]
One
Two
Three
Four or more
Fully granulating
Early/partial granulation
Not healing
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]
Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

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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)

ELIMINATION STATUS
(M1600)

Has this patient been treated for a Urinary Tract Infection in the past 14 days?

Enter Code

0
1
NA
UK

(M1610)

Urinary Incontinence or Urinary Catheter Presence:

Enter Code

0
1
2

(M1620)

Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

(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

0
1
2

No
Yes
Patient on prophylactic treatment
Unknown [Omit “UK” option on DC]
No incontinence or catheter (includes anuria or ostomy for urinary drainage)
Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic)
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]

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.

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NEURO/EMOTIONAL/BEHAVIORAL STATUS
(M1700)
Enter Code

Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
1
2

3
4
(M1710)
Enter Code

(M1720)
Enter Code

(M1730)
Enter Code

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.

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

When Anxious (Reported or Observed Within the Last 14 Days):
0
1
2
3
NA

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

Depression Screening: Has the patient been screened for depression, using a standardized,
validated depression screening tool?
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?”

PHQ-2©*

2
3

a)

Little interest or pleasure
in doing things

b)

Feeling down,
depressed, or hopeless?

Not at all
0-1 day

Several
days
2-6 days

More than
half of the
days
7-11 days

⃞0

⃞1

⃞2

⃞0

⃞1

⃞2

Nearly
NA
every day Unable to
12-14 days respond
⃞3
⃞3

⃞ NA
⃞ 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.

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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 -

Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24

⃞

2 -

Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop

hours, significant memory loss so that supervision is required
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

(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

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

(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 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.

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.

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ADL/IADLs, continued
(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.

Enter Code

0
1
2
3

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.

(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
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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ADL/IADLs, continued
(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.

(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.

(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.

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MEDICATIONS
(M2001)

Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?

Enter Code

0
1
9

(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

(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

(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

2
3
NA

No – No issues found during review [Go to M2010]
Yes – Issues found during review
NA – Patient is not taking any medications [Go to M2102]

No
Yes

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

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
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.

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CARE MANAGEMENT
(M2102)

Enter Code

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.
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

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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Section GG

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities: Indicate the patient’s usual ability with everyday activities prior
to the current illness, exacerbation, or injury.
Coding:
3. Independent – Patient completed the
activities by him/herself, with or without
an assistive device, with no assistance
from a helper.
2. Needed Some Help – Patient needed
partial assistance from another person to
complete activities.
1. Dependent – A helper completed the
activities for the patient.
8. Unknown
9. Not Applicable

↓ Enter Codes in Boxes
A.

Self Care: Code the patient’s need for assistance with
bathing, dressing, using the toilet, or eating prior to the
current illnesss, exacerbation, or injury.

B.

Indoor Mobility (Ambulation): Code the patient’s need
for assistance with walking from room to room (with or
without a device such as cane, crutch or walker) prior to
the current illness, exacerbation, or injury.

C.

Stairs: Code the patient’s need for assistance with
internal or external stairs (with or without a device such
as cane, crutch, or walker) prior to the current illness,
exacerbation or injury.

D.

Functional Cognition: Code the patient’s need for
assistance with planning regular tasks, such as shopping
or remembering to take medication prior to the current
illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,
exacerbation, or injury.

↓ Check all that apply
A.

Manual wheelchair

B.

Motorized wheelchair and/or scooter

C.

Mechanical lift

D.

Walker

E.

Orthotics/Prosthetics

Z.

None of the above

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Section GG: Self-Care
GG0130. Self-Care
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the
mouth and swallow food and/or liquid once the meal is placed before the
patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if
applicable): The ability to remove and replace dentures from and to the mouth,
and manage equipment for soaking and rinsing them.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes
before and after voiding or having a bowel movement. If managing an ostomy,
include wiping the opening but not managing equipment.

E.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and
drying self (excludes washing of back and hair). Does not include transferring
in/out of tub/shower

F.

Upper body dressing: The ability to dress and undress above the waist;
including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist,
including fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and
shoes or other footwear that is appropriate for safe mobility; including
fasteners, if applicable.

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Section GG: Mobility
GG0170. Mobility
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or
contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Roll left and right: The ability to roll from lying on back to left and right side,
and return to lying on back on the bed.

B.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the
bed.

C.

Lying to sitting on side of bed: The ability to 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.

D.

Sit to stand: The ability to come to a standing position from sitting in a chair,
wheelchair, or on the side of the bed.

E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a
chair (or wheelchair).

F.

Toilet tranfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the
passenger side. Does not include the ability to open/close door or fasten seat
belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room,
corridor, or similar space.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step
(curb)

J.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and
make two turns.

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K.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor
or similar space.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven
or sloping surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one
step.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.
N.

4 steps: The ability to go up and down four steps with or without a rail.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick
up a small object, such as a spoon, from the floor.
Q.

Does patient use wheelchair and/or scooter?
0. No → Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability
to wheel at least 50 feet and make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at
least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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OMB #XXXX-XXXX Expiration date xx/xx/xxxx

Home Health Patient Tracking Sheet
(M0032) Resumption of Care Date:

/
month

/
day

year

⃞ NA – Not Applicable

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

Items Used

Resumption of Care ---------------------------------------------

M0032, M0080-M0110, M1000-M1033, M1060M1306, M1311-M2003, M2010, M2020-M2200,
GG0100-GG0170

Resumption of care (after inpatient stay)

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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]
9
Discharge from agency [Go to M1041]

(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

[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?

Enter Code

1
2
UK
NA

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

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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 -

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 M1021]
(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown
(M1021/1023) Diagnoses and Symptom Control: 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.
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.

(Form on next page)

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

Column 2
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

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

ICD-10-CM / Symptom Control Rating

(M1021) Primary Diagnosis

V, W, X, Y codes NOT allowed

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
a.
(M1023) Other Diagnoses

All ICD-10–CM codes allowed
b.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

c.

c.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

d.

d.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

e.

e.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

f.

f.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

b.

(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)

⃞

3 -

None of the above

(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)

⃞

4 -

None of the above

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PATIENT HISTORY AND DIAGNOSES, continued
(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

(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

pounds

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.)

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

Living Arrangement

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

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SENSORY STATUS
(M1200)

Vision (with corrective lenses if the patient usually wears them):

Enter Code

0
1
2

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.

(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/Injury at Stage 2 or Higher or
designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure
ulcers/injuries)

Enter Code

0
1

No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]
Yes

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

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries 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/injuries due to coverage of wound bed by slough
and/or eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

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INTEGUMENTARY STATUS, continued
(M1322)

Current Number of Stage 1 Pressure Injuries: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. 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/Injury that is Stageable: (Excludes
pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of
wound bed by slough and/or eschar, or deep tissue injury.)

Enter Code

1
2
3
4
NA

(M1330)

Does this patient have a Stasis Ulcer?

Enter Code

0
1
2
3

(M1332)

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

Enter Code

1
2
3
4

(M1334)

Status of Most Problematic Stasis Ulcer that is Observable:

Enter Code

1
2
3

(M1340)

Does this patient have a Surgical Wound?

Enter Code

0
1
2

(M1342)

Status of Most Problematic Surgical Wound that is Observable

Enter Code

0
1
2
3

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries
No [Go to M1340]
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]
One
Two
Three
Four or more
Fully granulating
Early/partial granulation
Not healing
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]
Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

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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)

ELIMINATION STATUS
(M1600)

Has this patient been treated for a Urinary Tract Infection in the past 14 days?

Enter Code

0
1
NA
UK

(M1610)

Urinary Incontinence or Urinary Catheter Presence:

Enter Code

0
1
2

(M1620)

Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

(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

0
1
2

No
Yes
Patient on prophylactic treatment
Unknown [Omit “UK” option on DC]
No incontinence or catheter (includes anuria or ostomy for urinary drainage)
Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic)
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]

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.

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NEURO/EMOTIONAL/BEHAVIORAL STATUS
(M1700)
Enter Code

Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
1
2

3
4
(M1710)
Enter Code

(M1720)
Enter Code

(M1730)
Enter Code

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.

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

When Anxious (Reported or Observed Within the Last 14 Days):
0
1
2
3
NA

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

Depression Screening: Has the patient been screened for depression, using a standardized,
validated depression screening tool?
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?”

PHQ-2©*

2
3

a)

Little interest or pleasure
in doing things

b)

Feeling down,
depressed, or hopeless?

Not at all
0-1 day

Several
days
2-6 days

More than
half of the
days
7-11 days

⃞0

⃞1

⃞2

⃞0

⃞1

⃞2

Nearly
NA
every day Unable to
12-14 days respond
⃞3
⃞3

⃞ NA
⃞ 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.

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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 -

Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24

⃞

2 -

Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop

hours, significant memory loss so that supervision is required
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

(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

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

(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 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.

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.

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ADL/IADLs, continued
(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.

Enter Code

0
1
2
3

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.

(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
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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ADL/IADLs, continued
(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.

(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.

(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.

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MEDICATIONS
(M2001)

Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?

Enter Code

0
1
9

(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

(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

(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

2
3
NA

No – No issues found during review [Go to M2010]
Yes – Issues found during review
NA – Patient is not taking any medications [Go to M2102]

No
Yes

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

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
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.

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CARE MANAGEMENT
(M2102)

Enter Code

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.
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

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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Section GG

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities: Indicate the patient’s usual ability with everyday activities prior
to the current illness, exacerbation, or injury.
Coding:
3. Independent – Patient completed the
activities by him/herself, with or without
an assistive device, with no assistance
from a helper.
2. Needed Some Help – Patient needed
partial assistance from another person to
complete activities.
1. Dependent – A helper completed the
activities for the patient.
8. Unknown
9. Not Applicable

↓ Enter Codes in Boxes
A.

Self Care: Code the patient’s need for assistance with
bathing, dressing, using the toilet, or eating prior to the
current illnesss, exacerbation, or injury.

B.

Indoor Mobility (Ambulation): Code the patient’s need
for assistance with walking from room to room (with or
without a device such as cane, crutch or walker) prior to
the current illness, exacerbation, or injury.

C.

Stairs: Code the patient’s need for assistance with
internal or external stairs (with or without a device such
as cane, crutch, or walker) prior to the current illness,
exacerbation or injury.

D.

Functional Cognition: Code the patient’s need for
assistance with planning regular tasks, such as shopping
or remembering to take medication prior to the current
illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,
exacerbation, or injury.

↓ Check all that apply
A.

Manual wheelchair

B.

Motorized wheelchair and/or scooter

C.

Mechanical lift

D.

Walker

E.

Orthotics/Prosthetics

Z.

None of the above

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Section GG: Self-Care
GG0130. Self-Care
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the
mouth and swallow food and/or liquid once the meal is placed before the
patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if
applicable): The ability to remove and replace dentures from and to the mouth,
and manage equipment for soaking and rinsing them.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes
before and after voiding or having a bowel movement. If managing an ostomy,
include wiping the opening but not managing equipment.

E.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and
drying self (excludes washing of back and hair). Does not include transferring
in/out of tub/shower

F.

Upper body dressing: The ability to dress and undress above the waist;
including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist,
including fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and
shoes or other footwear that is appropriate for safe mobility; including
fasteners, if applicable.

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Section GG: Mobility
GG0170. Mobility
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or
contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Roll left and right: The ability to roll from lying on back to left and right side,
and return to lying on back on the bed.

B.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the
bed.

C.

Lying to sitting on side of bed: The ability to 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.

D.

Sit to stand: The ability to come to a standing position from sitting in a chair,
wheelchair, or on the side of the bed.

E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a
chair (or wheelchair).

F.

Toilet tranfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the
passenger side. Does not include the ability to open/close door or fasten seat
belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room,
corridor, or similar space.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step
(curb)

J.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and
make two turns.

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K.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor
or similar space.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven
or sloping surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one
step.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.
N.

4 steps: The ability to go up and down four steps with or without a rail.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick
up a small object, such as a spoon, from the floor.
Q.

Does patient use wheelchair and/or scooter?
0. No → Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability
to wheel at least 50 feet and make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at
least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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OMB #XXXX-XXXX Expiration date xx/xx/xxxx

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

Items Used

Follow-Up -----------------------------------------------------------

M0080-M0100, M0110, M1021-M1023, M1030,
M1200-M1306, M1311-M1400, M1610-M1630,
M1810-M1840, M1850-M1860, M2030, M2200,
GG0130-GG0170

Recertification (follow-up) assessment
Other follow-up assessment

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]
9
Discharge from agency [Go to M1041]

(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.

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PATIENT HISTORY AND DIAGNOSES
(M1021/1023) Diagnoses and Symptom Control: 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.
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.

(Form on next page)

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

Column 2
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

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

ICD-10-CM / Symptom Control Rating

(M1021) Primary Diagnosis

V, W, X, Y codes NOT allowed

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
a.
(M1023) Other Diagnoses

All ICD-10–CM codes allowed
b.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

c.

c.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

d.

d.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

e.

e.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

f.

f.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

b.

(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)

⃞

4 -

None of the above

SENSORY STATUS
(M1200)

Vision (with corrective lenses if the patient usually wears them):

Enter Code

0
1
2

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.

(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

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INTEGUMENTARY STATUS
(M1306)

Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or
designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure
ulcers/injuries)

Enter Code

0
1

No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]
Yes

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

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries 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/injuries due to coverage of wound bed by slough
and/or eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

(M1322)

Current Number of Stage 1 Pressure Injuries: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. 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/Injury that is Stageable: (Excludes
pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of
wound bed by slough and/or eschar, or deep tissue injury.)

Enter Code

1
2
3
4
NA

(M1330)

Does this patient have a Stasis Ulcer?

Enter Code

0
1
2
3

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries
No [Go to M1340]
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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INTEGUMENTARY STATUS, continued
(M1332)

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

Enter Code

1
2
3
4

(M1334)

Status of Most Problematic Stasis Ulcer that is Observable:

Enter Code

1
2
3

(M1340)

Does this patient have a Surgical Wound?

Enter Code

0
1
2

(M1342)

Status of Most Problematic Surgical Wound that is Observable

Enter Code

0
1
2
3

One
Two
Three
Four or more
Fully granulating
Early/partial granulation
Not healing
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]
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

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)

ELIMINATION STATUS
(M1610)

Urinary Incontinence or Urinary Catheter Presence:

Enter Code

0
1
2

(M1620)

Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

(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

0
1
2

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

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.

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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.

(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.

(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
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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ADL/IADLs, continued
(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

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.

1
2

3
4
5
6

MEDICATIONS
(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.

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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Section GG

Functional Abilities and Goals

Section GG: Self-Care
GG0130. Self-Care
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal is placed before the patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The
ability to insert and remove dentures into and from the mouth, and manage denture
soaking and rinsing with use of equipment.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

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Centers for Medicare & Medicaid Services

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Section GG: Mobility
GG0170. Mobility
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C.
D.
E.
F.
I.

J.

Lying to sitting on side of bed: The ability to 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.
Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.
Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).
Toilet tranfer: The ability to get on and off a toilet or commode.
Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Follow-Up performance is coded 07, 09, 10 or 88 → skip to GG0170M, 1 step (curb).
Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Follow-up performance is coded 07, 09, 10 or 88, skip to GG0170Q, Does patient use
wheelchair and/or scooter?
N. 4 steps: The ability to go up and down four steps with or without a rail.

R.

Q. Does patient use wheelchair and/or scooter?
0. No →Skip GG0170R
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.
Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.

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OMB #XXXX-XXXX Expiration date xx/xx/xxxx

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

Items Used

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

M0080-M0100, M1041-M1056, M2005, M2016,
M2301-M2410, M0906, J1800-J1900

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]
9
Discharge from agency [Go to M1041]

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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

0
1

(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

No [Go to M1051]
Yes

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.

(M1051)

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

Enter Code

0
1

(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

No
Yes [Go to M2005 at TRN; Go to M1242 at DC]

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

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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

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

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

0
1
2
UK

No [Go to M2401]
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 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis

⃞ 10 - Hypo/Hyperglycemia, diabetes out of control
⃞ 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?
Plan / Intervention

No

Yes

Not Applicable

a.

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).

b.

Falls prevention interventions

⃞0

⃞1

⃞NA

Every standardized, validated multi-factor
fall risk assessment conducted at or since
the most recent SOC/ROC assessment
indicates the patient has no risk for falls.

c.

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

⃞0

⃞1

⃞NA

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.

d.

Intervention(s) to monitor and mitigate
pain

⃞0

⃞1

⃞NA

Every standardized, validated pain
assessment conducted at or since the
most recent SOC/ROC assessment
indicates the patient has no pain.

e.

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞NA

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.

f.

Pressure ulcer treatment based on
principles of moist wound healing

⃞0

⃞1

⃞NA

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

1
2
3
4
NA

Hospital
Rehabilitation facility
Nursing home
Hospice
No inpatient facility admission [Omit “NA” option on TRN]

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

/
month

/
day

year

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Section J: Health Conditions
J1800.

Any Falls Since SOC/ROC, whichever is more recent

Enter Code

Has the patient had any falls since SOC/ROC, whichever is more recent?
0. No → Skip J1900
1. Yes → Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent

J1900.

Number of Falls Since SOC/ROC, whichever is more recent

CODING:
0. None
1. One
2. Two or
more

↓ Enter Codes in Boxes.
A.

No injury: No evidence of any injury is noted on physical assessment by the nurse or
primary care clinician; no complaints of pain or injury by the patient; no change in the
patient's behavior is noted after the fall

B.

Injury (except major): Skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains; or any fall-related injury that causes the patient to complain
of pain

C.

Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma

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OMB #XXXX-XXXX Expiration date xx/xx/xxxx

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

Items Used

Discharge from Agency – Not to an Inpatient Facility
Discharge from agency --------------------------------------

M0080-M0100, M1041-M1056, M1242-M1311,
M1324-M1330, M1334-M1600, M1620, M1700M1720, M1740-M1870, M2005, M2016-M2020,
M2102, M2301-M2420, M0906, GG0130-J1900

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]
9
Discharge from agency [Go to M1041]

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Page 1 of 13

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?
0
1

Enter Code

(M1046)

No [Go to M1051]
Yes

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)

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.

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

Enter Code

0
1

(M1056)

No
Yes [Go to M2005 at TRN; Go to M1242 at DC]

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

SENSORY STATUS
(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

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INTEGUMENTARY STATUS
(M1306)

Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or
designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure
ulcers/injuries)

Enter Code

0
1

(M1307)

The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2
pressure ulcers)

Enter Code

1
2

No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]
Yes

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

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

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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, Stage 3]
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, Stage 4]
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, Unstageable: Non-removable dressing/device]
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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
[If 0 – Go to M1311E1, Unstageable: Slough and/or eschar]
D2. Number of these unstageable pressure ulcers/injuries 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, Unstageable: Deep tissue injury]
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

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

Enter
Number

F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury
[If 0 – Go to M1324]
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

(M1324)

Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable: (Excludes
pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of
wound bed by slough and/or eschar, or deep tissue injury.)

Enter Code

1
2
3
4
NA

(M1330)

Does this patient have a Stasis Ulcer?

Enter Code

0
1
2
3

(M1334)

Status of Most Problematic Stasis Ulcer that is Observable:

Enter Code

1
2
3

(M1340)

Does this patient have a Surgical Wound?

Enter Code

0
1
2

(M1342)

Status of Most Problematic Surgical Wound that is Observable

Enter Code

0
1
2
3

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries
No [Go to M1340]
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]
Fully granulating
Early/partial granulation
Not healing
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]
Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

RESPIRATORY STATUS
(M1400)
Enter Code

When is the patient dyspneic or noticeably Short of Breath?
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)

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ELIMINATION STATUS
(M1600)

Has this patient been treated for a Urinary Tract Infection in the past 14 days?

Enter Code

0
1
NA
UK

(M1620)

Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

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

NEURO/EMOTIONAL/BEHAVIORAL STATUS
(M1700)
Enter Code

Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
1
2

3
4
(M1710)
Enter Code

(M1720)
Enter Code

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.

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

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

⃞

2 -

Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop

hours, significant memory loss so that supervision is required
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

(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

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

(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 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.

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.

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ADL/IADLs, continued
(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.

Enter Code

0
1
2
3

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.

(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
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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ADL/IADLs, continued
(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.

(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.

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

(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

(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

2
3
NA

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

No
Yes
Patient not taking any drugs

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

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CARE MANAGEMENT
(M2102)

Enter Code

Enter Code

Enter Code

Enter Code

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.
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
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
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
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

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

0
1
2
UK

No [Go to M2401]
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 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis

⃞ 10 - Hypo/Hyperglycemia, diabetes out of control
⃞ 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?
Plan / Intervention

No

Yes

Not Applicable

a.

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).

b.

Falls prevention interventions

⃞0

⃞1

⃞NA

Every standardized, validated multi-factor
fall risk assessment conducted at or since
the most recent SOC/ROC assessment
indicates the patient has no risk for falls.

c.

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

⃞0

⃞1

⃞NA

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.

d.

Intervention(s) to monitor and mitigate
pain

⃞0

⃞1

⃞NA

Every standardized, validated pain
assessment conducted at or since the
most recent SOC/ROC assessment
indicates the patient has no pain.

e.

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞NA

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.

f.

Pressure ulcer treatment based on
principles of moist wound healing

⃞0

⃞1

⃞NA

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

1
2
3
4
NA

(M2420)

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

Enter Code

1
2
3
4
UK

Hospital
Rehabilitation facility
Nursing home
Hospice
No inpatient facility admission [Omit “NA” option on TRN]

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

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

/
month

/
day

year

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Section GG

Functional Abilities and Goals

Section GG: Self-Care
GG0130. Self-Care
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
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.
Activities 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.
03. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
02. 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.
01. 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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal placed before the patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The
ability to insert and remove dentures into and from the mouth, and manage denture
soaking and rinsing with use of equipment.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

E.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self
(excludes washing of back and hair). Does not include transferring in/out of tub/shower.

F.

Upper body dressing: The ability to dress and undress above the waist; including
fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including
fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and shoes or
other footwear that is appropriate for safe mobility; including fasteners, if applicable.

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Section GG: Mobility
GG0170. Mobility
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.

B.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

C.

Lying to sitting on side of bed: The ability to 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.

D.

Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.

E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).

F.

Toilet tranfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the passenger side. Does
not include the ability to open/close door or fasten seat belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb).

J.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two
turns.

K.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar
space.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.
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N.

4 steps: The ability to go up and down four steps with or without a rail.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick up a small
object, such as a spoon, from the floor.
Q. Does patient use wheelchair and/or scooter?
0. No → Skip to J1800 Any falls since SOC/ROC, whichever is more recent.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R.

Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in
a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

Section J: Health Conditions
J1800.

Any Falls Since SOC/ROC, whichever is more recent

Enter Code

Has the patient had any falls since SOC/ROC, whichever is more recent?
0. No → Skip J1900
1. Yes → Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent

J1900.

Number of Falls Since SOC/ROC, whichever is more recent

CODING:
0. None
1. One
2. Two or
more

↓ Enter Codes in Boxes.
A.

No injury: No evidence of any injury is noted on physical assessment by the nurse or
primary care clinician; no complaints of pain or injury by the patient; no change in the
patient's behavior is noted after the fall

B.

Injury (except major): Skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains; or any fall-related injury that causes the patient to complain
of pain

C.

Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma

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OMB #XXXX-XXXX Expiration date xx/xx/xxxx

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

Items Used

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

M0080-M0100, M2005, M0906, J1800-J1900

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]
9
Discharge from agency [Go to M1041]

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

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

/
month

/
day

year

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Section J: Health Conditions
J1800.

Any Falls Since SOC/ROC, whichever is more recent

Enter Code

Has the patient had any falls since SOC/ROC, whichever is more recent?
0. No → Skip J1900
1. Yes → Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent

J1900.

Number of Falls Since SOC/ROC, whichever is more recent

CODING:
0. None
1. One
2. Two or
more

↓ Enter Codes in Boxes.
A.

No injury: No evidence of any injury is noted on physical assessment by the nurse or
primary care clinician; no complaints of pain or injury by the patient; no change in the
patient's behavior is noted after the fall

B.

Injury (except major): Skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains; or any fall-related injury that causes the patient to complain
of pain

C.

Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma

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OASIS Guidance Manual

CHAPTER 3

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

•

ITEM INTENT: Describes the rationale for collecting the information.

•

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 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 process to determine the most accurate response to this specific item. This may
include other clinicians, administrative records, online guidance regarding diagnosis coding or other
assessment guidelines, or standards promulgated by professional or accrediting organizations.

Some items have additional guidance in the following categories:
•

CODING INSTRUCTIONS: The proper method of recording each response, with explanations of individual
response categories.

•

CODING TIPS: Coding tips are clarifications, issues of note, and conditions to be considered when coding
each OASIS item.

•

EXAMPLES: Examples illustrate appropriate coding for several of the OASIS items.

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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

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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

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OASIS ITEM
(M0016) Branch ID Number:

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

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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

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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

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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, coverage criteria, regulatory requirements (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, 2019 = 05/04/2019).
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

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OASIS ITEM
(M0032) Resumption of Care Date:

/
month

/
day

year

ITEM INTENT
•

⃞ NA – Not Applicable

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
•
•

Resumption of Care
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, 2019 = 05/04/2019).
Enter all four digits of the year.
Assessment strategies: If question exists as to the resumption of care date, clarify with the agency
administrative staff.

DATA SOURCES/RESOURCES
•

Agency administrative staff

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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.

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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

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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) and 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

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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) and updated if change occurs during the episode

RESPONSE-SPECIFIC INSTRUCTIONS
•

In an effort to fight identity theft for Medicare beneficiaries, CMS is replacing the Social Security number
(SSN)-based Health Insurance Claim Number (HICN) with a new Medicare Beneficiary Identifier (MBI).
-

•
•

•
•

Prior to April 1, 2018: Enter the HICN, identified as the Medicare Claim Number on the patient’s
Medicare card. (Note: This may or may not be the patient’s Social Security number.)
April 1, 2018-December 31, 2019: Enter either the patient’s HICN, or the patient’s new MBI.
After December 31, 2019: Enter the MBI. Do not report the patient’s SSN-based HICN.

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.

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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.

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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) and 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.

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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, 2019 = 05/04/2019).
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.)

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Chapter 3: Section A - Patient Tracking

OASIS ITEM
(M0069)

Gender

Enter Code

1

Male

2

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

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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) and 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

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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) and 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 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:

•

Select Response 2 if the payment source is a Medicare HMO, another Medicare Advantage Plan, or
Medicare Part C.

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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.

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Chapter 3: Section B - Clinical Record Items

OASIS ITEM
(M0080)

Discipline of Person Completing Assessment

Enter Code

1

RN

2

PT

3

SLP/ST

4

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
•

While only the assessing clinician is responsible for accurately completing and signing a comprehensive
assessment, he/she may collaborate to collect data for all OASIS items, if agency policy allows.

•

Enter the response associated with the discipline of the individual completing the assessment (referred to as
the assessing clinician).
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
Additional information can be found in Chapter 1 of the OASIS Guidance Manual

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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, 2019 = 05/04/2019).
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.
-

•

•

•

•

The M0090 date assessment completed will indicate the last day the clinician gathered or received any
input used to complete the comprehensive assessment document, which includes the OASIS items.

The comprehensive assessment is a legal document and when signed by the assessing clinician, the
signature serves as an attestation that to the best of his/her knowledge, the document, including OASIS
responses, reflects the patient status as assessed, documented and/or supported in the patient’s clinical
record.
Some OASIS elements, for instance the Clinical Records Items (Patient Name, Birth Date, Medicare
Number, etc.), may be completed initially by clerical staff as part of the intake/referral process; but should be
verified by the assessing clinician when completing the assessment. For OASIS items requiring a patient
assessment, the collaborating healthcare providers (e.g., other agency clinical staff: LPN/LVN, PTA, COTA,
MSW, HHA) should have had direct in-person contact with the patient, or have had some other means of
gathering information to contribute to the OASIS data collection (health care monitoring devices, video
streaming, review of photograph, phone call, etc.).
When collaboration is utilized, the assessing clinician is responsible for considering available input from
these other sources, and selecting the appropriate OASIS item response(s), within the appropriate
timeframe and consistent with data collection guidance. M0090 (Date Assessment Completed) will indicate
the last day the assessing clinician gathered or receive an input used to complete the comprehensive
assessment document, which includes the OASIS items. Any exception to this general convention
concerning collaboration is identified in item-specific guidance.
If the assessing clinician gathers additional information during the assessment time frame that would result
in changing the coding of one or more OASIS items (for instance, identifies functional or cognitive
information that he/she believes is more representative of the patient’s usual status than the code originally
selected), the M0090 date would be changed to reflect the date the latest information was gathered and the
response change was made.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M0090)
• 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

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OASIS ITEM
(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]

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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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 to 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

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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.

/
month

[Go to M0110, if date entered]

/
day

year

⃞ NA - No specific SOC date ordered by physician
ITEM INTENT
•

Specifies the date that home care services are ordered to begin or to resume following an inpatient stay of
24 hours or longer and for reasons other than diagnostic tests, if a SOC/ROC date was specified by the
physician. The item refers to the order to start home care services (that is, provide the first covered service),
or resume home care services (that is provide the first visit following a qualifying inpatient stay) 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)/Resumption of Care (ROC) 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/resume home care services would be considered the date of physicianordered 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 physician-ordered 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, 2019 = 05/04/2019).
Enter all four digits of the year.
Mark “N/A” if the initial orders did not specify a SOC or ROC date.

•
•

In order to be considered a physician-ordered SOC/ROC date, the physician must give a specific date to
initiate or resume care, not a range of dates. If a single date to initiate or resume services is not provided,
the initial contact (via the initial assessment visit or resumption of care 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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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 or resume 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 or Resumption 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, 2019 = 05/04/2019).
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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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

Early

2

Later

UK

Unknown

NA

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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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: Section C - Patient History and Diagnoses

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 (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 M1021]
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.
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

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1000)
- 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.

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OASIS ITEM
(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown

ITEM INTENT
•

Identifies the date of the most recent discharge from an inpatient facility (within past 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
•

•
•

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.
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, 2019 = 05/04/2019).
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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OASIS ITEM
(M1021/1023)

Diagnoses and Symptom Control: 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.

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.

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OASIS ITEM
(M1021) Primary Diagnosis & (M1023) Other Diagnoses
Column 1
Column 2
Diagnoses (Sequencing of diagnoses should reflect the
ICD-10-CM and symptom control rating for each condition.
seriousness of each condition and support the disciplines and
Note that the sequencing of these ratings may not match the
services provided)
sequencing of the diagnoses
Description
ICD-10-CM / Symptom Control Rating
(M1021) Primary Diagnosis

V, W, X, Y codes NOT allowed

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
a.
(M1023) Other Diagnoses

All ICD-10–CM codes allowed
b.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

c.

c.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

d.

d.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

e.

e.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

f.

f.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

b.

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.

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.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1021/1023)

•

‒

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 and may elicit input from other agency staff that have had direct in-person contact with
the patient, or have had some other means of gathering information to contribute to the OASIS data
collection.

‒

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 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.”

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1021/1023)
•

•

•

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).

‒

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 Zcodes 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.

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).

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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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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)

⃞

3 -

None of the above

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).

Time Points Item(s) Completed
Start of care
Resumption of care

Response-Specific Instructions
1. 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.
•

•

Clinical 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, physician orders, and consults.
‒

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 clinical 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 clinical record by the

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1028)

•

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.

2. Determine whether diagnoses are active: Once a diagnosis is identified, determine whether
the diagnosis is active.
•

•

If information regarding active diagnoses is
learned after the end of the assessment time
frame, 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 after the data set
is submitted that a documented active
diagnosis was present but 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.
‒

DEFINITION
ACTIVE DIAGNOSES
•

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, or mood or
behavior status; medical
treatments; nurse monitoring; or
risk of death at the time of
assessment.

A copy of this memo is located on
CMS.gov under Provider Enrollment and Certification/Quality Safety & Oversight –
General Information/Policy & Memos to States and Regions. For additional details,
please reference the OASIS Submission User’s Guide and Training site (QTSO site).

Coding Instructions
Code 1, Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease
(PAD), 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:
•
•
•

I70.2, Atherosclerosis of native arteries of the extremities
I70.3, Atherosclerosis of unspecified type of bypass graft(s) of the extremities
I70.4, Atherosclerosis of autologous vein bypass graft(s) of the extremities

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1028)

•
•
•
•
•

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:
•

I73, Other peripheral vascular diseases

Code 2, Diabetes Mellitus (DM), 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:
•
•
•
•
•

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 specified diabetes mellitus

Code 3, None of the Above, if the patient does not have any of the active diagnoses
listed above.
•

A dash is a valid response for this item. CMS expects dash use to be a rare
occurrence.

Coding Tips
The following tips may assist staff in determining whether a disease or condition should
be coded as an active diagnosis.
•

•

The physician (nurse practitioner, physician assistant, clinical nurse specialist, or
other authorized licensed staff if allowable under state licensure laws) may
specifically indicate that a diagnosis is active.
If there is documentation in the clinical record that a patient has diabetes mellitus,
Select Response 2, Diabetes Mellitus (DM). If there is only documentation in the
clinical record of a complication such as nephropathy or neuropathy and there is no
documentation that the patient has diabetes, it should not be assumed the
complication is associated with diabetes, and Response 2, Diabetes Mellitus, should
not be checked.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1028)

•

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
medication regimen needed to be modified.

Examples
1. Active Diagnosis of Diabetes Mellitus
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.
Coding: M1028, Active Diagnoses, would be coded 2, Diabetes Mellitus.
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.
2. None of the Above
During the SOC/ROC assessment, Mrs. K told Nurse J, RN that she has had diabetes for
20 years. Nurse J reviewed the transfer documents from the acute care facility and all clinical
records on the patient but was unable find a documented diagnosis of Diabetes Mellitus by
physician, nurse practitioner, physician assistant or authorized licensed staff member in their
state. There is no documented diagnosis of PVD or PAD.
Coding: M1028, Active Diagnoses, would be coded 3, None of the Above.
Rationale: This would be considered a “none of the above” response because the nurse
was unable to find the diagnosis of diabetes at the time of assessment, documented by a
physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other
authorized licensed staff if allowable under state licensure laws). And, there is no
documented diagnosis of PVD or PAD.

Data Sources/Resources
Transfer documents
Clinical Records
Referrals

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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 -

Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the
alimentary canal)

⃞

4 -

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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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 include 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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OASIS ITEM
(M1041)
Enter Code

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?
0

No [Go to M1051]

1

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 an 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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OASIS ITEM
(M1046)
Enter Code

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

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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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1046)
•

•

•
•

Enter Response 5 if the influenza vaccine is contraindicated for medical reasons. Refer to the Centers for
Disease Control and Prevention (CDC) website for information on contraindications for the influenza vaccine
(See link in Chapter 5).
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. 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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OASIS ITEM
(M1051)
Enter Code

Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example,
pneumovax)?
0

No

1

Yes [Go to M2005 at TRN; Go to M1242 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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OASIS ITEM
(M1056)

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

Enter Code

1

Offered and declined

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

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. Refer
to the Centers for Disease Control and Prevention (CDC) website for information on contraindications for the
pneumococcal vaccination (See link in Chapter 5).
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

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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.

Time Points Item(s) Completed
Start of care
Resumption of care

Response-Specific Instructions
Coding Instructions
•

M1060 – a, Height
‒
‒
‒

‒

•

Measure height in accordance with the agency’s policies and procedures.
Measure and 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.
Only enter a height that has been directly measured by agency staff. Do not enter
a height that is self-reported or derived from documentation from another
provider setting.

M1060 – b, Weight
‒
‒
‒

Weight should be measured in accordance with the agency’s policies and
procedures.
Measure and record the patient’s weight in pounds.
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.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEMS M1060)

‒
‒

•

If agency staff weighs the patient multiple times during the assessment period, use
the first weight.
Only enter a weight that has been directly measured by agency staff. Do not enter
a weight that is self-reported or derived from documentation from another
provider setting.

A dash is a valid response for this item. CMS expects dash use to be a rare
occurrence.

Coding Tips
•

•

•

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).
If a patient cannot be weighed, for example, because of extreme pain, immobility, or
risk of pathological fractures, the use of a dash ( – ) is appropriate. Document the
rationale on the patient’s medical record.
When there is an unsuccessful attempt to measure a patient’s height or weight, at
SOC/ROC, and there is a documented agency-obtained height or weight from one or
more previous home health visits, an agency-obtained height or weight from a
documented visit conducted within the previous 30-day window may be used to
complete M1060 for this SOC/ROC assessment. Whenever possible, a current height
and weight should be obtained by the agency as part of the SOC/ROC assessment.

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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

Living Arrangement
a. Patient lives alone
b. Patient lives with other
person(s) in the home
c. Patient lives in congregate
situation (for example, assisted
living, residential care home)

Around the
clock

Regular
daytime

Regular
nighttime

Occasional /
short-term
assistance

No
assistance
available

⃞ 01

⃞ 02

⃞ 03

⃞ 04

⃞ 05

⃞ 11

⃞ 12

⃞ 13

⃞ 14

⃞ 15

⃞ 06

⃞ 07

⃞ 08

⃞ 09

⃞ 10

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.

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Chapter 3: Section D - Living Arrangements

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1100)
-

-

•

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.
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:






-

-

-

-

-

•

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
M2102.
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.)

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Chapter 3: Section D - Living Arrangements

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1100)
-

-

-

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.)
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

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Chapter 3: Section E - Sensory Status

OASIS ITEM
(M1200)

Vision (with corrective lenses if the patient usually wears them):

Enter Code

0
1
2

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
•
•
•

Start of care
Resumption of care
Follow-up

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)

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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

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Chapter 3: Section F – Integumentary

OASIS ITEM
(M1306)

Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or
designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure
ulcers/injuries)

Enter Code

0
1

No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]
Yes

ITEM INTENT
•

Identifies the presence or absence of Unhealed Stage 2 or higher or Unstageable pressure ulcers/injuries
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&A’s,
providers should rely on the CMS OASIS instructions.
Pressure ulcers/injuries 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/injury.
Terminology referring to “healed” vs. “unhealed” ulcers can refer to whether the ulcer is “closed” vs. “open”.
Recognize, however, that Stage 1 pressure injuries and Deep Tissue Injury (DTI), although closed (intact
skin), would not be considered healed. Unstageable pressure ulcers/injuries, whether covered with a nonremovable dressing or eschar or slough, would not be considered healed.
Enter Response 0 (No), if the only pressure ulcer/injury is one or more Stage 1 OR healed pressure
ulcers/injuries (of any previous stage) AND the patient has no other pressure ulcers/injuries.
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/injury, defined as:
-

-

Pressure ulcers/injuries 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/injury exists under the non-removable
dressing/device.
Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown)
tissue present such that the anatomic depth of soft tissue damage cannot be visualized in the wound
bed, should be classified as unstageable. If the wound bed is only partially covered by eschar or slough,
and the anatomical depth of tissue damage can be visualized, numerically stage the ulcer, and do not
code this as unstageable.
o Pressure ulcers that are covered with slough and/or eschar, and the wound bed
cannot be visualized, should be coded as unstageable because the true anatomic
depth of soft tissue damage (and therefore stage) cannot be determined. Only until
enough slough and/or eschar is removed to expose the anatomic depth of soft tissue
damage involved, can the stage of the wound be determined.

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Chapter 3: Section F – Integumentary

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1306)
-

•
•

Deep tissue injury 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.

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.

DATA SOURCES / RESOURCES
•
•
•
•
•
•

Patient/caregiver interview
Observation
Physical Assessment
Referral documentation
Physician
See references/resources in Chapter 5 of the OASIS Guidance Manual

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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

NA

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 at the first skin assessment completed 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 first skin assessment completed at the 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, 2019 would be 05/04/2019).
If no pressure ulcer existed at the SOC, then a Stage 1 pressure injury 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).

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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

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Chapter 3: Section F – Integumentary

OASIS ITEM
SOC/ROC
Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries 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/injuries due to coverage of wound bed by slough
and/or eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

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Chapter 3: Section F – Integumentary

Follow-up
Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries 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/injuries due to coverage of wound bed by slough
and/or eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

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Chapter 3: Section F – Integumentary

Discharge
Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or 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, Stage 3]
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, Stage 4]
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, Unstageable: Non-removable dressing/device]
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/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
[If 0 – Go to M1311E1, Unstageable: Slough and/or eschar]
D2. Number of these unstageable pressure ulcers/injuries 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, Unstageable: Deep tissue injury]
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
Number of unstageable pressure injuries presenting as deep tissue injury
[If 0 – Go to M1324]
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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Chapter 3: Section F – Integumentary

ITEM INTENT
•
•
•

This item identifies the number of pressure ulcers/injuries at each stage (Stage 2, 3, and 4) and designated
as Unstageable, that are observed on assessment.
At discharge, this item also identifies if each pressure ulcer/injury present on the discharge assessment was
observed at the same stage at the time of the most recent SOC/ROC.
Stage 1 pressure injuries and all healed pressure ulcers/injuries 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/injuries can refer to whether the ulcer/injury is
“closed” vs. “open”. Recognize, however, that Stage 1 pressure injuries and Deep Tissue Injury (DTI),
although closed (intact skin), would not be considered healed. Unstageable pressure ulcers/injuries, whether
covered with a non-removable dressing or eschar or slough, would not be considered healed.

Determining “Present at the most recent SOC/ROC” to answer M1311X2
•

•

•

•

For each pressure ulcer/injury observed and coded in items M1311A1-F1 on Discharge, determine whether
that pressure ulcer/injury was observed at the same stage at the time of the most recent SOC/ROC, and did
not form during this home health quality episode.
If the pressure ulcer/injury was unstageable at SOC/ROC, but becomes numerically stageable later, when
completing the Discharge assessment, its “Present at the most recent SOC/ROC” 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 the most recent SOC/ROC” when
completing the Discharge assessment.
The general standard of practice for patients starting or resuming care is that patient assessments are
completed as close to the actual time of the SOC/ROC as possible. For example, if a pressure ulcer/injury
that is identified on the SOC date increases in numerical stage within the assessment time frame, the stage
of the pressure ulcer/injury at the first skin assessment completed would be reported in M1311X1 at the
SOC.
At SOC/ROC and FU, 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 observed at the first skin
assessment completed during the SOC assessment timeframe. Enter 0 if no Stage 3 pressure ulcers
are observed.

At Discharge, enter a response for each row of this item: A1, A2, B1, B2, C1, C2, D1, D2, E1, E2, F1, F2,
unless directed to skip.
-

Example: At Discharge, in A1 enter the number of Stage 2 pressure ulcers that are observed at the
discharge assessment.
o If no Stage 2 pressure ulcers are observed, enter 0 in A1 and skip A2.
o If at least one Stage 2 pressure ulcer is observed, and reported in A1, enter in A2 the number of
these Stage 2 pressure ulcers that were observed at the same stage at the most recent SOC/ROC.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1311)
Stage 2 Ulcers
•
•

•

Report in M1311A1 the number of Stage 2 pressure ulcers that are observed 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.
Examine the area adjacent to or surrounding an intact blister for evidence of tissue damage. If other
conditions are ruled out and the tissue adjacent to or surrounding the blister demonstrates signs of tissue
damage (e.g., color change, tenderness, bogginess or firmness, warmth or coolness), these characteristics
suggest a deep tissue injury (DTI) rather than a Stage 2 pressure ulcer.

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 pressure ulcer that is currently open again should be reported as a Stage 3
pressure ulcer. A previously closed Stage 4 pressure ulcer that is currently open again should be reported
as a Stage 4 pressure ulcer.
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 highest numerical stage of the wound. The
clinician should make every effort to contact previous providers (including patient’s physician) to determine
the highest numerical stage of the pressure ulcer.
Any type of flap procedure performed to surgically replace a pressure ulcer is reported as a surgical wound,
until healed. It should not be reported as a pressure ulcer/injury on M1311.
A pressure ulcer treated with any type of graft is no longer reported as a pressure ulcer/injury, and until
healed, 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
•

Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue
present such that the anatomic depth of soft tissue damage cannot be visualized in the wound bed, should
be classified as unstageable. If the wound bed is only partially covered by eschar or slough, and the
anatomical depth of tissue damage can be visualized, numerically stage the ulcer, and do not code this as
unstageable.
-

•

Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized,
should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore
stage) cannot be determined. Only until enough slough and/or eschar is removed to expose the
anatomic depth of soft tissue damage involved, can the stage of the wound be determined.

Any numerically stageable pressure ulcer/injury observed at SOC/ROC that is unstageable due to slough
and/or eschar at discharge, should be considered new, and not coded as present at the most recent
SOC/ROC for M1311X2.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1311)
•

•

•

•

Pressure ulcers/injuries that are known to be present but
DEFINITIONS
that are Unstageable due to a non-removable
dressing/device, such as a cast that cannot be removed
SLOUGH TISSUE
to assess the skin underneath, should be reported in
Non-viable yellow, tan, gray, green or brown
M1311D1, Unstageable. “Known” refers to when
tissue; usually moist, can be soft, stringy and
documentation is available that states a pressure
mucinous in texture. Slough may be adherent
ulcer/injury exists under the non-removable
to the base of the wound or present in
dressing/device. Examples of a non-removable
clumps throughout the wound bed.
dressing/device include a dressing that is not to be
removed per physician’s order (such as those used in
ESCHAR TISSUE
negative-pressure wound therapy [NPWT], an
Dead or devitalized tissue that is hard or soft
orthopedic device, or a cast).
in texture; usually black, brown, or tan in
If an unknown pressure ulcer/injury is discovered upon
color, and may appear scab-like. Necrotic
removal of a non-removable dressing/device, that
tissue and eschar are usually firmly adherent
pressure ulcer/injury should be considered new, and not
to the base of the wound and often the
be coded as present at the most recent SOC/ROC for
sides/edges of the wound.
M1311X2.
Response F1 refers to deep tissue injury, 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 injuries 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.
A deep tissue injury with intact skin at SOC/ROC, that becomes stageable, is considered present at the
most recent SOC/ROC at the stage at which it first becomes numerically stageable.

EXAMPLES – Identify “Present at the most recent SOC/ROC” to answer M1311 at Discharge
1.

Deep Tissue Injury (DTI) with intact skin at a SOC assessment becomes numerically stageable

The RN assesses Mr. J’s skin at the SOC and identifies a DTI with intact skin on his left heel. This DTI remains
unchanged until the RN skin assessment 10 days later, which reveals open skin presenting as a Stage 3 pressure
ulcer. The pressure ulcer does not change for the remainder of the episode. At the discharge (DC) skin assessment,
the ulcer remains a Stage 3. (In this example, there are no other pressure ulcers/injuries at the SOC assessment,
during the episode or at DC).
Coding: On the DC assessment, M1311B1, Number of Stage 3 pressure ulcers, would be coded “1”. M1311B2,
Number of these Stage 3 pressure ulcers that were present at the most recent SOC/ROC would be coded “1”.
M1311F1, Number of unstageable pressure injuries presenting as DTI, would be coded “0”. (Skip M1311F2).
Rationale: At the DC assessment, Mr. J had one Stage 3 pressure ulcer, and zero unstageable pressure injuries
presenting as DTI. The Stage 3 pressure ulcer observed on the DC skin assessment is reported “present at the
most recent SOC/ROC” because that is the stage at which the DTI observed at the SOC assessment first
became numerically stageable.
2.

Deep tissue injury (DTI) with intact skin at SOC, becomes numerically stageable and increases in
numerical stage by discharge (DC)

The RN completes a skin assessment during the SOC visit for Mrs. K, and identifies a right hip DTI with intact skin.
This DTI is first numerically stageable 10 days later as a Stage 3 pressure ulcer and increases in numerical stage five
days after that, to a Stage 4 pressure ulcer. The pressure ulcer remains a Stage 4 at DC.
Coding: On the DC assessment M1311C1, Number of Stage 4 pressure ulcers, would be coded “1”. M1311C2,
Number of these Stage 4 pressure ulcers that were present at the most recent SOC/ROC, would be coded “0”.
M1311F1, unstageable pressure injuries presenting as DTI, would be coded “0”. (Skip M1311F2).

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Rationale: The DTI with intact skin observed on the SOC skin assessment first became numerically stageable
as a Stage 3. Because the Stage 3 pressure ulcer increased in numerical stage to a Stage 4 by the DC
assessment, the Stage 4 pressure ulcer at DC is considered new, and not coded as present at the most recent
SOC/ROC.
3.

Deep Tissue Injury (DTI) with intact skin at SOC, becomes numerically stageable, then is unstageable due to
slough and/or eschar at DC
The RN assesses Mr. L’s skin during the assessment timeframe for the SOC, and identifies a DTI with intact skin on
his right heel. This DTI first becomes numerically stageable at the third home visit, as a Stage 3 pressure ulcer. At the
DC skin assessment, this pressure ulcer is unstageable due to slough and eschar.
Coding: On the DC assessment, M1311E1, number of unstageable pressure ulcers due to slough and/or
eschar, would be coded “1”. M1311E2, number of these unstageable pressure ulcers that were present at the
most recent SOC/ROC, would be coded “0”. M1311F1, unstageable pressure injuries presenting as DTI, would
be coded “0”. (Skip M1311F2).
Rationale: The DTI with intact skin observed on the SOC skin assessment first became stageable as a Stage 3
pressure ulcer. This ulcer did not remain a Stage 3, however. At the DC skin assessment the ulcer was observed
to be unstageable due to slough and eschar. Any pressure ulcer/injury that is observed to be unstageable due to
slough and/or eschar, but was previously numerically stageable, is considered new, and not coded as present at
the most recent SOC/ROC.

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

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Chapter 3: Section F – Integumentary

OASIS ITEM
(M1322)

Current Number of Stage 1 Pressure Injuries: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. 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 injuries.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care
Resumption of care
Follow-up

RESPONSE-SPECIFIC INSTRUCTIONS
•

•

NPUAP defines a Stage 1 pressure injury 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 injuries 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 injuries 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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OASIS ITEM
(M1324)

Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable: (Excludes
pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of
wound bed by slough and/or eschar, or deep tissue injury.)

Enter Code

1
2
3
4
NA

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

ITEM INTENT
•
•

Identifies the stage of the most problematic stageable pressure ulcer/injury.
Please note; pressure ulcers/injuries 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
•

•

Terminology referring to “healed” vs. “unhealed” ulcers can refer to whether the ulcer is “closed” vs. “open”.
Recognize, however, that Stage 1 pressure injuries and Deep Tissue Injury (DTI), although closed (intact
skin), would not be considered healed. Unstageable pressure ulcers/injuries, whether covered with a nonremovable dressing or eschar or slough, would not be considered healed.
Determine which pressure ulcer(s)/injur(ies) are stageable or Unstageable. A pressure ulcer/injury is
considered Unstageable if:
-

•

it is covered with a non-removable dressing/device, such as a cast, that cannot be removed.
it presents as a deep tissue injury, 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.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1324)
•

Enter the response that most accurately describes the stage of the most problematic stageable pressure
ulcer/injury using the definitions of Stage in M1311. Enter “NA” if the patient has NO pressure ulcers or only
has pressure ulcers that are Unstageable as defined above.
-

-

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. Unless it
becomes unstageable, clinical standards require that a Stage 4 pressure 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

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OASIS ITEM
(M1330)

Does this patient have a Stasis Ulcer?

Enter Code

0
1
2
3

No [Go to M1340]
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
Observation
Physical assessment
See references/resources in Chapter 5 of the OASIS Guidance Manual

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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

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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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.
-

•

Determine status of the most problematic stasis ulcer that is observable using healing status definitions
developed by the Wound Ostomy and Continence Nurses (WOCN) Society:
-

-

-

•

“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.

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.

DATA SOURCES / RESOURCES
•
•
•
•

Observation
Physical Assessment
Review of health history
See references/resources in Chapter 5 of the OASIS Guidance Manual

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OASIS ITEM
(M1340)

Does this patient have a Surgical Wound?

Enter Code

0
1
2

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]

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, thoracostomy,
tracheostomy, gastrostomy, etc.
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.
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.

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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: 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.
-

-

•

Identify the most problematic observable surgical wound.
-

•

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.

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 healing status definitions developed by the
Wound Ostomy and Continence Nurses (WOCN) Society. 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 primary
intention. A surgical incision would not automatically be considered 3 – Not healing solely due to the
presence of staples.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1342)
-

-

-

-

-

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 in Chapter 5 of the OASIS Guidance Manual

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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

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)

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 an 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.

‒

See Responses 2, 3, and 4 for assessment examples for these patients as well as ambulatory patients.

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).

DATA SOURCES/RESOURCES
•
•
•
•

Observation
Physical assessment
Patient/caregiver interview
Review of health history

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Chapter 3: Section I - Elimination Status

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 an 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

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Chapter 3: Section I - Elimination Status

OASIS ITEM
(M1610)

Urinary Incontinence or Urinary Catheter Presence:

Enter Code

0
1
2

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

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

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.
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.

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Chapter 3: Section I - Elimination Status

DATA SOURCES/RESOURCES
•
•
•
•
•
•

Patient/caregiver interview
Observation
Physical assessment
Physician orders
Review of health history
Referral information

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Chapter 3: Section I - Elimination Status

OASIS ITEM
(M1620)

Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

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]

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 an 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

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Chapter 3: Section I - Elimination Status

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

0
1
2

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.

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

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Chapter 3: Section J - Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1700)
Enter Code

Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
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.

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 an 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

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Chapter 3: Section J - Neuro, Emotional, and Behavioral Status

OASIS ITEM
(M1710)
Enter Code

When Confused (Reported or Observed Within the Last 14 Days):
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 an 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.”

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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

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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 an 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

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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

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?”

PHQ-2©*

2
3

a)

Little interest or pleasure
in doing things

b)

Feeling down,
depressed, or hopeless?

Not at all
0-1 day

Several
days
2-6 days

More than
half of the
days
7-11 days

⃞0

⃞1

⃞2

⃞0

⃞1

⃞2

Nearly
NA
every day Unable to
12-14 days respond
⃞3
⃞3

⃞ NA
⃞ 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.

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. 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.
-

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.

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Chapter 3: Section J - Neuro, Emotional, and Behavioral Status

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS Item M1730)
-

-

•

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.
-

•

In order to enter Response 1, 2 or 3, the standardized, validated depression screening must be
completed during the time frame specified by CMS for completion of the assessment (specifically, within
five days of SOC or within two days of inpatient facility discharge at ROC, or on the physician-ordered
ROC date.
A clinician other than the assessing clinician may complete the standardized, validated depression
screening for consideration by the assessing clinician.

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.

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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

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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

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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
•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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.

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1800)

‒

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.

DATA SOURCES/RESOURCES
•
•
•
•

Observation/demonstration is the preferred method
Patient/caregiver interview
Physical assessment
Environmental assessment

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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

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.

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
•

•
•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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/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 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.

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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

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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

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.

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
•

•

•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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.

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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.
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. 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

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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

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.

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

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Chapter 3: Section K - ADLs / IADLs

RESPONSE-SPECIFIC INSTRUCTIONS
•

•
•

•
•

•

•
•

•

•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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

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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

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.

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
•

•
•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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.

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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

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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.

Enter Code

0
1
2
3

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.

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
•

•
•

•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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.

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Chapter 3: Section K - ADLs / IADLs

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M1845)
•

•
•
•
•

This item refers to 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

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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

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.

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
•

•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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: 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

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.

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
•

•
•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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.
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.

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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: 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
•

•

•

When coding this item, the assessing clinician may consider available input from other agency staff who
have had direct patient contact. Refer to Chapter 1 for additional details on this and other OASIS
conventions.
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: 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: 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.
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
•

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.

‒
•

•

A clinician other than the assessing clinician may complete the standardized, validated fall risk
screening for consideration by the assessing clinician.

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.”

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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,

‒

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

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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

0
1
9

No – No issues found during review [Go to M2010]
Yes – Issues found during review
NA – Patient is not taking any medications [Go to M2102]

ITEM INTENT
•

Identifies if review of the patient’s medications indicated any potential or actual clinically significant
medication issues.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care
Resumption of care

RESPONSE-SPECIFIC INSTRUCTIONS
•

•

The drug regimen review includes all medications, prescribed
and over the counter (OTC) including nutritional
supplements, vitamins and herbals, administered by any
route (for example, oral, topical, sublingual and by infusion).
The drug regimen review also includes total parenteral
nutrition (TPN) and oxygen.
Potential or actual clinically significant medication issues may
include, but are not limited to, the following:

‒
‒
‒
‒
‒
‒
‒
‒
•

•

•

DEFINITION
DRUG REGIMEN REVIEW
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.

adverse reactions to medications (such as a rash)
ineffective drug therapy (such as analgesic that does not reduce pain)
side effects (such as potential bleeding from an anticoagulant)
drug interactions (such as serious drug-drug, drug-food and drug-disease interactions)
duplicate therapy (such as generic name and brand name equivalent drugs are both prescribed)
omissions (such as missing drugs from a prescribed regimen)
dosage errors (either too high or too low)
nonadherence (purposeful or accidental)

Any of the 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 for the purpose of the drug
regimen review items.
The drug regimen review is part of the comprehensive patient
assessment. The comprehensive patient assessment is the
responsibility of and must ultimately be completed by one
clinician, but collaboration is allowed. Agency policy and
practice will determine this process and how it is documented.

OASIS-D Guidance Manual
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DEFINITION
POTENTIAL OR ACTUAL CLINICALLY
SIGNIFICANT MEDICATION ISSUE
A clinically significant medication issue is
a potential or actual issue that, in the
clinician’s professional judgment,
warrants physician (or physiciandesignee) communication and
completion of prescribed/recommended
actions by midnight of the next calendar
day (at the latest).

Chapter 3: L-1

OASIS Guidance Manual

Chapter 3: Section L - Medications

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2001)

‒

‒

‒

For example, for this drug regimen review item, 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) is allowed.
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 assessing clinician responsible for the SOC/ROC OASIS assessment so that the appropriate
response for M2001 may be entered.
The M0090 date assessment completed will indicate the last day the clinician gathered or received any
input used to complete the comprehensive assessment document, which includes the OASIS items.

Coding Instructions:
Code 0, No, No issues found during review, if, based on assessing clinician’s professional judgment, no potential
or actual clinically significant issues are identified. Examples may include, but are not limited to:
•
•
•
•

Patient’s inpatient facility discharge medication list matches medications patient has on hand.
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.
The diagnoses/conditions for which the patient is taking the medications appear adequately controlled.

Code 1, Yes, issues found during review if a drug regimen review is conducted upon SOC/ROC and based on
assessing clinician’s professional judgment, potential or actual clinically significant medication issues are identified.
Examples may include, but are not limited to:
•
•
•
•
•
•
•

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.
Patient seems confused about when/how to take medications indicating a high risk for medication errors.
Patient has not obtained medications or indicates that s/he will 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.

Code 9, NA – Patient is not taking any medications, if a drug regimen review indicates there are no medications
prescribed for the patient and the patient is not taking any medications, by any route, at the time of the assessment.
A dash is a valid response for this item. CMS expects dash use to be a rare occurrence. If elements of the drug
regimen review were skipped, (for example drug-to-drug interactions were not completed), a dash (–) should be
reported, indicating the drug regimen review was not completed.

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Chapter 3: Section L - Medications

EXAMPLES
1.

No issues identified

During the comprehensive assessment visit to Mr. K., 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, Nancy, states
they were only going to pick it up from the pharmacy if “the pain got bad enough.” The PT reviews the physician’s
instructions for the new medication with the Mr. K and Nancy; they agree the medication should be on hand, and to
follow physician’s instructions for administration. Prior to the PT leaving the home, the daughter has gone to the
drugstore and returned with the medication.
Coding: M2001 would be coded 0, No – No issues found during review.
Rationale: Because the issue, in the PT’s professional judgment, did not require physician (or physiciandesignee) contact by midnight of the next calendar day, at the latest to resolve, it does not meet the criteria for a
potential or actual clinically significant medication issue.
2.

Drug regimen review (DRR) not complete; use of the dash

During the SOC comprehensive assessment, Nurse Richard completes all elements of the DRR except for checking
for drug-drug interactions.
Coding: M2001, enter a dash, “–”
Rationale: When any element is not assessed, the DRR is considered incomplete.

DATA SOURCES/RESOURCES
•
•
•
•
•

Patient assessment
HH Condition of Participation
Clinical record including communication notes, medication list
Collaboration with other agency staff as allowed, including review of documentation
CMS OASIS Q&As related to the drug regimen review can be accessed through the CMS OASIS web page

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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
1

No
Yes

ITEM INTENT
•

Identifies if potential or actual clinically significant medication issues identified through the drug regimen
review were communicated to the physician (or physician-designee) and to the extent possible,
prescribed/recommended actions were completed by midnight of the next calendar day following their
identification.

TIME POINTS ITEM(S) COMPLETED
•
•

Start of care
Resumption of care

RESPONSE-SPECIFIC INSTRUCTIONS
•

•
•

•

For each potential or actual clinically significant medication
issue identified during the SOC/ROC comprehensive
assessment, identify if the physician/physician-designee was
contacted, and prescribed/recommended actions were
completed by midnight of the next calendar day (at the latest).
Examples of by midnight of the next calendar day:
A clinically significant medication issue is identified at
th
10:00 AM on February 12 and physician/physician-designee
prescribed/recommended action is completed on or before
th
11:59 PM on February 13 .
A clinically significant medication issue is identified at
th
10:00 PM on February 12 . physician/physician-designee
prescribed/recommended action is completed on or before
th
11:59 PM on February 13 .

OASIS-D Guidance Manual
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DEFINITION
POTENTIAL OR ACTUAL CLINICALLY
SIGNIFICANT MEDICATION ISSUE
A clinically significant medication issue is
a potential or actual issue that, in the
clinician’s professional judgment,
warrants physician (or physiciandesignee) communication and
completion of prescribed/recommended
actions by midnight of the next calendar
day (at the latest).

Chapter 3: L-4

OASIS Guidance Manual

Chapter 3: Section L - Medications

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2003)
Coding Instructions
Code 0, No, if all identified potential or actual clinically significant
medication issues were not communicated to the physician/physician
designee, with prescribed/recommended actions completed to the
extent possible by midnight of the next calendar day.
•

Examples:

‒
‒

‒

Clinician did not communicate all clinically significant
medication issues to physician/physician-designee until
after midnight of the next calendar day.
Clinician communicated all clinically significant
medication issues to physician/physician-designee by
midnight of the next calendar day, but the clinician did
not receive a response from the physician/physiciandesignee to communicate prescribed/recommended
actions until after midnight of the next calendar day.
Clinician did not complete all physician/physiciandesignee prescribed/recommended actions until after
midnight of the next calendar day.

Code 1, Yes, if the two-way communication AND completion of the
prescribed/recommended actions to the extent possible occurred by
midnight of the next calendar day after the potential clinically
significant medication issue was identified.
•

Examples:

‒

‒

‒

DEFINITIONS
CONTACT WITH PHYSICIAN/
PHYSICIAN DESIGNEE
•
Communication to the
physician/physician-designee to
convey an identified potential or
actual clinically significant
medication issue, AND a response
from the physician/physiciandesignee to acknowledge receipt
and/or convey
prescribed/recommended actions in
response to the medication issue.
•
Communication can be in person, by
telephone, voicemail, electronic
means, facsimile, or any other
means that appropriately conveys
the message of patient status.
•
Communication can be directly
to/from the physician or physiciandesignee, or indirectly through
physician’s office staff on behalf of
the physician or physician-designee,
in accordance with the legal scope
of practice.

Clinician communicated all identified clinically
significant medication issue to the physician/physicianMEDICATION FOLLOW-UP
designee, and all physician/physician-designee
The process of contacting a
•
prescribed/recommended actions for all identified
physician/physician-designee to
medication issues were completed by midnight of the
next calendar day.
communicate the identified
Clinician contacted the physician/physician-designee
medication issue and, to the extent
regarding all identified medication issues, and the
possible, completing all
physician/physician-designee communicated to the
physician/physician-designee
clinician that no actions were necessary regarding the
prescribed/recommended actions by
reported issues. All communications took place before
midnight of the next calendar day (at
midnight of the next calendar day.
the latest).
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.




An example of a recommended action that would take longer than the allowed time to complete
might include physician order(s) for intervention followed by monitoring 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.

A dash (–) is a valid response for this item. CMS expects dash use to be a rare occurrence.

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EXAMPLE
1.

Clinically significant medication issue identified, with follow-up

During the SOC comprehensive assessment visit, the RN completes a drug regimen 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.
Coding: M2001, Drug Regimen Review, would be coded 1, Yes, Issues found during review.
M2003, Medication Follow-up, would be coded 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 communicated to the physician and the
prescribed/recommended action was completed by midnight of the next calendar day, M2003 would be coded 1
– Yes.

DATA SOURCES/RESOURCES
•
•
•
•

Clinical record
Communication notes
Plan of Care
Medication list

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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

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

ITEM INTENT
•

Identifies if potential or actual clinically significant medication issues identified at the time of or at any time
since the most recent SOC/ROC were communicated to the physician (or physician-designee) and to the
extent possible, prescribed/recommended actions were completed by midnight of the next calendar day
following their identification.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Transfer to an inpatient facility
Death at home
Discharge from agency – not to an inpatient facility

RESPONSE-SPECIFIC INSTRUCTIONS
•

•

DEFINITION
POTENTIAL OR ACTUAL CLINICALLY
SIGNIFICANT MEDICATION ISSUE
A clinically significant medication issue is
a potential or actual issue that, in the
clinician’s professional judgment,
warrants physician (or physiciandesignee) communication and
completion of prescribed/recommended
actions by midnight of the next calendar
day (at the latest).

To complete M2005, the assessing clinician (alone or in
collaboration with other agency staff) reviews the patient’s
clinical record back to and including the most recent
SOC/ROC, to determine if for each clinically significant
medication issue identified, communication occurred and, to
the extent possible, physician (or physician-designee) prescribed or recommended actions were completed
by midnight of the next calendar day.
Potential or actual clinically significant medication issues may include, but are not limited to, the following:

‒
‒
‒
‒
‒
‒
‒
‒

adverse reactions to medications (such as a rash)
ineffective drug therapy (such as analgesic that does not reduce pain)
side effects (such as potential bleeding from an anticoagulant)
drug interactions (such as serious drug-drug, drug-food and drug-disease interactions)
duplicate therapy (such as generic name and brand name equivalent drugs are both prescribed)
omissions (such as missing drugs from a prescribed regimen)
dosage errors (either too high or too low)
nonadherence (purposeful or accidental)

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RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2005)
•

Examples of by midnight of the next calendar day:

‒

‒

A clinically significant medication issue is identified at
th
10:00 AM on February 12 . Communication occurs and
the physician/physician-designee
prescribed/recommended action is completed on or
th
before 11:59 PM on February 13 .
A clinically significant medication issue is identified at
th
10:00 PM on February 12 . Communication occurs and
the physician/physician-designee
prescribed/recommended action is completed on or
th
before 11:59 PM on February 13 .

Coding Instructions
Code 0, No, if all clinically significant medication issues identified at
the time of or at any time since the most recent SOC/ROC were not
communicated to the physician/physician-designee and/or all
prescribed/recommended actions were not completed, to the extent
possible, by midnight of the next calendar day.
•

Examples:

‒

‒

‒

At the time of or at any time since the most recent
SOC/ROC, the clinician(s) did not communicate all
identified potential or actual clinically significant
medication issues to the physician until after midnight of
the next calendar day.
At the time of or at any time since the most recent
SOC/ROC, the clinician’s communicated to the
physician/physician-designee all identified potential or
actual clinically significant medication issues, but the
physician/physician-designee did not respond until after
midnight of the next calendar day.
At the time of or at any time since the most recent
SOC/ROC, the clinician(s) did not complete all
physician/physician-designee prescribed/recommended
actions for all identified potential or actual clinically
significant medication issues by midnight of the next
calendar day.

DEFINITIONS
CONTACT WITH PHYSICIAN/
PHYSICIAN DESIGNEE
•
Communication to the
physician/physician-designee to
convey an identified potential or
actual clinically significant
medication issue, AND a response
from the physician/physiciandesignee to acknowledge receipt
and/or convey prescribed/
recommended actions in response
to the medication issue.
•
Communication can be in person, by
telephone, voicemail, electronic
means, facsimile, or any other
means that appropriately conveys
the message of patient status.
•
Communication can be directly
to/from the physician or physiciandesignee, or indirectly through
physician’s office staff on behalf of
the physician or physician-designee,
in accordance with the legal scope
of practice.
MEDICATION FOLLOW-UP
•
The process of contacting a
physician/physician-designee to
communicate the identified
medication issue and, to the extent
possible, completing all physician/
physician-designee prescribed/
recommended actions by midnight
of the next calendar day (at the
latest).

Code 1, Yes, if all clinically significant medication issues identified at
the time of or at any time since the most recent SOC/ROC were
communicated to the physician/physician-designee and all prescribed/recommended actions were completed, to the
extent possible, by midnight of the next calendar day each time a potential clinically significant issue was identified.
•

Examples:

‒

‒

At the most recent SOC/ROC and throughout the quality episode, the clinician(s) communicated all
identified clinically significant medication issues to the physician/physician-designee, and all
physician/physician-designee prescribed/recommended actions for the identified issues were completed
by midnight of the next calendar day.
At the most recent SOC/ROC and throughout the quality episode, the clinician(s) contacted the
physician/physician-designee regarding all identified potential or actual clinically significant medication
issues, and the physician/physician-designee communicated to the clinician(s) that no actions were
necessary regarding the reported issues. All communications took place before midnight of the next
calendar day.

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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. An
example of a recommended action 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. 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.

Code 9, NA, if there were no potential or actual clinically significant medication issues identified at the time of or at
any time since the most recent SOC/ROC, or if the patient is not taking any medications at the time of or at any time
since the most recent SOC/ROC.
A dash (–) value is a valid response for this item. CMS expects dash use to be a rare occurrence.
EXAMPLES
1.

No clinically significant medication issues identified throughout the episode

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 at SOC, and no potential clinically significant medication issues were identified. There
is no other documentation to indicate that potential or actual clinically significant medication issues occurred during
the episode of care.
Coding: 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 that the agency looked for potential
clinically significant medication issues via completion of a drug regimen review and that no potential or actual
clinically significant medication issues were identified at any time during the episode, from SOC through
Discharge.
2.

Clinically significant medication issue identified, late follow-up

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.
Coding:
At SOC:
M2001: ENTER Response 1 – Yes – Issues found during review.
M2003: ENTER Response 0 – No.
At DC:
M2005: enter Response 0 – No.
Rationale: Because an issue identified was determined by the clinician to be clinically significant, warranting
physician contact by midnight of the next calendar day, it meets the criteria for a 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.

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DATA SOURCES/RESOURCES
•
•
•
•

Clinical record
Communication notes
Medication list
Plan of Care

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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

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

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 an authoritative source, such as the Institute for Safe
Medication Practices 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.
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 – 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
all high-risk medications in his/her medication profile.
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
Documentation of other agency staff responsible for educating patient/caregivers on medications.
Authoritative sources to identify high-risk medications for the purposes of responding to this item can include
but are not limited to the Institute for Safe Medication Practices, the American Geriatrics Society, and The
Joint Commission.
Links to resources for identifying high-risk medications can be found in Chapter 5 of this manual.

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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

0
1
NA

No
Yes
Patient not taking any drugs

ITEM INTENT
•

•

Identifies if agency staff and/or other health care providers, such as pharmacists, instructed the
patient/caregiver about how to manage all medications effectively and safely within the time period under
consideration, including instruction related to monitoring the effectiveness of drug therapy, adverse drug
reactions, and significant side effects, and how and when to report problems that may occur.
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
•
•
•

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.
Enter Response 1 if all interventions were provided (monitor effectiveness of drug therapy, adverse drug
reactions and significant side effects, and how and when to report problems that may occur).

‒
‒
•

AND, Within the time period under consideration (at or since the most recent SOC/ROC)
AND, By agency staff and/or other health care providers

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.

DATA SOURCES/RESOURCES
•
•
•
•
•

Review of clinical record including teaching guidelines, flow sheets, clinical notes, etc.
Medication list
Plan of Care
Documentation of 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

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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.)

Enter Code

0
1

2
3
NA

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
Unable to take medication unless administered by another person.
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 on
the day of assessment.
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:

‒
‒
‒
‒

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) p.o. 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 using this device, enter Response 0.

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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
set up and 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 new interventions, such as
reminders or a med planner, provided adequate support 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
Documentation of other agency staff
Patient/caregiver interview
Physical assessment
Cognitive assessment
Environmental assessment
CMS OASIS Q&As can be accessed through the CMS OASIS web page

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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.

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.

ITEM INTENT
•
•

This item is intended to assess the patient’s ability to take all injectable medications reliably and safely at on
day of assessment.
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:

‒
‒
‒
‒

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
doorway.

TIME POINTS ITEM(S) COMPLETED
•
•
•

Start of care
Resumption of care
Follow-up

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.

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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 the correct 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
Documentation of other agency staff
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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OASIS ITEM
SOC/ROC
(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

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
3

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

4

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Chapter 3: Section M - Care Management

Discharge
(M2102)

Enter Code

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.
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
3

Enter Code

c.

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
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
3

Enter Code

d.

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
4 Assistance needed, but no non-agency caregiver(s) available
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
3

Enter Code

f.

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
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
3

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

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.

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Chapter 3: Section M - Care Management

RESPONSE-SPECIFIC INSTRUCTIONS (cont’d for OASIS ITEM M2102)
•
•
•

•

For each row, 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 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.
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 f – Supervision and safety includes needs related to the ability of the patient to safely remain in the
home. This category of assistance needs should focus on supervision and safety necessary due to cognitive
or mental health issues. Such assistance may range from calls to remind the forgetful patient to take
medications, to in-person visits to ensure that a patient with impaired decision making is safe, to the need for
the physical presence of another person in the home to ensure that the patient doesn’t wander, harm
themselves or others or to monitor other safety risks related to cognitive/mental health concerns.

DATA SOURCES/RESOURCES
•
•

Patient/caregiver interview
Review of previous health history

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Chapter 3: Section N - Therapy Need

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 time points. In such cases, the total number of therapy visits planned for the
upcoming 60-day episode should be reported in M2200.

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Chapter 3: Section N - Therapy Need

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

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Chapter 3: Section O - Emergent Care

OASIS ITEM
(M2301)
Enter Code

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)?
0
1
2
UK

No [Go to M2401]
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. 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
Discharge from agency – not to an inpatient facility

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 inpatient stay was for 24 hours or
longer, and for reasons other than diagnostic testing).

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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 entered 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- Yes, used hospital emergency department WITHOUT hospital admission for a
patient who, at the time of or at any time since the most recent SOC/ROC, 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 - Yes, used hospital emergency with hospital admission 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 inpatient stay is
for 24 hours or longer, and 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

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Chapter 3: Section O - Emergent Care

OASIS ITEM
(M2310)
⃞1

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.)
Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis

⃞ 10

Hypo/Hyperglycemia, diabetes out of control

⃞ UK

Reason unknown

⃞ 19

Other than above reasons

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
Discharge from agency – not to an inpatient facility

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 Response 19, Other than above reasons (for the fall), and Response 1 (for the medication
side effects).
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 – select Response 19 – Other than above
reasons).
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

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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

No

Yes

Not Applicable

a.

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).

b.

Falls prevention interventions

⃞0

⃞1

⃞ NA

Every standardized, validated multi-factor
fall risk assessment conducted at or since
the most recent SOC/ROC assessment
indicates the patient has no risk for falls.

c.

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

⃞0

⃞1

⃞ NA

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.

d.

Intervention(s) to monitor and
mitigate pain

⃞0

⃞1

⃞ NA

Every standardized, validated pain
assessment conducted at or since the
most recent SOC/ROC assessment
indicates the patient has no pain.

e.

Intervention(s) to prevent
pressure ulcers

⃞0

⃞1

⃞ NA

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.

f.

Pressure ulcer treatment based
on principles of moist wound
healing

⃞0

⃞1

⃞ NA

Patient has no pressure ulcers OR has no
pressure ulcers for which moist wound
healing is indicated.

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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 at the time of or at any time since the
most recent SOC/ROC assessment. “Included in the physician-ordered 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.
The problem-specific interventions referenced in the item may or may not directly correlate to stated
requirements 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
•

•

•
•

•
•
•
•

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 quality episode, 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, c, d and e, the standardized, validated assessment that is referred to in the last column refers to
a tool that 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.
-

For rows b and c, a formal assessment (as defined in the relevant OASIS item M1730, and M1910)
must have been performed to select “NA.”

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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 modifications, 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).

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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

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Chapter 3: Section P - Discharge

OASIS ITEM
(M2410)

To which Inpatient Facility has the patient been admitted?

Enter Code

1
2
3
4
NA

Hospital
Rehabilitation facility
Nursing home
Hospice
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 an inpatient facility
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 (Response 2).
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 (Response 3).
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: 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

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

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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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
Death at home
Discharge from agency – not to an inpatient facility

RESPONSE-SPECIFIC INSTRUCTIONS
•
•
•
•

If the date or month is only one digit, that digit is preceded by a “0” (for example, May 4, 2019 = 05/04/2019).
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.

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Chapter 3 Section GG Functional Abilities and Goals

SECTION GG: FUNCTIONAL ABILITIES AND GOALS
GG0100: Prior Functioning: Everyday Activities
GG0100. Prior Functioning: Everyday Activities: Indicate the patient’s usual ability with everyday activities prior
to the current illness, exacerbation, or injury.
Coding:
3. Independent – Patient completed the
activities by him/herself, with or without
an assistive device, with no assistance
from a helper.
2. Needed Some Help – Patient needed
partial assistance from another person to
complete activities.
1. Dependent – A helper completed the
activities for the patient.
8. Unknown
9. Not Applicable

↓ Enter Codes in Boxes
A.

B.

C.

D.

Self Care: Code the patient’s need for assistance with
bathing, dressing, using the toilet, or eating prior to the
current illnesss, exacerbation, or injury.
Indoor Mobility (Ambulation): Code the patient’s need
for assistance with walking from room to room (with or
without a device such as cane, crutch or walker) prior to
the current illness, exacerbation, or injury.
Stairs: Code the patient’s need for assistance with
internal or external stairs (with or without a device such
as cane, crutch, or walker) prior to the current illness,
exacerbation or injury.
Functional Cognition: Code the patient’s need for
assistance with planning regular tasks, such as shopping
or remembering to take medication prior to the current
illness, exacerbation, or injury.

Item Intent
This item identifies the patient’s usual ability with everyday activities, prior to the current illness,
exacerbation or injury.

Time Points Item(s) Completed
Start of care
Resumption of care

Response-Specific Instructions
Interview patient or family or review patient’s clinical records describing patient’s prior
functioning with everyday activities.
Coding Instructions
•
•
•
•
•

Code 3, Independent, if the patient completed the activities by him/herself, with
or without an assistive device, with no assistance from a helper.
Code 2, Needed Some Help, if the patient needed partial assistance from another
person to complete activities.
Code 1, Dependent, if the helper completed the activities for the patient.
Code 8, Unknown, if the patient’s usual ability prior to the current illness,
exacerbation or injury is unknown.
Code 9, Not Applicable, if the activity was not applicable to the patient prior the
current illness, exacerbation or injury.

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Chapter 3 Section GG Functional Abilities and Goals

A dash is a valid response for this item. CMS expects dash use to be a rare
occurrence.

Coding Tips
If no information about the patient’s ability is available after attempt to interview patient
or family and after reviewing patient’s clinical record, code 8, Unknown.

Examples
1. When to Code “Not Applicable”
Mr. S ambulates with a walker around his home, and uses a stair lift to negotiate the stairs to the
second floor, where his bedroom is located.
Coding: GG0100C, Stairs, would be coded 9, Not Applicable.
Rationale: Mr. S is not able to go up and down stairs; he uses a stair lift. So, he did not
perform this activity.

Data Sources/Resources
Patient interview
Family interview
Clinical record

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GG0110: Prior Device Use
GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,
exacerbation, or injury.

↓ Check all that apply
A.

Manual wheelchair

B.

Motorized wheelchair and/or scooter

C.

Mechanical lift

D.

Walker

E.

Orthotics/Prosthetics

Z.

None of the above

Item Intent
This item identifies the patient’s use of devices and aids immediately prior to the current illness,
exacerbation, or injury to align treatment goals.

Time Points Item(s) Completed
Start of care
Resumption of care

Response-Specific Instructions
Interview patient or family or review the patient’s clinical record describing the patient’s use of
prior devices and aids.
Coding Instructions
•

Check all devices that apply.

•

GG0110C - Mechanical lift, any device a patient or caregiver requires for lifting
or supporting the patient’s bodyweight. Examples include, but are not limited to:
o Stair lift
o Hoyer lift
o Bath tub lift
GG0110D - Walker, All types of walkers. Examples include, but are not limited to:
o Pick-up walker
o Hemi-walker
o Rolling walker
o Platform walker
Check Z, None of the Above, if the patient did not use any of the listed devices or
aids immediately prior to the current illness, exacerbation or injury.
A dash is a valid response for this item. CMS expects dash use to be a rare
occurrence.

•

•
•

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Examples
1. Mobilized Wheelchair and/or Scooter
Mrs. M is a bilateral lower extremity amputee and has multiple diagnoses including diabetes,
obesity and peripheral vascular disease. She is unable to walk and did not walk prior to the
current episode of care that started due to a pressure ulcer and respiratory infection. She used a
motorized wheelchair to mobilize.
Coding: GG0110B, Motorized wheelchair and/or scooter would be checked.
Rationale: Mrs. M used a motorized wheelchair prior to the current illness/injury.
2. None of the Above
Mr. C has bilateral lower extremity neuropathy secondary to his diabetes. Prior to this current
episode, he used a cane. Today, he is using a walker.
Coding: GG0110Z, None of the above, would be checked.
Rationale: A cane is not a device included as part of the item list above. Not all devices
and aids are included in this item.

Data Sources/Resources
Patient interview
Family interview
Clinical record

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GG0130 Self-Care
SOC/ROC
GG0130. Self-Care
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the
mouth and swallow food and/or liquid once the meal is placed before the
patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if
applicable): The ability to remove and replace dentures from and to the mouth,
and manage equipment for soaking and rinsing them.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes
before and after voiding or having a bowel movement. If managing an ostomy,
include wiping the opening but not managing equipment.

E.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and
drying self (excludes washing of back and hair). Does not include transferring
in/out of tub/shower

F.

Upper body dressing: The ability to dress and undress above the waist;
including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist,
including fasteners; does not include footwear.
(continued)

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1.
SOC/ROC
Performance

Chapter 3 Section GG Functional Abilities and Goals

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
H.

Putting on/taking off footwear: The ability to put on and take off socks and
shoes or other footwear that is appropriate for safe mobility; including
fasteners, if applicable.

Follow-Up
GG0130. Self-Care
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal is placed before the patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The
ability to insert and remove dentures into and from the mouth, and manage denture
soaking and rinsing with use of equipment.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

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Discharge
GG0130. Self-Care
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal placed before the patient.

B.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The
ability to insert and remove dentures into and from the mouth, and manage denture
soaking and rinsing with use of equipment.

C.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

E.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self
(excludes washing of back and hair). Does not include transferring in/out of tub/shower.

F.

Upper body dressing: The ability to dress and undress above the waist; including
fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including
fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and shoes or
other footwear that is appropriate for safe mobility; including fasteners, if applicable.

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Item Intent
This item identifies the patient’s ability to perform the listed self-care activities, and discharge
goal(s).

Time Points Item(s) Completed
Start of care
Resumption of care
Follow-up
Discharge from agency – not to an inpatient facility
Note: This item, GG0130, includes Performance assessment and Discharge Goal(s) at
the SOC/ROC. Refer to sections for instructions, tips and examples for each.

Response-Specific Instructions – Performance Assessment
(SOC/ROC, FU and DC)
•

Licensed clinicians may assess the patient’s performance based on direct observation
(preferred) as well as reports from the patient, clinicians, care staff, and/or family.

•

When possible, CMS invites a multidisciplinary approach to patient assessment.

•

Patients should be allowed to perform activities as independently as possible, as long as they
are safe.

•

‒

If helper assistance is required because patient’s performance is unsafe or of poor quality,
score according to amount of assistance provided.

‒

Activities may be completed with or without assistive device(s). Use of assistive
device(s) to complete an activity should not affect coding of the activity.

Patients with cognitive impairments/limitations may need physical and/or verbal assistance
when completing an activity. Code based on the patient’s need for assistance to perform the
activity safely (for example, choking risk due to rate of eating, amount of food placed into
mouth, risk of falling).

Response-Specific Instructions – SOC/ROC Performance Assessment
•

Code the patient’s functional status based on a functional assessment that occurs at or soon
after the patient’s SOC/ROC. The SOC/ROC function scores are to reflect the patient’s
SOC/ROC baseline status and are to be based on observation of activities, to the extent
possible. When possible, the assessment should occur prior to the start of therapy services to
capture the patient’s true baseline status. This is because therapy interventions can affect the
patient’s functional status.

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Chapter 3 Section GG Functional Abilities and Goals

A patient’s functional ability can be impacted by
the environment or situations encountered in the
home. Observing the patient in different locations
and circumstances within the home is important
for a comprehensive understanding of the patient’s
functional status.
‒

DEFINITION
ASSESSMENT TIMEFRAME
• The assessment timeframe is
the maximum number of days
within which to complete the
comprehensive assessment.

If the patient’s ability varies during the
assessment timeframe, record their usual ability to perform each activity. Do not record
the patient’s best performance and do not record the patient’s worst performance, but
rather the patient’s usual performance; what is true greater than 50% of the assessment
timeframe.

Response-Specific Instructions –
SOC/ROC Discharge Goal(s)

DEFINITION
USUAL PERFORMANCE, ABILITY
• A patient’s usual performance is
his/her ability greater than 50% of
the assessment timeframe.

•

For the Home Health (HH) Quality Reporting
Program (QRP) a minimum of one self-care or
mobility goal must be coded. However,
agencies may choose to complete more than
one self-care or mobility discharge goal. Code the patient’s discharge goal(s) using the 6point scale. Use of the activity not attempted codes (07, 09, 10 or 88) is permissible to code
discharge goal(s). Use of a dash is permissible for any remaining self-care or mobility goals
that were not coded.

•

Discharge goal(s) may be the coded the same as SOC/ROC performance, higher than
SOC/ROC performance or lower than SOC/ROC performance.

•

If the SOC/ROC performance of an activity was coded using one of the activity not
attempted codes (07, 09, 10 or 88) a discharge goal may be submitted using the 6-point scale
if the patient is expected to be able to perform the activity by discharge.

•

Licensed clinicians can establish a patient’s discharge goal(s) at the time of SOC/ROC based
on the patient’s prior medical condition, SOC/ROC assessment, self-care and mobility status,
discussions with the patient and family, professional judgment, the profession’s practice
standards, expected treatments, patient motivation to improve, anticipated length of stay, and
the discharge plan. Goals should be established as part of the patient’s care plan.

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Response Specific Instructions – Follow-Up and Discharge
Performance
•

•

Follow-up Performance: Clinicians
should code the patient’s functional
status based on a functional assessment
that occurs within the assessment
timeframe.

DEFINITION
TIME PERIOD UNDER CONSIDERATION
The time period under consideration is the
span of time for data collection and
assessment. For most OASIS items this is
the day of assessment. For other items,
item wording or related guidance will
specify the time period under
consideration, such as, since the most
recent SOC/ROC.

Discharge Performance: The discharge
time period under consideration
includes the last 5 days of care. This
includes the date of the discharge visit
plus the four preceding calendar days.
Code the patient’s functional status
based on a functional assessment that occurs at or close to the time of discharge.

Coding Instructions for SOC/ROC Performance and Discharge Goal(s), and
Follow-up and Discharge Performance
Code 06, Independent, if the patient completes the activity by him/herself with no
assistance from a helper.
Code 05, Setup or Clean-up Assistance, if the helper sets up or cleans up; patient
completes activity. Helper assists only prior to or following the activity, but not during
the activity. For example, the patient requires assistance cutting up food or opening
container, or requires setup of hygiene item(s) or assistive device(s).
Code 04, Supervision or Touching Assistance, if the helper provides verbal cues
and/or touching/steadying and/or contact guard assistance as patient completes activity.
Assistance may be provided 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
assistance during the activity.
Code 03, Partial/Moderate Assistance, if the helper does LESS THAN HALF the
effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
Code 02, Substantial/Maximal Assistance, if the helper does MORE THAN
HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
Code 01, Dependent, if the helper does ALL of the effort. Patient does none of the
effort to complete the activity; or the assistance of two or more helpers is required for the
patient to complete the activity.
Code 07, Patient Refused, if the patient refused to complete the activity.
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Code 09, Not Applicable, if the patient did not attempt to perform the activity and did
not perform this activity prior to the current illness, exacerbation, or injury.
Code 10, Not Attempted Due to Environmental Limitations, if the patient did
not attempt this activity due to environmental limitations. Examples include lack of
equipment, weather constraints
Code 88, Not Attempted Due to Medical Condition or Safety Concerns, if the
activity was not attempted due to medical condition or safety concerns.
A Dash is a valid response for this item. CMS expects dash use to be a rare occurrence.
Coding Tips
GG0130A. Eating
Patient uses a gastrostomy tube (G-Tube) or total parenteral nutrition (TPN):
•

Assistance with tube feedings or TPN is not considered when coding the item eating.

•

If the patient does not eat or drink by mouth and relies solely on nutrition and liquids
through tube feedings or TPN due to a new (recent-onset) medical condition, code
GG0130A as 88, Not attempted due to medical condition or safety concerns.

•

If the patient does not eat or drink by mouth at the time of the assessment, and the
patient did not eat or drink by mouth prior to the current illness, injury or
exacerbation, code GG0130A as 09, Not applicable.

•

If the patient eats and drinks by mouth, and relies partially on obtaining nutrition
and liquids via tube feedings or TPN, code eating based on the amount of assistance
the patient requires to eat and drink by mouth.

GG0130B. Oral Hygiene
•

If a patient does not perform oral hygiene during home visit, determine the patient’s
abilities based on the patient’s performance of similar activities during the
assessment, or on patient and/or caregiver report.

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Examples – Performance
1. Eating – Food Consistency
Mrs. H does not have any food consistency restrictions, but often needs to swallow two or three
times so that the food clears her throat due to difficulty with pharyngeal peristalsis. She requires
verbal cues to use the compensatory strategy of extra swallows to clear the food.
Coding: GG0130A, Eating, would be coded 04, Supervision or touching assistance.
Rationale: Mrs. H swallows all types of food consistencies and requires verbal cueing
(supervision) from the helper. Code based on assistance from the helper. The coding is
not based on whether the patient had restrictions related to food consistency.
2. Eating – Visual Deficit
Mrs. V has difficulty seeing on her left side since her stroke. During meals, a helper must remind
her to scan the entire plate to ensure she has seen all the food.
Coding: GG0130A, Eating, would be coded 04, Supervision or touching assistance.
Rationale: The helper provides verbal cueing assistance as Mrs. V completes the
activity of eating. Supervision, such as reminders, may be provided throughout the
activity or intermittently.
3. Eating – G-tube
Mr. R is unable to eat or drink by mouth since he had a stroke 1 week ago. He receives nutrition
and hydration through a G-tube, which is administered by a helper.
Coding: GG0130A, Eating, would be coded 88, Not attempted due to medical condition
or safety concerns.
Rationale: The patient does not eat or drink by mouth at this time due to a recent-onset
medical condition (his recent-onset stroke). This item includes eating and drinking by
mouth only.
4. Oral Hygiene – Assistance to and from the Bathroom
The helper provides steadying assistance to Mr. S as he walks to the bathroom. The helper
applies toothpaste onto Mr. S’s toothbrush. Mr. S then brushes his teeth at the sink in the
bathroom without physical assistance or supervision. Once Mr. S is done brushing his teeth and
washing his hands and face, the helper returns and provides steadying assistance as the patient
walks back to his bed.
Coding: GG0130B, Oral hygiene, would be coded 05, Setup or clean-up assistance.
Rationale: The helper provides setup assistance (putting toothpaste on the toothbrush)
before Mr. S brushes his teeth. Do not consider assistance provided to get to or from the
bathroom to score Oral hygiene.
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Examples - SOC/ROC Performance
1. SOC/ROC Performance When the Activity Did Not Occur at the Time of the
Assessment, Nor Prior to the Current Illness, Injury or Exacerbation
Ms. J cannot swallow any food or liquids secondary to ALS. She has a J-tube and has been on
tube feedings for several years. She is being admitted to skilled home health care for treatment of
a sacral pressure injury. Her treatment includes TPN to support wound healing.
Coding: GG0130A1, Eating, SOC Performance would be coded, 09, Not Applicable.
GG0130A2, Eating, Discharge Goal, would be coded 09, Not Applicable.
Rationale: Mr. J does not eat or drink by mouth at the time of assessment, and did not
eat or drink by mouth prior to the current illness, injury or exacerbation. And, Mr. J is not
expected to eat or drink by mouth by discharge.
2. SOC/ROC Performance When the Activity Did Not Occur at the Time of the
Assessment, but Did Occur Prior to the Current Illness, Injury or Exacerbation
Mr. B has been prescribed bowel rest for pancreatitis, and he is not to eat or drink anything for
one week, after which the home health nurse will support advancing back to a regular diet. TPN
has been prescribed, and he is being admitted to home care for TPN teaching and management.
Coding: GG0130A1, Eating, SOC Performance, would be coded 88, Not attempted
due to medical condition or safety concerns.

Examples – Establish Discharge Goal(s) at SOC/ROC
3. Discharge Goal Code is Higher than SOC/ROC Performance Code
During SOC/ROC functional assessment, Mr. M states he prefers to bathe himself rather than
depending on helpers or his wife to perform this activity. The clinician assesses Mr. M’s
SOC/ROC performance for Shower/Bathe self, and determines the helper performs more than
half the effort. The assessing clinician, using professional judgement, available information and
collaboration as allowed anticipates that by discharge Mr. M will require a helper for less than
half of the activity Shower/Bathe self.
Coding: GG0130E1, Shower/Bathe self, SOC Performance, would be coded 02,
Substantial/maximal assistance. GG0130E2 Shower/Bathe self, Discharge Goal, would
be coded 03, Partial/moderate assistance.
Rationale: At SOC/ROC assessment, Mr. M participates in the activity Shower/bathe
self, but a helper performs more than half the activity, the definition of
substantial/maximal assistance. The assessing clinician expects Mr. M has the potential to
improve in performance of this activity, to the extent that a helper needs to assist for less
than half the activity, the definition for partial/moderate assistance.
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4. Discharge Goal Code is the Same as SOC/ROC Performance Code
During the SOC/ROC assessment, Mrs. E states she prefers to participate in her oral hygiene
twice daily. On assessment, the clinician identifies that Mrs. E’s caregiver completes more than
half of this activity. Mrs. E has severe arthritis, Parkinson’s disease, diabetic neuropathy, and
renal failure. These conditions result in multiple impairments, including limited endurance, weak
hand grasp, slow movements and tremors. The assessing clinician, using professional judgment,
all available information and collaboration as allowed, determines that Mrs. E is not expected to
progress to a higher level of functioning during the episode of care. However, the clinician
anticipates that Mrs. E will be able to maintain her SOC/ROC performance level. The clinician
discusses functional goals with Mrs. E and they agree maintaining functioning is a reasonable
goal.
Coding: GG0130B1 Oral Hygiene, SOC/ROC Performance, would be coded 02,
Substantial/maximal assistance. GG0130B2, Oral Hygiene, Discharge Goal, would be
coded 02, Substantial/maximal assistance.
Rationale: Performance assessment revealed Mrs. E’s caregiver completes more than
half the activity, Oral Hygiene, which matches Code 02, substantial/maximal assistance.
Mrs. E’s condition in this example makes it unlikely that her performance of this activity
will improve, but that maintenance of her current level of function is possible, so the
discharge goal is coded the same as admission performance.
5. Discharge Goal Code is Lower than SOC/ROC Performance Code
Mrs. T has a progressive neurological illness that affects her strength, coordination, and
endurance. Mrs. T prefers to use the bedside commode for as long as possible rather than using
incontinence undergarments. The helper currently supports Mrs. T while she is standing so that
Mrs. T can pull down her underwear before sitting onto the bedside commode. When Mrs. T has
finished voiding, she wipes her perineal area. Mrs. T then requires the helper to support her trunk
while Mrs. T pulls up her underwear. The assessing clinician, using professional judgment, all
available information and collaboration as allowed anticipates that Mrs. T will weaken further by
discharge, and while she will still be able to use the bedside commode, she will need the helper
to assist with all toileting hygiene.
Coding: GG0130C1, Toileting hygiene, SOC/ROC Performance, would be coded 03,
Partial/moderate assistance. GG0130C2, Toileting hygiene, Discharge Goal, would be
coded 02, substantial/maximal assistance.
Rationale: Assessment of SOC/ROC performance of toileting hygiene demonstrated
that the helper provided less than half the effort for Mrs. T’s toileting hygiene. The
assessing clinician expects that by discharge, Mrs. T will need the helper to assist with
more than half the effort of toileting hygiene.

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6. Discharge Goal Code Is Established for a Patient Where the Activity Was 09 –
Not Applicable at SOC/ROC
Mrs. D has been unable to eat or drink by mouth for several weeks, due to a large, cancerous
lesion on the soft palate. A week ago, the lesion worsened becoming very painful and required
surgical removal. At the SOC, she remains restricted from any oral intake, with the expected goal
of progressing to small sips of water and soft foods by mouth with supervision by discharge from
home health.
Coding: GG0130A1, Eating, SOC Performance, would be coded 09, Not Applicable.
GG0130A2, Eating, Discharge Goal, would be coded 04, Supervision or Touching
Assistance.
Rationale: Mrs. D does not eat or drink by mouth at the time of the SOC assessment,
and did not eat or drink by mouth prior to the current illness, injury or exacerbation (the
recent worsening necessitating surgery). The assessing clinician expects that by
discharge, Mrs. D will be able to manage at least some food and drink by mouth, with
supervision.

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GG0170 Mobility
SOC/ROC
GG0170. Mobility
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
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.
Activities 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 and/or touching/steadying and/or
contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Roll left and right: The ability to roll from lying on back to left and right side,
and return to lying on back on the bed.

B.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the
bed.

C.

Lying to sitting on side of bed: The ability to 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.

D.

Sit to stand: The ability to come to a standing position from sitting in a chair,
wheelchair, or on the side of the bed.

E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a
chair (or wheelchair).

F.

Toilet tranfer: The ability to get on and off a toilet or commode.
(continued)

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1.
SOC/ROC
Performance

Chapter 3 Section GG Functional Abilities and Goals

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
G. Car Transfer: The ability to transfer in and out of a car or van on the
passenger side. Does not include the ability to open/close door or fasten seat
belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room,
corridor, or similar space.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step
(curb)

J.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and
make two turns.

K.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor
or similar space.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven
or sloping surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one
step.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.
N.

4 steps: The ability to go up and down four steps with or without a rail.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick
up a small object, such as a spoon, from the floor.
Q.

Does patient use wheelchair and/or scooter?
0. No → Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability
to wheel at least 50 feet and make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at
least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Follow-Up
GG0170. Mobility
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C.
D.
E.
F.
I.

J.
L.

Lying to sitting on side of bed: The ability to 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.
Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.
Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).
Toilet tranfer: The ability to get on and off a toilet or commode.
Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Follow-Up performance is coded 07, 09, 10 or 88 → skip to GG0170M, 1 step (curb).
Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.
Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.
(continued)

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4.
Follow-Up
Performance
Enter Codes
in Boxes
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Follow-up performance is coded 07, 09, 10 or 88, skip to GG0170Q, Does patient use
wheelchair and/or scooter?
N. 4 steps: The ability to go up and down four steps with or without a rail.

R.

Q. Does patient use wheelchair and/or scooter?
0. No →Skip GG0170R
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.
Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.

Discharge
GG0170. Mobility
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
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.
Activities 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 and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
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 – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.
(continued)

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3.
Discharge
Performance
Enter Codes
in Boxes
B.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

C.

Lying to sitting on side of bed: The ability to 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.

D.

Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.

E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).

F.

Toilet tranfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the passenger side. Does
not include the ability to open/close door or fasten seat belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb).

J.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two
turns.

K.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar
space.

L.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.
N.

4 steps: The ability to go up and down four steps with or without a rail.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick up a small
object, such as a spoon, from the floor.
Q. Does patient use wheelchair and/or scooter?
0. No → Skip to J1800 Any falls since SOC/ROC, whichever is more recent.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R.

Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in
a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Item Intent
This item identifies the patient’s ability to perform the listed mobility activities, and discharge
goal(s).

Time Points Item(s) Completed
Start of care
Resumption of care
Follow-up
Discharge from agency – not to an inpatient facility
Note: This item, GG0170, includes Performance assessment and Discharge Goal(s) at
SOC/ROC. Refer to sections for instructions, tips and examples for each.

Response-Specific Instructions – Performance Assessment
(SOC/ROC, FU and DC)
•

Licensed clinicians may assess the patient’s performance based on direct observation
(preferred) as well as reports from patient, clinicians, care staff, and/or family.

•

When possible, CMS invites a multidisciplinary approach to patient assessment.

•

Patients should be allowed to perform activities as independently as possible, as long as they
are safe.

•

‒

If helper assistance is required because the patient’s performance is unsafe or of poor
quality, score according to amount of assistance provided.

‒

Activities may be completed with or without assistive device(s). Use of assistive
device(s) to complete an activity should not affect coding of the activity.

Patients with cognitive impairments/limitations may need physical assistance and/or verbal
assistance when completing an activity. Code based on the patient’s need for assistance to
complete an activity safely

Response-Specific Instructions – SOC/ROC Performance Assessment
•

Code the patient’s functional status based on a functional assessment that occurs at or soon
after the patient’s SOC/ROC. The SOC/ROC function scores are to reflect the patient’s
SOC/ROC baseline status, and are to be based on observation of activities, to the extent
possible. When possible, the assessment should occur prior to the start of therapy services to
capture the patient’s true baseline status. This is because therapy interventions can affect the
patient’s functional status.

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•

Chapter 3 Section GG Functional Abilities and Goals

A patient’s functional ability can be impacted by
the environment or situations encountered in the
home. Observing the patient in different locations
and circumstances within the home is important for
a comprehensive understanding of the patient’s
functional status.
‒

If the patient’s ability varies during the
assessment timeframe, record their usual
ability to perform each activity. Do not record
the patient’s best performance and do not
record the patient’s worst performance, but
rather the patient’s usual performance; what is
true greater than 50% of the assessment
timeframe.

DEFINITION
ASSESSMENT TIMEFRAME
• The assessment timeframe is
the maximum number of days
within which to complete the
comprehensive assessment.
DEFINITION
USUAL PERFORMANCE, ABILITY
• A patient’s usual performance is
his/her ability greater than 50%
of the assessment timeframe.

Response-Specific Instructions – SOC/ROC Discharge Goal(s)
•

For the Home Health (HH) Quality Reporting Program (QRP) a minimum of one self-care or
mobility discharge goal must be coded. However, agencies may choose to complete more
than one self-care or mobility discharge goal. Code the patient’s discharge goal(s) using the
6-point scale. Use of the activity not attempted codes (07, 09, 10 or 88) is permissible to code
discharge goal(s). Use of a dash is permissible for any remaining self-care or mobility goals
that were not coded.

•

Discharge goal(s) may be coded the same as SOC/ROC performance, higher than SOC/ROC
performance, or lower than SOC/ROC performance (See Examples).

•

If the SOC/ROC performance of an activity was coded using one of the activity not
attempted codes (07, 09, 10 or 88), a discharge goal may be submitted using the 6-point scale
if the patient is expected to be able to perform the activity by discharge.

•

Licensed clinicians can establish a patient’s discharge goal(s) at the time of SOC/ROC based
on the patient’s prior medical condition, SOC/ROC assessment, self-care and mobility status,
discussions with the patient and family, professional judgment, the profession’s practice
standards, expected treatments, patient motivation to improve, anticipated length of stay, and
the discharge plan. Goals should be established as part of the patient’s care plan.

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Response-Specific Instructions – Follow-Up and Discharge
Performance
•

•

Follow-up Performance: Clinicians
should code the patient’s functional status
based on a functional assessment that
occurs within the assessment timeframe.
Discharge Performance: The discharge
time period under consideration includes
the last 5 days of care. This includes the
date of the discharge visit plus the four
preceding calendar days. Code the
patient’s functional status based on a
functional assessment that occurs at or
close to the time of discharge.

DEFINITION
TIME PERIOD UNDER CONSIDERATION
• The time period under consideration is
the span of time for data collection and
assessment. For most OASIS items this
is the day of assessment. For other
items, item wording or related guidance
will specify the time period under
consideration, such as, since the most
recent SOC/ROC.

Coding Instructions
Code 06, Independent, if the patient completes the activity by him/herself with no
assistance from a helper.
Code 05, Setup or clean-up assistance, if the helper sets up or cleans up; patient
completes activity. Helper assists only prior to or following the activity, but not during
the activity. For example, the patient requires placement of a bed rail to facilitate rolling,
or requires setup of a leg lifter or other assistive devices.
Code 04, Supervision or touching assistance, if the helper provides verbal cues
and/or touching/steadying and/or contact guard assistance as patient completes activity.
Assistance may be provided throughout the activity or intermittently. For example, the
patient requires verbal cueing, coaxing, or general supervision for safety to complete the
activity, or patient may require only incidental help such as contact guard or steadying
assistance during the activity.
Code 03, Partial/moderate assistance, if the helper does LESS THAN HALF the
effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
For example, the patient requires assistance such as partial weight-bearing assistance, but
HELPER does LESS THAN HALF the effort.
Code 02, Substantial/maximal assistance, if the helper does MORE THAN HALF
the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
Code 01, Dependent, if the helper does ALL of the effort. Patient does none of the
effort to complete the activity, or the assistance of two or more helpers is required for the
patient to complete the activity.
Code 07, Patient refused, if the patient refused to complete the activity.
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Code 09, Not applicable, if the patient did not attempt to perform the activity and did
not perform this activity prior to the current illness, exacerbation, or injury.
Code 10, Not attempted due to environmental limitations, if the patient did not
attempt this activity due to environmental limitations. Examples include lack of
equipment, weather constraints, etc.
Code 88, Not attempted due to medical condition or safety concerns, if the
activity was not attempted due to medical condition or safety concerns.
A dash is a valid response for this item. CMS expects dash use to be a rare occurrence.

Coding Tips and Examples
General Coding Tips
•

If a patient does not attempt the activity and a helper does not complete the activity,
and the patient’s usual status cannot be determined based on patient or caregiver
report, code the reason the activity was not attempted:
‒
‒
‒

‒

•

•
•

Code 07 if the patient refused to attempt the activity
Code 10 if the activity was not attempted due to environmental limitations
Code 09 if the patient could not perform an activity at the time of assessment, and
also could not perform the activity prior to the current illness, exacerbation or
injury
Code 88 if the patient could not perform an activity at the time of the assessment,
but could perform the activity prior to the current illness, exacerbation or injury

If the only help a patient needs to complete an activity is for a helper to retrieve an
assistive device or adaptive equipment, such as a cane for walking, or a tub bench for
bathing then enter code 05, Setup or clean-up assistance.
If two or more helpers are required to assist the patient to complete the activity, code
as 01 Dependent.
A dash (–) indicates “No information.” Do not use a dash if the reason that the item
was not assessed was because the patient refused (code 07), the item is not applicable
(code 09), the activity was not attempted due to environmental limitations (code 10),
or the activity was not attempted due to medical condition or safety concerns
(code 88).

Coding Tips and Examples GG0170A, Roll Left and Right
•
•

The activity includes the patient rolling to both the left and to the right while in a
lying position,
If at the time of the assessment the patient is unable to lie flat due to medical
conditions or restrictions, but could perform this activity prior to the current illness,
exacerbation or injury, code 88, Not attempted due to medical condition or safety
concerns.

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•

•

•

For example, if a clinician determines that a patient’s new medical need
requires that the patient sit in an upright sitting position rather than a slightly
elevated position, then code GG0170A, Roll left and right as 88, Not
attempted due to medical or safety concerns.
If at the time of the assessment the patient is unable to lie flat due to medical
conditions or restrictions, and could not perform the activity prior to the current
illness, exacerbation or injury, code 09, Not applicable.
For GG0170A, Roll left and right, clinical judgment should be used to determine
what is considered a “lying” position for the patient. For example, a clinician could
determine that a patient’s preferred slightly elevated resting position is “lying” for
that patient.

1. GG0170A, Roll Left and Right
At SOC, the physical therapist helps Mr. R turn onto his right side by instructing him to bend his
left leg and roll to his right side. He then instructs him how to position his limbs to return to
lying on his back and then to repeat a similar process for rolling onto his left side and then return
to lying on his back. Mr. R completes the activity without physical assistance from a helper. Mr.
R was moving about in bed without difficulty prior to hospitalization. The therapist expects Mr.
R will roll left and right by himself by discharge.
Coding: GG0170A, Roll left and right, SOC Performance would be coded 04,
Supervision or touching assistance. Discharge Goal would be coded 06, Independent.
Rationale: At SOC, the physical therapist provides verbal cues (i.e., instructions) to
Mr. R as he rolls from his back to his right side and returns to lying on his back. The
physical therapist does not provide any physical assistance. After assessment and
considering his current condition, the therapist expects Mr. R will be independently
rolling left and right at discharge.
Coding Tips and Examples GG0170B, Sit to Lying
•
•

The activity includes the ability to move from sitting on side of bed to lying flat on
the bed.
If at the time of the assessment the patient is unable to lie flat due to medical
conditions or restrictions, but could perform this activity prior to the current illness,
exacerbation or injury, code 88, Not attempted due to medical condition or safety
concerns.
• For example, if a clinician determines that a new patient medical need requires
that the patient sit in an upright sitting position rather than a slightly elevated
position, then code GG0170B, Sit to lying as 88, Not attempted due to medical or
safety concerns.

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If at the time of the assessment the patient is unable to lie flat due to medical
conditions or restrictions, and could not perform the activity prior to the current
illness, exacerbation or injury, code 09, Not applicable.
For GG0170B, Sit to lying, clinical judgment should be used to determine what is
considered a “lying” position for the patient. For example, a clinician could determine
that a patient’s preferred slightly elevated resting position is “lying” for that patient.

2. GG0170B, Sit to Lying
Mr. A suffered multiple vertebral fractures due to a fall off a ladder. At SOC, he requires
assistance from a therapist to get from a sitting position to lying flat on the bed because of
significant pain in his lower back. The therapist supports his trunk and lifts both legs to assist
Mr. A from sitting at the side of the bed to lying flat on the bed. Mr. A assists himself a small
amount by raising one leg onto the bed and then bending both knees while transitioning into a
lying position.
Coding: GG0170B, Sit to lying SOC Performance would be coded 02,
Substantial/maximal assistance.
Rationale: The therapist provided more than half the effort for the patient to complete
the activity of sit to lying.
At SOC, Mrs. H requires assistance from two helpers to transfer from sitting at the edge of the
bed to lying flat on the bed due to paralysis on her right side, obesity, and cognitive limitations.
One of the helpers explains to Mrs. H each step of the sitting to lying activity. Mrs. H is then
fully assisted to get from sitting to a lying position on the bed. Mrs. H makes no attempt to assist
when asked to perform the incremental steps of the activity.
Coding: GG0170B, Sit to lying, SOC Performance would be coded 01, Dependent.
Rationale: The patient does none of the effort to complete the activity, and the
assistance of two helpers is needed to complete the activity of sit to lying. If two or more
helpers are required to assist the patient to complete an activity, code as 01, Dependent.
Coding Tips and Examples GG0170C, Lying to Sitting on Side of Bed
•

•

•
•

The activity includes patient transitions from lying on his/her back to sitting on the
side of the bed with feet flat on the floor and sitting upright on the bed without back
support.
If a patient’s feet do not reach the floor upon lying to sitting, the clinician will
determine if a bed height adjustment (if applicable), or a foot stool is required to
accommodate foot placement on the floor/footstool.
Back support refers to an object or person providing support of the patient’s back.
If at the time of the assessment the patient is unable to lie flat due to medical
conditions or restrictions, but could perform this activity prior to the current illness,

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exacerbation or injury, code 88, Not attempted due to medical condition or safety
concerns.
• If a clinician determines that a new patient medical need requires that the patient
sit in an upright sitting position rather than a slightly elevated position, then code
GG0170C, Lying to sitting on side of bed as 88, Not attempted due to medical or
safety concerns,
If at the time of the assessment the patient is unable to lie flat due to medical
conditions or restrictions, and could not perform the activity prior to the current
illness, exacerbation or injury, code 09, Not applicable.
For GG0170C, Lying to sitting on side of bed, clinical judgment should be used to
determine what is considered a “lying” position for the patient. For example, a
clinician could determine that a patient’s preferred slightly elevated resting position is
“lying” for that patient.

3. GG0170C, Lying to Sitting on Side of Bed
Ms. H is recovering from a spinal fusion. At SOC, she rolls to her right side and pushes herself
up from the bed to get from a lying to a seated position. The therapist provides needed verbal
cues to guide Ms. H as she safely uses her hands and arms to support her trunk and avoid
twisting as she raises herself from the bed. Ms. H then safely maneuvers to the edge of the bed,
finally lowering her feet to the floor to complete the activity without hands-on assistance.
Coding: GG0170C, Lying to sitting on side of bed SOC Performance would be
coded 04, Supervision or touching assistance.
Rationale: The therapist provides verbal cues only as Ms. H safely moves from a lying
to sitting position on the side of the bed with her feet on the floor.
Coding Tips and Examples, GG0170D, Sit to Stand
•
•

The activity includes the patient coming to a standing position from sitting in a chair,
wheelchair, or on the side of the bed.
If the only help a patient needs to complete the sit to stand activity is for a helper to
retrieve an assistive device or adaptive equipment, such as a walker or ankle foot
orthosis, then enter code 05, Setup or clean-up assistance.

4. GG0170D, Sit to Stand
Mr. B is being admitted to home health for pressure ulcer care. He has complete tetraplegia from
an injury one year ago and has been unable to bear weight in standing since the injury. At SOC,
using a patient lift that does not require him to come to standing, he is transferred from his bed
into a wheelchair with assistance.
Coding: GG0170D, Sit to stand SOC Performance would be coded 09, Not applicable.

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Rationale: The activity was not attempted at admission and the patient did not perform
this activity prior to the current illness, exacerbation or injury (the pressure ulcer) due to
the diagnosis of complete tetraplegia.
Coding Tips and Examples GG0170E, Chair/Bed-to-Chair Transfer
•
•
•

The activity begins with the patient sitting (in a chair, wheelchair, or at the edge of
the bed) and transferring to sitting in a chair, wheelchair, or at the edge of the bed.
Sit to lying and lying to sitting are not assessed as part of GG0170E.
If a mechanical lift is used to assist in transferring a patient for a chair/bed-to-chair
transfer and two helpers are needed to assist with a mechanical lift transfer, then
code 01, Dependent, even if the patient assists with any part of the chair/bed-to-chair
transfer.

5. GG0170E, Chair/Bed-to-Chair Transfer
Mr. L had a stroke and uses a wheelchair for mobility. When Mr. L gets out of bed at SOC, the
therapist moves the wheelchair into the correct position and locks the brakes so that Mr. L can
transfer into the wheelchair safely. Mr. L transfers into the wheelchair by himself without the
need for supervision or assistance during the transfer. The family reports that Mr. L does transfer
safely without the need for supervision, once the wheelchair is placed and locked. The nurse
does not expect Mr. L’s mobility status to change by discharge.
Coding: GG0170E, Chair/bed-to-chair transfer, SOC Performance would be coded 05,
Setup or clean-up assistance. Discharge Goal would be coded 05, Setup or clean up
assistance.
Rationale: A helper must provide setup assistance only. Once set up is provided, Mr. L
transfers safely and does not need supervision or physical assistance during the transfer.
The nurse expects Mr. L will continue to need wheelchair setup assistance for this
transfer at discharge.
Coding Tips and Examples GG0170F, Toilet Transfer
•
•
•

•
•

The activity includes the patient getting on and off a toilet or commode.
Use of assistive device(s) and adaptive equipment (for instance a grab bar or elevated
toilet) required to complete the toilet transfer should not affect coding of the activity.
If the only help a patient needs to complete the toilet transfer activity is for a helper to
retrieve and place the toilet seat riser, and remove it after patient use, then enter
code 05, Setup or clean-up assistance.
Toileting hygiene and clothing management are not considered part of the toilet
transferring activity.
If the patient requires assistance from two or more helpers to get on and off the toilet
or commode, then enter code 01, Dependent.

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6. GG0170F, Toilet Transfer
The assessing clinician notes that the home health aide visit note (documented on the afternoon
visit on the SOC date) stated that the aide needed to steady Mrs. Z with a light contact when the
patient lowers her underwear and then transfers onto the toilet. After voiding, Mrs. Z cleanses
herself. She then stands up supporting her own weight as the aide steadies her. Mrs. Z pulls up
her underwear as the aide steadies her to ensure Mrs. Z does not lose her balance.
Coding: GG0170F, Toilet transfer, SOC Performance would be coded 04, Supervision
or touching assistance.
Rationale: The aide provides steadying assistance only as the patient transfers on and
off the toilet. Assistance with managing clothing and cleansing is coded under item
GG0130C, Toileting hygiene, and is not considered when rating the Toilet transfer item.
At SOC, Mrs. S is on bedrest due to a new medical complication. She uses a bedpan for bladder
and bowel management. The assessing clinician expects the patient will return to independent
use of the bathroom toilet once the current condition resolves.
Coding: GG0170F, Toilet transfer SOC Performance would be coded 88, Not
attempted due to medical condition or safety concerns. Discharge Goal would be coded
06 Independent.
Rationale: At SOC, the patient does not transfer onto or off a toilet due to being on
bedrest because of a new medical condition, but was able to perform this activity prior to
the current medical condition. It is expected that the patient will be independent in the
activity at discharge.
Coding Tips and Examples GG0170G, Car Transfer
•
•
•

•

The activity includes transferring in and out of a car or van on the passenger side.
Does not include opening or closing the car door, or fastening seat belt.
If the patient is not able to attempt car transfers (for example because no car is
available, or there are weather or other environmental constraints), and the patient’s
usual status cannot be determined based on patient or caregiver report, enter code 10
Not attempted due to environmental limitations.
If at the time of the assessment the patient is unable to attempt car transfers, and
could not perform the car transfers prior to the current illness, exacerbation or injury,
code 09, Not applicable.

7. GG0170, Car Transfer
Mrs. W uses a wheelchair and ambulates for only short distances. At SOC, Mrs. W requires the
physical therapist to lift most of her weight to get from a seated position in the wheelchair to a
standing position. The therapist provides trunk support when Mrs. W takes several steps during
the transfer turn. Mrs. W lowers herself into the car seat with steadying assistance from the

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therapist. Mrs. W moves her legs into the car as the therapist lifts the weight of her legs from the
ground.
Coding: GG0170G, Car transfer SOC Performance would be coded 02,
Substantial/maximal assistance.
Rationale: The therapist completed more than half the effort to transfer Mrs. W into the
car by providing significant lifting assistance from the wheelchair, trunk support when
taking steps toward the car seat, steadying when lowering into the car seat and lifting
support when moving legs into the car. Mrs. W contributes less than half of the effort to
complete the activity.
The day after being admitted to home health, Mrs. N works with an occupational therapist on
transfers in and out of the passenger side of a car. When reviewing the therapist’s evaluation, the
assessing clinician reads that when performing car transfers, Mrs. N required verbal reminders
for safety and contact guarding assistance from the OT for guidance and direction. The therapist
instructed the patient on strategic hand placement while Mrs. N transitioned to sitting into the car
seat. Documentation showed that the therapist opened and closed the car door.
Coding: GG0170G, Car transfer SOC Performance would be coded 04, Supervision or
touching assistance.
Rationale: The therapist provides touching assistance only as the patient transfers in the
passenger seat of the car. Assistance with opening and closing the car door is not
included in the definition of this item and is not considered when coding this item.
Coding Tips and Examples GG0170I, Walk 10 Feet
•
•
•

Starting from standing, the activity includes walking at least 10 feet in a room,
corridor, or similar space.
Use of assistive device(s) and adaptive equipment (for instance a cane or leg brace)
required to complete the walking activity should not affect coding of the activity.
If the only help a patient needs to complete the walking activity is for a helper to
retrieve and place the walker and/or put it away after patient use, then enter code 05,
Setup or clean-up assistance.

8. GG0170I, Walk 10 Feet
Mr. L had bilateral amputations 3 years ago, and prior to this HH admission he used a wheelchair
and did not walk. At SOC, Mr. L does not use prosthetic devices and only uses a wheelchair for
mobility. Mr. L’s care plan includes assisting with fitting and use of bilateral lower extremity
prostheses. The therapist’s care plan goal is for Mr. L to walk distances of 30 feet with
supervision within his home and then discharge to outpatient therapy.
Coding: GG0170I, Walk 10 feet, SOC Performance would be coded 09, Not
applicable. Discharge Goal would be coded 04, Supervision or touching assistance.

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Rationale: When assessing the resident for GG0170I, Walk 10 feet, consider the
patient’s status prior to the current illness, exacerbation or injury. Use code 09, Not
applicable, because Mr. L could not perform the activity of walking at SOC, and did not
perform the activity of walking prior to the current episode of care. The therapist expects
Mr. L will be walking more than 10 feet with supervision by discharge.
Coding Tips and Examples GG0170J, Walk 50 Feet with Two Turns
•
•

•

Starting from standing, the activity includes walking 50 feet and making two turns.
The turns are 90 degree turns and may be in the same direction (two 90 degree turns
to the right or two 90 degree turns to the left) or may be in different directions (one
90 degree turn to the right and one 90 degree turn to the left).
The 90 degree turns should occur at the patient’s ability level (i.e., not jeopardizing
patient safety), and can include the use of an assistive device (for example walker or
crutches) without affecting coding of the activity.

9. GG0170, Walk 50 Feet with Two Turns
At SOC, Mr. B is recovering from a recent stroke and now has difficulty walking. Even with
assistance, he is able to walk only 30 feet. Mr. B’s care plan includes muscle strengthening and
gait training. The therapist expects Mr. B will be able to walk 50 feet with two turns safely with
the assistance of a caregiver for verbal cues and contact guard for steadying on the turns at
discharge.
Coding: GG0170J, Walk 50 feet with two turns, would be coded 88, Not attempted due
to medical condition or safety concerns. Discharge Goal would be 04 Supervision or
touching assistance.
Rationale: Mr. B is ambulatory but was not able to walk the entire distance because of
his new medical condition (stroke). Since the patient is unable to complete the activity at
SOC, but was completing the activity prior to the recent stroke, Code 88 is appropriate.
Although not able to complete the activity at SOC, the therapist anticipates Mr. B will be
able to walk 50 feet with two turns safely with the assistance of a caregiver for verbal
cues and contact guarding at discharge.
Coding Tips and Examples GG0170K, Walk 150 Feet
•
•

•

Starting from standing, the activity includes walking 150 feet in a corridor, or similar
space.
If the patient’s environment does not accommodate a walk of 150 feet without turns,
but the patient demonstrates the ability to walk with or without assistance 150 feet
with turns without jeopardizing the patient’s safety, code using the 6-point scale.
Use of assistive device(s) and adaptive equipment (for instance a rolling walker or
quad cane) required to complete the walking activity should not affect coding of the
activity.

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If the only help a patient needs to complete the walking activity is for a helper to
retrieve and place the assistive device and/or put it away after patient use, then enter
code 05, Setup or clean-up assistance.

10. GG0170K, Walk 150 Feet
Mr. R has recent endurance limitations due to an exacerbation of heart failure and is only
walking about 30 feet before he tires, loses strength and must sit and rest. He reports he was
walking 150 feet or more with his cane prior to this exacerbation of his heart failure.
Coding: GG0170K, Walk 150 feet would be coded 88, Activity not attempted due to
medical or safety concerns.
Rationale: The activity was not attempted due to Mr. R’s recent endurance limitations
and current medical condition, but he was able to complete the activity prior to the recent
exacerbation of his condition.
Coding Tips and Examples GG0170L, Walking 10 Feet on Uneven Surfaces
•
•

•

Once standing, the activity includes walking 10 feet on uneven or sloping surfaces
(indoor or outdoor), such as turf or gravel.
If the patient is not able to attempt walking on uneven surfaces (for example because
no uneven surfaces are available, or there are weather or other environmental
constraints limiting access), and the patient’s usual status for walking 10 feet on
uneven surfaces cannot be determined based on patient or caregiver report, enter code
10 Not attempted due to environmental limitations.
Use of assistive device(s) and adaptive equipment (for instance a rolling walker or
quad cane) required to complete the walking activity should not affect coding of the
activity.

11. GG0170L, Walking 10 Feet on Uneven Surfaces
Mrs. N has severe joint degenerative disease and is recovering from sepsis. When walking on the
uneven driveway was attempted yesterday when Mrs. N came home from the hospital, she
reports that her neighbor had to hold her belt and help lift her a little during a few steps. The
neighbor also provided help to advance the walker across the gravel driveway as the patient
walked.
Coding: GG0170L, Walking 10 feet on uneven surfaces would be coded 03,
Partial/moderate assistance.
Rationale: Per patient report, Mrs. N requires help provide some weight-bearing
support, and assist in advancing the walker as she walked 10 feet on uneven surfaces. The
helper does less than half the effort for walking 10 feet on uneven surfaces.
Coding Tips and Examples GG0170M, 1 Step (curb)
•

The activity includes the patient going up and down a curb and/or one step.

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Use of assistive device(s) and adaptive equipment (for instance a railing or cane)
required to complete the activity should not affect coding of the activity.

12. GG0170M, 1 Step (curb)
Mrs. Z had a stroke and needs to learn how to step up and down one step to enter and exit her
home. At SOC, the physical therapist provides needed verbal cueing as Mrs. Z uses her quad
cane to aid her balance in stepping up and back down one step. The therapist does not provide
any physical assistance.
Coding: GG0170M, 1 step would be coded 04, Supervision or touching assistance.
Rationale: The patient needs only verbal cueing to complete the activity of stepping up
and down one step.
Coding Tips and Examples GG0170N, 4 Steps
•
•
•

The activity includes the patient going up and down four steps with or without a rail.
Use of assistive device(s) and adaptive equipment (for instance a railing or cane)
required to complete the activity should not affect coding of the activity.
If at the time of the assessment the patient is unable to complete the activity due to a
physician prescribed restriction (for instance, no stair climbing for 2 weeks), but
could perform this activity prior to the current illness, exacerbation or injury, code 88,
Not attempted due to medical condition or safety concern.

13. GG0170N, 4 Steps
At SOC, Mr. J has lower body weakness and the physical therapist provides light touching
assistance when he ascends 4 steps. While descending 4 steps, the physical therapist faces the
patient and descends the stairs providing minimal trunk support, with one hand on the patient’s
hip and the other holding the gait belt, as Mr. J holds the stair railing.
Coding: GG0170N, 4 steps would be coded 03, Partial/moderate assistance.
Rationale: The therapist provides touching assistance as Mr. J ascends 4 steps. The
therapist provides minimal trunk support when he descends the 4 steps, providing less
than half the effort to complete the activity. The patient requires partial/moderate
assistance to up and down 4 steps.
Coding Tips and Examples GG0170O, 12 Steps
•
•
•

The activity includes the patient going up and down 12 steps with or without a rail.
Use of assistive device(s) and adaptive equipment (for instance a railing or cane)
required to complete the activity should not affect coding of the activity.
If at the time of the assessment the patient is unable to complete the activity due to a
physician prescribed restriction (for instance, no stair climbing for 2 weeks), but
could perform this activity prior to the current illness, exacerbation or injury, code 88,
Not attempted due to medical condition or safety concern.

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14. GG0170O, 12 Steps
At SOC, Ms. Y is recovering from a stroke and has 12 stairs with a railing and she needs to use
these stairs to enter and exit her home. The physical therapist uses a gait belt around her trunk
and at times is required to support much of the patient’s weight as Ms. Y ascends and then
descends 12 stairs.
Coding: GG0170O, 12 steps would be coded 02, Substantial/maximal assistance.
Rationale: The therapist provides more than half the effort in providing the necessary
support for Ms. Y as she ascends and descends 12 stairs by intermittently supporting
much of her weight using a gait belt.
Mrs. D is returning home after a hip replacement. She is restricted from stair climbing until she
is seen for her follow-up MD appointment. Just prior to her surgery, she was able to climb her
flight of 12 stairs with stand-by assist of her niece.
Coding: GG0170O, 12 steps would be coded 88 – Not attempted due to medical
condition or safety concerns.
Rationale: At the SOC, the patient is unable to complete the activity of going up and
down 12 steps due to a temporary physician-ordered activity restriction. Prior to the
recent surgery, Mrs. D was able to complete that activity with assistance so code 88 is
appropriate.
Coding Tips and Examples GG0170P, Picking up Object
•
•

•

The activity includes the patient bending/stooping from a standing position to pick up
a small object, such a spoon, from the floor.
Use of assistive device(s) and adaptive equipment (for instance a cane to support
standing balance and a reacher to pick up the object) required to complete the activity
should not affect coding of the activity.
If at the time of the assessment the patient is unable to complete the activity (for
instance is unable to stand), and could not stand to perform this activity prior to the
current illness, exacerbation or injury, code 09, Not applicable.

15. GG0170P, Picking up Object
Mr. P has a neurologic condition that has resulted in coordination and balance problems. At
SOC, he reports he and his wife worked with the OT in the SNF on picking things off the floor.
He demonstrates how he stoops to pick up a pencil from the floor as his wife provides the right
amount of verbal cues for safety and stands by, ready to help in case he loses his balance.
Coding: GG0170P, Picking up object would be coded 04, Supervision or touching
assistance.
Rationale: A caregiver is needed to provide verbal cues and stand-by assistance when
Mr. P picks up an object due to his coordination issues.
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Ms. C has recently undergone a hip replacement. At SOC, she walks with a walker without
assistance. When she drops a hair brush from her walker basket, she asks her daughter to locate
her long-handled reacher and bring it to her. Using the reacher, Mrs. C is able to bend slightly,
and safely pick up the hair brush with the reacher, without need of additional assistance or verbal
cues.
Coding: GG0170P, Picking up object would be coded 05, Set-up or clean-up assistance.
Rationale: The daughter provides set-up assistance only by retrieving the reacher and
then the patient is able use the device to pick up the hairbrush safely.
Coding Tips and Examples GG0170Q, Does the Patient Use a
Wheelchair/Scooter?
•

•
•

The intent of the wheelchair mobility item is to assess the ability of patients who are
learning how to self-mobilize using a wheelchair or patients who used a wheelchair
prior to admission.
Use clinical judgment to determine if the patient’s use of a wheelchair is for selfmobilization due to the patient’s medical condition or safety.
If the patient is ambulatory and is not learning how to mobilize in a wheelchair, and
only uses a wheelchair for transport within a larger living facility (assisted living
facility or apartment complex), or for community mobility outside the home (for
instance to a physician appointment or to dialysis), enter code 0 – No for GG0170Q
Does the patient use a wheelchair/scooter, and skip all remaining wheelchair
questions.

Coding Tips and Examples GG0170R, Wheel 50 Feet with Two Turns, and
GG0170RR, Indicate the Type of Wheelchair or Scooter Used
•
•
•

•

Once seated in the wheelchair or scooter, the activity includes wheeling at least
50 feet and making two turns.
Indicate whether the wheelchair or scooter used is manual or motorized.
The turns are 90 degree turns and may be in the same direction (two 90 degree turns
to the right or two 90 degree turns to the left) or may be in different directions (one
90 degree turn to the right and one 90 degree turn to the left).
The 90 degree turns should occur at the patient’s ability level (i.e., not jeopardizing
patient safety).

16. GG0170R, Wheel 50 Feet with Two Turns, and GG0170RR, Indicate the Type of
Wheelchair or Scooter Used
At SOC, Mrs. M is unable to bear any weight on her right leg due to a recent fracture. The nurse
observes as the certified nursing assistant in the assisted living facility provides steadying
assistance when transferring Mrs. M from the bed into her manual wheelchair. Once in her
wheelchair, Mrs. M propels herself safely about 60 feet down the hall using her left leg and
safely makes two turns without any necessary physical assistance or supervision.
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Coding: GG0170R, Wheel 50 feet with two turns would be coded 06, Independent.
Rationale: Mrs. M wheels herself more than 50 feet safely without need for supervision
or physical assistance. Assistance provided with the transfer is not considered when
scoring Wheel 50 feet with two turns. Score assistance with bed to chair transfer in
GG0170E.
Indicate the type of wheelchair/scooter used: In the above example Mrs. M used a manual
wheelchair.
Coding: GG0170RR, Indicate the type of wheelchair/scooter used would be coded 1,
Manual.
Rationale: Mrs. M uses a manual wheelchair to self-mobilize.
Once seated in the manual wheelchair, Ms. R wheels about 10 feet, including around one corner
to the hallway. Due to shoulder pain, she asks her son to push the wheelchair the additional
40 feet around another corner and into her bathroom.
Coding: GG0170R, Wheel 50 feet with two turns would be coded 02,
Substantial/maximal assistance.
Rationale: The helper provides more than half the effort to assist the patient to complete
the activity.
Indicate the type of wheelchair/scooter used: In the above example Ms. R used a manual
wheelchair.
Coding: GG0170RR, Indicate the type of wheelchair/scooter used would be coded 1,
Manual.
Rationale: Ms. R used a manual wheelchair.
Coding Tips and Examples GG0170S, Wheel 150 Feet and GG0170SS,
Indicate the Type of Wheelchair/Scooter Used
•
•
•

Once seated in the wheelchair or scooter, the activity includes wheeling at least
150 feet in a corridor or similar space.
Indicate whether the wheelchair or scooter used is manual or motorized.
If the patient’s environment does not accommodate wheelchair/scooter use of
150 feet without turns, but the patient demonstrates the ability to mobilize the
wheelchair/scooter with or without assistance 150 feet with turns without
jeopardizing the patient’s safety, code using the 6-point scale.

17. GG0170S, Wheel 150 Feet and GG0170SS, Indicate the Type of
Wheelchair/Scooter Used
Mr. N uses a below-the-knee prosthetic limb. Mr. N has peripheral neuropathy and limited vision
due to complications of diabetes. Via observation and patient report, the assessing clinician
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determines that Mr. N’s usual performance is that a helper is needed to provide verbal cues for
safety due to vision deficits, and the patient mobilizes his manual wheelchair a distance of
150 within his home.
Coding: GG0170S, Wheel 150 feet would be coded 04, Supervision or touching
assistance.
Rationale: Mr. N requires the helper to provide verbal cues for his safety when using a
wheelchair for 150 feet.
Indicate the type of wheelchair/scooter used: In the above example Mr. N used a manual
wheelchair.
Coding: GG0170SS, Indicate the type of wheelchair/scooter used would be coded 1,
Manual.
Rationale: Mr. N used a manual wheelchair.

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SECTION J: HEALTH CONDITIONS
J1800: Any Falls Since SOC/ROC, whichever is more recent
J1800.

Any Falls Since SOC/ROC, whichever is more recent

Enter Code

Has the patient had any falls since SOC/ROC, whichever is more recent?
0. No → Skip J1900
1. Yes → Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent

Item Intent
This item identifies if the patient had any witnessed
or unwitnessed falls since the most recent
SOC/ROC.

Time Points Item(s) Completed
Transfer to an inpatient facility
Death at home
Discharge from agency – not to an inpatient facility

Response-Specific Instructions
Review home health clinical record, incident
reports and any other relevant clinical
documentation (for example, fall logs)
Interview patient and/or caregiver about occurrence
of falls
Coding Instructions
•

•
•

Code 0, No, if the patient has not had
any fall since the most recent
SOC/ROC.
Code 1, Yes, if the patient has fallen
since the most recent SOC/ROC.
A dash is a valid response for this
item. CMS expects dash use to be a rare
occurrence.

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DEFINITION
FALL
• Unintentional change in position
coming to rest on the ground,
floor, or onto the next lower
surface (such as a bed or chair).
The fall may be witnessed or
unwitnessed, reported by the
patient or an observer, or
identified when a patient is found
on the floor or ground. Falls are
not a result of an overwhelming
external force (such as, a person
pushes a patient).
• An intercepted fall occurs when
the patient would have fallen if
he or she had not caught
him/herself or had not been
intercepted by another person—
this is still considered a fall.
• CMS understands that
challenging a patient’s
balance and training him/her to
recover from a loss of balance is
an intentional therapeutic
intervention and does not
consider anticipated losses of
balance that occur during
supervised therapeutic
interventions as intercepted falls.

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Examples
1. Unwitnessed Fall
The discharging RN reviews the clinical record and interviews the patient and caregiver, Mrs. K
and her daughter Susan, determining that a single fall occurred since the most recent SOC/ROC.
The fall is documented on a clinical note from an RN home visit in which Susan reported her
mother slipped from her wheelchair to the floor the previous day.
Coding: J1800, Any Falls since SOC/ROC, would be coded 1, Yes.
Rationale: This item addresses unwitnessed as well as witnessed falls.
2. Intercepted Fall
An incident report describes an event in which Mr. S appeared to slip on a wet spot on the floor
during a home health aide bath visit. He lost his balance and bumped into the wall, but was able
to steady himself and remain standing.
Coding: J1800, Any Falls since SOC/ROC, would be coded 1, Yes.
Rationale: An intercepted fall is considered a fall.
3. Balance Training – Challenge Balance
A patient is participating in balance retraining activities during a therapy visit. The therapist is
intentionally challenging patient’s balance, anticipating a loss of balance. The patient has a loss
of balance to the left due to hemiplegia and the physical therapist provides minimal assistance to
allow the patient to maintain standing.
Coding: J1800, Any Falls since SOC/ROC, would be coded 0, No.
Rationale: The patient’s balance was intentionally being challenged by the physical
therapist, so a loss of balance is anticipated. When assistance is provided to a patient to
allow him/her to maintain standing during an anticipated loss of balance during a
supervised therapeutic intervention, this is not considered a fall or intercepted fall.
4. Unanticipated Fall During Therapy
A patient is ambulating with a walker with the help of the physical therapist. The patient
stumbles and the therapist has to bear some of the patient’s weight in order to prevent a fall.
Coding: J1800, Any Falls since SOC/ROC would be coded 1, Yes.
Rationale: The patient’s stumble was not anticipated by the therapist. The therapist
intervened to prevent a fall. An intercepted fall is considered a fall.

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Data Sources/Resources
Patient report
Caregiver report
Patient record
Incident reports
Relevant clinical documentation, such as fall logs

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J1900: Number of Falls Since SOC/ROC, whichever is more
recent
J1900.

Number of Falls Since SOC/ROC, whichever is more recent

CODING:
0. None
1. One
2. Two or
more

↓ Enter Codes in Boxes.
A.

No injury: No evidence of any injury is noted on physical assessment by the nurse or
primary care clinician; no complaints of pain or injury by the patient; no change in the
patient's behavior is noted after the fall

B.

Injury (except major): Skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains; or any fall-related injury that causes the patient to complain
of pain

C.

Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma

Item Intent
This item identifies the number of falls a patient
had since the most recent SOC/ROC, and fallrelated injury.

Time Points Item(s) Completed
Transfer to an inpatient facility
Death at home
Discharge from agency – not to an inpatient facility

Response-Specific Instructions
Review the home health clinical record, incident
reports and any other relevant clinical
documentation, such as fall logs.
Interview the patient and/or caregiver about
occurrence of falls.
Determine the number of falls that occurred since
the most recent SOC/ROC, and, code the level of
fall-related injury for each.
Code falls no matter where the fall occurred.
Code each fall only once.
If the patient has multiple injuries in a single fall,
code the fall for the highest level of injury.

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DEFINITIONS
INJURY RELATED TO A FALL
Any documented or reported injury
that occurred as a result of, or was
recognized within a short period of
time (e.g., hours to a few days) after
the fall and attributed to the fall.
NO INJURY
No evidence of any injury noted on
assessment; no complaints of pain
or injury by the patient; no change in
the patient's behavior is noted after
the fall.
INJURY (EXCEPT MAJOR)
Includes skin tears, abrasions,
lacerations, superficial bruises,
hematomas, and sprains; or any fallrelated injury that causes the patient
to complain of pain.
MAJOR INJURY
Includes bone fractures, joint
dislocations, closed head injuries
with altered consciousness,
subdural hematoma.

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Coding Instructions for J1900A, No Injury
•
•
•
•

Code 0, None, if the patient had no injurious falls since the most recent SOC/ROC.
Code 1, One, if the patient had one non-injurious fall since the most recent
SOC/ROC.
Code 2, Two or more, if the patient had two or more non-injurious falls since the
most recent SOC/ROC.
A dash is a valid response for this item. CMS expects dash use to be a rare
occurrence.

Coding Instructions for J1900B, Injury, Except Major
•
•
•
•

Code 0, None, if the patient had no falls with injury, except major, since the most
recent SOC/ROC.
Code 1, One, if the patient had one fall with injury, except major, since the most
recent SOC/ROC.
Code 2, Two or more, if the patient had two or more falls with injury, except
major, since the most recent SOC/ROC.
A dash is a valid response for this item. CMS expects dash use to be a rare
occurrence.

Coding Instructions for J1900C, Major Injury
•
•
•
•

Code 0, None, if the patient had no falls with major injury since the most recent
SOC/ROC.
Code 1, One, if the patient had one fall with major injury since the most recent
SOC/ROC.
Code 2, Two or more, if the patient had two or more falls with major injury since
the most recent SOC/ROC.
A dash is a valid response for this item. CMS expects dash use to be a rare
occurrence.

Examples
1. One Fall Since Most Recent SOC/ROC, with No Injury
The discharging RN reviews the clinical record and interviews Mrs. K and her daughter Susan,
the patient and caregiver, determining that a single fall occurred since the most recent
SOC/ROC. The fall is documented on a clinical note from an RN home visit in which Susan
reported that her mother slipped from her wheelchair to the floor the previous day. Susan
contacted the EMTs for help returning Mrs. K to her wheelchair; the EMT assessment at that
time identified no injury. Documentation of the RN assessment during the home visit details no
injury identified related to the fall.

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Coding:
J1900A, No injury would be coded 1, one non-injurious fall since the most recent
SOC/ROC.
J1900B, Injury (except major), would be coded 0, no falls with injury, except major,
since the most recent SOC/ROC.
J1900C, Major injury would be coded 0, no falls with major injury since the most recent
SOC/ROC.
Rationale: Only one fall is identified since the most recent SOC/ROC, and the patient
sustained no injury in the fall.
2. One Fall Since Most Recent SOC/ROC with Injury (not major)
Review of the clinical record and incident reports, and, patient and caregiver report, identify that
a single fall occurred since the most recent SOC/ROC. The fall is documented on a clinical note
from an RN home visit that describes the patient Mr. R’s report of a fall that occurred between
visits, in which he tripped on the dog, fell against the wall and banged his elbow, sustaining a
skin tear that he treated himself. Documentation of the RN assessment during the home visit
details the healing skin tear, and no other injury or symptom identified related to the fall.
Coding:
J1900A. No injury, would be coded 0, no non-injurious falls since the most recent
SOC/ROC.
J1900B. Injury (except major), would be coded 1, one injurious (except major) fall since
the most recent SOC/ROC.
J1900C. Major injury, would be coded 0, no falls with major injury since the most recent
SOC/ROC.
Rationale: Documentation of only one fall since the most recent SOC/ROC is
identified. A laceration is considered an injury (except major).
3. One Fall Since the Most Recent SOC/ROC, with Major Injury
Review of the patient record and incident reports, and, patient and caregiver report identify that a
single fall occurred since the most recent SOC/ROC. The fall is documented on an incident
report that describes a telephone call received from the patient, Mrs. B’s, daughter Mary, in
which Mary reported Mrs. B fell at home and hit her head, and was transported via ambulance to
the emergency room. Examination and testing revealed a subdural hematoma. Mrs. B was held in
observation stay and received treatment, returning home in stable condition after 48 hours.
Coding:
J1900A, No injury, would be coded 0, no non-injurious falls since the most recent
SOC/ROC.
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J1900B, Injury (except major), would be coded 0, no falls with injury (except major)
since the most recent SOC/ROC.
J1900C, Major injury, would be coded 1, one fall with major injury since the most recent
SOC/ROC.
Rationale: Documentation of only one fall since the most recent SOC/ROC is
identified. Subdural hematoma is considered a major injury.
4. Two Falls Since the Most Recent SOC/ROC, One with Injury (except major),
One with No Injury
Review of the patient record, incident reports and patient and caregiver report identify that two
falls occurred since the most recent SOC/ROC. The falls are documented on clinical notes. The
first describes an event during which Mr. G tripped on the bathroom rug and almost fell, but
caught himself against the sink. The RN assessment identified no injury. The second describes an
event during which Mr. G, while coming up the basement stairs with the laundry, fell against the
stair and sustained a bruise and laceration on his left knee.
Coding:
J1900A, No injury, would be coded 1, one non-injurious fall since the most recent
SOC/ROC.
J1900B, Injury (except major), would be coded 1, one injurious (except major) fall since
the most recent SOC/ROC.
J1900C, Major injury, would be coded 0, no falls with major injury since the most recent
SOC/ROC.
Rationale: The first fall is an intercepted fall, which is considered a fall. The patient
sustained no injury as a result of this fall. The second fall resulted in a laceration and
bruising, considered injury, but not major injury.
5. One Fall Since the Most Recent SOC/ROC, with Multiple Injuries
Review of the patient record, incident reports and patient and caregiver report identify that a
single fall occurred since the most recent SOC/ROC. The fall is documented on an incident
report, which describes an event during which Mrs. J fell while walking from her bedroom to the
bathroom and was transported to the emergency room via ambulance. Examination and testing
revealed a skin tear on Mrs. J’s left hand, bruising on both knees, and a fractured left hip.
Coding:
J1900A, No injury, would be coded 0, no non-injurious falls since the most recent
SOC/ROC.
J1900B, Injury (except major), would be coded 0, no injurious (except major) falls since
the most recent SOC/ROC.
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J1900C, Major injury, would be coded 1, one fall with major injury since the most recent
SOC/ROC.
Rationale: Documentation of only one fall since the most recent SOC/ROC was
identified. The patient sustained multiple injuries in the fall. When multiple injuries are
sustained in a single fall, code the injury of highest severity.

Data Sources/Resources
Patient report
Caregiver report
Patient record
Incident reports
Relevant clinical documentation, such as fall logs

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Chapter 4

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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 practices.

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.

Home Health Quality Help Desk
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
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

Home Health Agency (HHA Center)
https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html
Enrollment, Participation & Certification
Policies/Regulations
Billing/Payment
Educational Resources
CMS Manuals & Transmittals
Demonstrations
Initiatives (Quality Initiative, Home Health
Research & Analysis
Compare, etc.)
The Medicare Learning Network®
http://www.cms.hhs.gov/MLNGenInfo/
National Provider Identifier (NPI) Registry
https://npiregistry.cms.hhs.gov/
Outcome and Assessment Information Set (OASIS)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/OASIS/index.html
Background & Regulations
Automation Coordinators
iHAVEN
OASIS PPS
Data Set
Home Health Agency Q&A
Data Specifications
Reports
User Manual
Training
Education Coordinators
Archives

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Measures Management System (MMS)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/index.html

Guidelines and Best Practices
Home Health Best Practice Intervention Packages (BPIPs), 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
National Guideline Clearinghouse (NGC)
http://www.guideline.gov
Vaccination Guidelines
Influenza Vaccine Guidelines
https://www.cdc.gov/flu/professionals/vaccination/vaccine_safety.htm
Pneumococcal vaccine recommendations
https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html
Wound Care
The National Pressure Ulcer Advisory Panel – NPUAP: Educational and Clinical Resources
http://www.npuap.org/resources/educational-and-clinical-resources/
International Skin Tear Advisory Panel (ISTAP)
http://www.skintears.org/education/tools/
Wound, Ostomy and Continence Nurses Society’s Guidance on OASIS-C2 Integumentary Items: Best
Practice for Clinicians
http://c.ymcdn.com/sites/www.wocn.org/resource/resmgr/publications/WOCN_Guidance_on_OASIS-C2_In.pdf

Healthcare Technology
National Quality Forum and Health Information Technology
http://www.qualityforum.org/HealthIT/
Office of the National Coordinator for Health Information Technology (ONC)
http://www.healthit.gov
Home Page
About ONC
https://www.healthit.gov/topic/about-onc
Healthcare Information and Management Systems Society (HIMSS)
http://www.himss.org/
Healthcare Information Technology Standards Panel
http://www.hitsp.org/news.aspx

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ICD-10-CM Official Guidelines for Coding and Reporting
ICD-10-CM Release
https://www.cdc.gov/nchs/icd/icd10cm.htm#icd
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2018-ICD-10-CM-Coding-Guidelines.pdf

Clinical Resources
Medications
Institute of Safe Medication Practices (ISMP) List of High-Alert Medications in Community/Ambulatory
Healthcare
https://www.ismp.org/recommendations/high-alert-medications-community-ambulatory-list
MEDLINE
http://www.nlm.nih.gov/medlineplus/druginformation.html
Activities of Daily Living: Definition and History
http://aspe.hhs.gov/daltcp/reports/guide.htm
Diabetes
http://www.diabetes.org
https://www.niddk.nih.gov/health-information/diabetes
Diabetic Foot Care
http://www.niddk.nih.gov/health-information/health-topics/Diabetes/prevent-diabetes-problems/Pages/index.aspx
Caregivers
https://www.aarp.org/home-family/caregiving/caregiving-tools/
http://www.nextstepincare.org/

Mental Health Resources
Alzheimer’s
http://www.alz.org
National Alzheimer’s and Dementia Resource Center (NADRC)
https://nadrc.acl.gov/
Brief Interview for Mental Status (BIMS) – Assessment Tool
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentMDS 3.0 Report
Instruments/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
CAM Assessment
https://www.hospitalelderlifeprogram.org/delirium-instruments/
Depression Recognition & Assessment in Older Home Care Patients
http://www.geriu.org/uploads/applications/DepressionInHomecare/DinHomecare.html
Online Training
Journal Article
Training Nursing Staff to Recognize Depression in Home Healthcare. Full text link:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684961/

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Cognitive Assessment
Clock Drawing Test http://alzheimers.about.com/od/testsandprocedures/a/The-Clock-Drawing-Test.htm
MMSE
https://www.mountsinai.on.ca/care/psych/on-call-resources/on-call-resources/mmse.pdf

Risk Assessment Tools
Depression: Patient Health Questionnaire Resources
Agency for Healthcare Research & Quality (AHRQ) PHQ2
https://innovations.ahrq.gov/qualitytools/patient-health-questionnaire-phq-2
Screen for Obesity – BMI
National Heart, Lung, and Blood Institute
https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Anxiety
SAMHSA-HRSA Center for Integrated Health Solutions link
https://www.integration.samhsa.gov/clinical-practice/screening-tools#anxiety
Pain
Wong-Baker FACES®
http://wongbakerfaces.org
Brief Pain Inventory
https://www.mdanderson.org/research/departments-labs-institutes/departments-divisions/symptomresearch/symptom-assessment-tools/brief-pain-inventory.html
Fall Risk
MAHC 10 – Fall Risk Assessment Tool
https://www.homecaremissouri.org/projects/falls/documents/Oct2012FINALValidatedFallriskassessmenttool.pdf

Professional Organizations
American Nurses Association (ANA)
American Occupational Therapy Association (AOTA)
American Physical Therapy Association (APTA)
American Speech-Language-Hearing Association (ASHA)

http://www.nursingworld.org/
http://www.aota.org/
http://www.apta.org/
https://www.asha.org/

Quality Resources
Agency for Healthcare Research and Quality (AHRQ)
https://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/

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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/find_guidelines/
Institute for Healthcare Improvement
http://www.ihi.org/Pages/default.aspx
Institute of Medicine
http://www.nationalacademies.org/hmd/
Crossing the Quality Chasm
https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Chapter 13 Patient Safety and Quality in Home Health Care:
https://www.ncbi.nlm.nih.gov/books/NBK2631/
Care Transitions
Transitional Care Model
https://www.nursing.upenn.edu/ncth/transitional-care-model/
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
National Transitions of Care Coalition (NTOCC)
http://www.ntocc.org/
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
http://www.patientsafety.va.gov/
The Joint Commission
http://www.jointcommission.org/accreditation/home_care_accreditation_requirements.aspx

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Appendix A

APPENDIX A: OASIS AND THE COMPREHENSIVE ASSESSMENT
OASIS Elements Incorporated into the Comprehensive Assessment. What is the
association between the Comprehensive Assessment and the OASIS data sets?
Since 1999, the Home Health Agency (HHA) Conditions of Participation (CoPs) have required that each patient receive
a patient-specific comprehensive assessment. A revised CoP for comprehensive assessment went into effect
January 13, 2018. The majority of requirements were retained. A new standard “Content of the comprehensive
assessment” was established, incorporating much of the previous standard and adding new requirements.
Users are encouraged to refer directly to the HHA CoPs for complete, current information:
•

The Medicare & Medicaid Program Conditions of Participation for Home Health Agencies Rule published by
the Centers for Medicare & Medicaid Services in the Federal Register on 1/13/17.
https://www.federalregister.gov/documents/2017/01/13/2017-00283/medicare-and-medicaid-programconditions-of-participation-for-home-health-agencies.

•

HHAs must incorporate the current version of the OASIS items into the comprehensive assessment for adult,
non-maternity patients. The HHAs 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.

•

OASIS data elements form a substantial portion of the comprehensive assessment. However, the data items
in OASIS alone do not constitute a thorough comprehensive 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 patient assessment.

•

OASIS data collection and reporting is not required for non-Medicare or Medicaid payers, however, all home
health patients who receive skilled care are required to have a comprehensive assessment regardless of
payer source per the requirements. Patients who receive non-skilled home health services such as
homemaker, chore, or companion services are not required by the CoPs to have a comprehensive
assessment.

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Appendix A-1

OASIS Guidance Manual

Appendix B

APPENDIX B: OASIS DATA ACCURACY
1.

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.

2.

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.
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:
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.

QI
coordinator,
IS/IT
coordinator,
or data entry
staff

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

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Appendix B-1

OASIS Guidance Manual

a.

Appendix B

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.

2.

3.
4.

5.

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
number, n, will be used to select records. Divide this number by 2 to obtain the starting point, m, for selecting
records.
th
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-10-CM 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

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Appendix B-2

OASIS Guidance Manual

Appendix B

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
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
(ASAP) and OASIS Correction policy. A copy of this memo is located on CMS.gov under Provider Enrollment and
Certification/Quality Safety & Oversight – General Information/Policy & Memos to States and Regions. For additional
details, please reference the OASIS Submission User’s Guide and Training site (QTSO site).

1

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.

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Appendix B-3

OASIS Guidance Manual

Appendix C

APPENDIX C: OASIS-D ITEMS, TIME POINTS, AND USES
This table can be used in identifying the time points and potential uses for each OASIS-D data item.
The following key should be used for the Item Uses column:
A
Q
PRA
$

=
=
=
=

Administrative
Quality Measure
Potential Quality Measure Risk Adjustment
Payment

The following key should be used for the Time Points columns:
S
R
F
T
D
H

=
=
=
=
=
=

Start of Care (SOC)
Resumption of Care (ROC)
Follow-Up (FU)
Transfer (TRF)
Discharge (DC)
Death at Home (DAH)
Items

Item #

Item Description

Item
Uses

Time Points
SOC

ROC

FU

TRF

DC

DAH

-

-

-

M0010

CMS Certification Number

S

M0014

Branch State

S

M0016

Branch ID Number

S

M0018

National Provider Identifier (NPI)

S

M0020

Patient ID Number

S

M0030

Start of Care Date

S

-

M0032

Resumption of Care Date

-

R

M0040

Patient Name

S

M0050

Patient State of Residence

S

M0060

Patient ZIP Code

S

M0063

Medicare Number

S

M0064

Social Security Number

S

M0065

Medicaid Number

S

M0066

Birth Date

S

M0069

Gender

S

-

-

S

R

F

T

D

H

A

S

R

F

T

D

H

A, Q

S

R

F

T

D

H

Q, PRA

S

R

-

-

-

-

Q

-

-

-

Q

M0080
M0090
M0100
M0102

Discipline of Person Completing
Assessment
Date Assessment Completed
This Assessment is Currently Being
Completed for the Following Reason
Date of Physician-ordered Start of Care
(Resumption of Care)

M0104

Date of Referral

S

R

-

M0110

Episode Timing

S

R

F

OASIS-D Guidance Manual
Effective 1/1/2019
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A
A
A
A
A
$, Q
Q
A
A
A
A
A
A
PRA
PRA

$, PRA

Appendix C-1

OASIS Guidance Manual

Appendix C

Items
Item #

Item Description

Item
Uses

Time Points
SOC

ROC

FU

TRF

DC

DAH

-

-

-

-

A, PRA

T

D

H

Q

-

-

-

M0140

Race/Ethnicity

S

M0150

Current Payment Sources for Home Care

S

M0906

Discharge/Transfer/ Death Date

-

-

M1000

From which of the following Inpatient
Facilities was the patient discharged within the
past 14 days?

S

R

M1005

Inpatient Discharge Date

S

R

-

-

-

-

A, Q

S

R

F

-

-

-

$, PRA

S

R

F

-

-

-

$, PRA

S

R

-

-

-

-

PRA

-

-

$, PRA

T

D

T

D

T

D

-

M1021
M1023
M1028

Primary Diagnosis, ICD-10-CM and Symptom
Control Rating
Other Diagnoses, ICD-10-CM and Symptom
Control Rating
Active Diagnoses – Comorbidities and Coexisting Conditions

A

Q, PRA

M1030

Therapies the patient receives at home

S

R

F

M1033

Risk for Hospitalization

S

R

M1041

Influenza Vaccine Data Collection Period

M1046

Influenza Vaccine Received

M1051

Pneumococcal Vaccine

-

-

-

M1056

Reason Pneumococcal Vaccine not
received

-

-

-

T

D

-

Q

M1060

Height and Weight

S

R

Patient Living Situation

S

R

M1200

Vision

S

R

F

-

-

-

PRA

M1100

-

$, PRA

S

R

F

-

D

-

$, Q, PRA

S

R

F

-

D

-

Q, PRA

-

-

-

-

D

-

Q

S

R

F

-

D

-

$, Q, PRA

S

R

F

-

-

-

$, PRA

S

R

F

-

D

-

$, Q

S

R

F

-

D

-

$, PRA

S

R

F

-

-

-

$, PRA

S

R

F

-

D

-

$, Q, PRA

S

R

F

-

D

-

Q, PRA

S

R

F

-

D

-

$, Q, PRA

S

R

F

-

D

-

$, Q, PRA

M1242
M1306
M1307
M1311
M1322
M1324
M1330
M1332
M1334
M1340
M1342
M1400

Frequency of Pain Interfering with patient's
activity or movement
Does this patient have at least one Unhealed
Pressure Ulcer/Injury at Stage 2 or Higher or
designated as Unstageable?
The Oldest Stage 2 Pressure Ulcer that is
present at discharge
Current Number of Unhealed Pressure
Ulcers/Injuries at Each Stage
Current Number of Stage 1 Pressure
Injuries
Stage of Most Problematic Unhealed
Pressure Ulcer/Injury that is Stageable
Does this patient have a Stasis Ulcer?
Current Number of Stasis Ulcer(s) that are
Observable
Status of Most Problematic Stasis Ulcer
that is Observable
Does this patient have a Surgical Wound?
Status of Most Problematic Surgical Wound
that is Observable
When is the patient dyspneic or noticeably
Short of Breath?

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Effective 1/1/2019
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PRA
Q
Q
Q

PRA

Appendix C-2

OASIS Guidance Manual

Appendix C

Items
Item #
M1600
M1610

Item Description
Has this patient been treated for a Urinary
Tract Infection in the past 14 days?
Urinary Incontinence or Urinary Catheter
Presence

Item
Uses

Time Points
SOC

ROC

FU

TRF

DC

DAH

S

R

-

-

D

-

Q

S

R

F

-

-

-

$, PRA

D

$, Q, PRA

D

-

M1620

Bowel Incontinence Frequency

S

R

F

M1630

Ostomy for Bowel Elimination

S

R

F

M1700

Cognitive Functioning

S

R

-

-

S

R

-

-

D

-

Q, PRA

S

R

-

-

D

-

Q, PRA

S

R

-

-

-

-

Q, PRA

S

R

-

-

D

-

Q, PRA

S

R

-

-

D

-

PRA

D

Q, PRA
$, Q, PRA

D

-

M1710
M1720
M1730
M1740
M1745

When Confused (Reported or Observed
Within the Last 14 Days)
When Anxious (Reported or Observed
Within the Last 14 Days)
Depression Screening
Cognitive, behavioral, and psychiatric
symptoms that are demonstrated at least
once a week (Reported or Observed)
Frequency of Disruptive Behavior
Symptoms (Reported or Observed)

-

$
Q, PRA

M1800

Grooming

S

R

-

M1810

Ability to Dress Upper Body

S

R

F

M1820

Ability to Dress Lower Body

S

R

F

-

M1830

Bathing: Excludes grooming (washing face,
washing hands, and shampooing hair).

S

R

F

-

D

-

$, Q, PRA

M1840

Toilet Transferring

S

R

F

D

Toileting Hygiene

S

R

-

M1850

Transferring

S

R

F

M1860

Ambulation/Locomotion

S

R

F

M1870

Feeding or Eating

S

R

M1910

Falls Risk Assessment

S

R

M2001

Drug Regimen Review

S

R

M2003

Medication Follow-up

S

R

-

M2005

Medication Intervention

-

-

T

D

H

Q

M2010

Patient/Caregiver High-Risk Drug Education

S

R

-

-

$, Q, PRA

M1845

-

-

-

-

Patient/Caregiver Drug Education
Intervention
Management of Oral Medications: Excludes
injectable and IV medications
Management of Injectable Medications:
Excludes IV medications

-

-

-

T

D

-

Q

S

R

-

-

D

-

Q, PRA

S

R

F

-

-

-

$, PRA

M2102

Types and Sources of Assistance

S

R

-

D

Therapy Need

S

R

F

M2301

Emergent Care

T

D

M2401

Intervention Synopsis

-

D

Reason for Emergent Care

-

T

M2310

-

T

D

-

Q, PRA

M2200

-

M2016
M2020
M2030

OASIS-D Guidance Manual
Effective 1/1/2019
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D

D
D
D
D

-

$, Q, PRA

Q, PRA
$, Q, PRA
$, Q, PRA
Q, PRA
Q, PRA
Q, PRA
Q

$, PRA
Q
Q
Q

Appendix C-3

OASIS Guidance Manual

Appendix C

Items
Item #

SOC

ROC

FU

TRF

DC

DAH

M2410

To which Inpatient Facility has the patient
been admitted?

-

-

-

T

D

-

Q

M2420

Discharge Disposition

-

-

S

R

GG0110

Prior Device Use

S

R

GG0130

GG0130A. Eating

S

R

F

GG0130B. Oral Hygiene

S

R

F

GG0130C. Toileting Hygiene

S

R

F

GG0130E. Shower/bathe self

S

R

GG0130F. Upper body dressing

S

R

GG0130G. Lower body dressing

S

R

GG0130H. Putting on/taking off footwear

S

R

-

GG0170A. Roll left and right

S

R

F

GG0170B. Sit to lying

S

R

F

GG0170C. Lying to sitting

S

R

F

GG0170D. Sit to stand

S

R

F

GG0170E. Chair/bed-to-chair transfer

S

R

F

GG0170F. Toilet transfer

S

R

F

GG0170G. Car transfer

S

R

-

GG0170I. Walk 10 feet

S

R

F

GG0170J. Walk 50 feet with two turns

S

R

F

GG0170K. Walk 150 feet

S

R

-

D

-

Q

Prior Functioning: Everyday Activities

-

D

GG0100

-

GG0170L. Walking 10 feet on uneven
surfaces

S

R

F

-

D

-

PRA

GG0170M. 1 step (curb)

S

R

F

D

S

R

F

GG0170O. 12 steps

S

R

GG0170P. Picking up object

S

R

-

D

-

PRA

GG0170N. 4 steps

-

GG0170Q. Does patient use wheelchair
and/or scooter?

S

R

F

-

D

-

Q, PRA

GG0170R. Wheel 50 feet with two turns

S

R

F

D

S

R

GG0170S. Wheel 150 feet

S

R

GG0170SS. Type of wheelchair or scooter

S

R

D

J1800

Any Falls Since SOC/ROC

D

H

Q, PRA

Number of Falls Since SOC/ROC

-

T

J1900

-

-

-

Q, PRA

GG0170RR: Type of wheelchair or scooter

T

D

H

Q, PRA

TOTAL

Total items per timepoint

99

84

46

16

72

7

GG0170

Item Description

Item
Uses

Time Points

OASIS-D Guidance Manual
Effective 1/1/2019
Centers for Medicare & Medicaid Services

D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D

D
D

D
D

PRA
PRA
Q, PRA
Q, PRA
Q, PRA
PRA
PRA
PRA
PRA
PRA
Q, PRA
Q, PRA
Q, PRA
Q, PRA
Q, PRA
PRA
PRA
Q, PRA
Q, PRA

PRA
PRA
PRA

Q, PRA
Q, PRA
Q, PRA

Appendix C-4

OASIS Guidance Manual

Appendix D

APPENDIX D: PAGE INTENTIONALLY LEFT BLANK

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Effective 1/1/2019
Centers for Medicare & Medicaid Services

Appendix D-1

OASIS Guidance Manual

Appendix E

APPENDIX E: DATA REPORTING REGULATIONS
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). If errors are identified or
suspected, staff entering data or preparing for submission may need to contact the qualified clinician who was
responsible for completing the comprehensive assessment document, allowing necessary corrections to be made per
agency policy. Delaying data entry or submission may impact the assessing clinician’s recall, and the resulting data
accuracy.
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 of assessment. 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. In addition, the State
survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted.
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.

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Final Validation Report
Once transmitted, the data submission is validated and feedback is provided to the HHA via the OASIS Final Validation
Report or OASIS Submitter Final Validation Report 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:

•
•
•
•

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 on-line 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. Additionally, CMS maintains a toll-free help line to support this software
product. For questions, please call the help desk at 800-339-9313 or you can email questions to “[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 set, 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 on the Home Health Quality Reporting
Requirements page, at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Requirements.html.
HHAs can download the required OASIS data set documents by clicking on “OASIS User Manuals,” and then go to
Downloads for the OASIS Guidance Manual. In Chapter 2 of the Guidance Manual, there is one document that

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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
Automation Coordinator, and a link to the QIES Technical Support Office (QTSO) for OASIS Questions and Answers
are located at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/OASIS/index.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.
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 https://www.cms.gov/Regulations-and-Guidance/AdministrativeSimplification/HIPAA-ACA/.)
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 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 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 of 1974, requires records described in the System of Records Notices (SORNs) to be published in the
1
Federal Register and posted to the internet. Each SORN describes legal authority for data collection and maintenance
2
and describes the types of information in the records. In the group of Centers for Medicare & Medicaid Services
(CMS) SORNs, there is a specific SORN for HHA OASIS. The OASIS data set is the assessment information collected

1

U. S. Department of Health and Human Services, Privacy Act. https://www.hhs.gov/foia/privacy/index.html

2

U. S. Department of Health and Human Services, HHS System of Records Notices(SORNs)
https://www.hhs.gov/foia/privacy/sorns/index.html

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in the SOR. For additional details on categories of individuals covered, categories of records captured in the system,
3
authority for maintenance of the system, and general purpose, please see the HHA OASIS SORN 09-79-9522.
Deficit Reduction Act of 2005 Requirement for Reporting Quality Data and Public Reporting for Quality
Measures
The requirements for reporting quality data and public reporting for quality measures are addressed in two rules:

•
•

4

In the Deficit Reduction Act (DRA) of 2005, Section 5201(c) (2) , the rule addresses adjustments,
submission of data and public availability of data.
In the Social Security Act, Prospective Payment for Home Health Services, Section 1895 1895(B)(3) (ii)
5
(V) specifies the manner in which CMS determines whether an HHA is in compliance.

HHAs are required to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare
Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements of section
1895(b)(3)(B)(v) of the Deficit Reduction Act. Additional information related to Home Health Quality Reporting is
available on the CMS Home Health Quality Initiatives website.

3

U. S. Department of Health and Human Services, SORN 09-70-0522: Home Health Agency (HHA) Outcome and Assessment
Information Set (OASIS). https://www.hhs.gov/foia/privacy/sorns/09700522/index.html

4

Deficit Reduction Act of 2005. https://www.gpo.gov/fdsys/pkg/PLAW-109publ171/pdf/PLAW-109publ171.pdf (pg. 46).

5

Social Security Act, Prospective Payment for Home Health Services. https://www.ssa.gov/OP_Home/ssact/title18/1895.htm

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Appendix F

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 Improving Medicare Post-Acute Care Transformation Act of
2014 (IMPACT Act).

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 (www.Medicare.gov). This initiative encouraged consumers to use
publicly available home health quality measures when selecting a home health agency. The launch of Home Health
Compare 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),
patient status, and home health agency care processes. These include the measures of “Improvement in AmbulationLocomotion” “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
“Drug Regimen Review Conducted with Follow-Up for Identified Issues.”
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 national reference rate. A subset of all quality measures is available to the public on
Home Health Compare.

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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 include quality measures that address
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. A
complete list of quality measures and measure descriptions are available on the CMS Home Health Quality Initiative
website.

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,
and therefore is excluded.

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EXAMPLES – OUTCOME MEASURES
Measure
Name

Consumer Language
(on Home Health
Compare)

Improvement
in AmbulationLocomotion

Stabilization in
Grooming

Measure
Description

Measure Focus
(Numerator)

OASIS Items Used in
Measure Calculation

How often patients got
better at walking or
moving around.

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

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

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/resumption of care and immunizations.
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 home health quality episodes during which
patients received the influenza immunization for the current flu season. 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 included
quality episodes. The process items in OASIS have been carefully developed to represent “evidence-based”
practice.

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. Quality episodes that are
excluded are not counted favorably or unfavorably toward the measure calculation.

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EXAMPLE – PROCESS MEASURES
Measure
Name
Influenza
Immunization
Received for
Current Flu
Season

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)

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

OASIS Items Used in
Measure Calculation
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
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.

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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 the OASIS-based measures, we use the OASIS items for this calculation.
To calculate quality measures, we also need to understand the measure definition. The measure tables include the
measure numerator, denominator, and measure exclusions.

EXAMPLE: IMPROVEMENT IN DYSPNEA
Measure Definition: 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.
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

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OASIS Guidance Manual

Appendix F

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

Discharge

0

0–4

Excluded

1

0

Improved

1

1–4

Did Not Improve

2

0–1

Improved

2

2–4

Did Not Improve

3

0–2

Improved

3

3–4

Did Not Improve

4

0–3

Improved

4

4

Calculation

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 (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/or “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

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Appendix F-6

OASIS Guidance Manual

Appendix F

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.

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 on CMS’s QIES Technical Support Office (QTSO) website
https://www.qtso.cms.gov/hhatrain.html.
Report Title

Report Description

Report Uses
Agencies can use this report as a
companion to their Outcome Report
and their Process Measures Report.

1.

Agency Patient-Related
Characteristics (Case Mix)
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 observed values for the
same period.

2.

Outcome Report

End Results Outcome measures,
Utilization Outcome measures, and
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);
OASIS-based 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;
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 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.

3.

Potentially Avoidable Event
Report

Lists each of the 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.

4.

Potentially Avoidable Event:
Patient Listing Report

Lists each of the 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.

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OASIS Guidance Manual

Appendix F

Report Title

Report Description

Report Uses

5.

Process Measures Report

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 observed values for
the same period:
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 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.

6.

Agency Patient-Related
Characteristics (Case Mix)
Tally Report

Details the patient-related characteristics
of each episode of care that ended
during a specified period for the agency.

Agencies can use this report to drilldown to the individual patient-level to
identify cases that triggered for each
of the indicators on the AgencyPatient -Related Characteristics
(Case Mix) Report.

7.

Outcome Tally Report

Details the episodes of care that ended
during a specified period for a select
agency and were used to calculate the
Outcome Reports.

Agencies can use this report to drilldown to the individual patient-level to
identify cases that triggered for each
of the measures on the Outcome
Report. Agencies may find this report
useful in investigating unfavorable
OASIS- based outcome measures.

8.

Process Tally 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.

Agencies can use this report to drilldown to the individual patient-level to
identify cases that triggered for each
of the measures on the Process
Measures Report.
Agencies may find this report useful
in investigating unfavorable OASISbased process measures.

9.

Home Health Compare
Provider Preview Report

This report is a preview of the agency’s
Home Health Compare data.

This report is placed in the agency’s
CASPER folders no less than 3
months prior to the Home Health
Compare update to allow the agency
to preview their Home Health
Compare data and contact CMS with
any potential data issues.

10. 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.

This report is placed in the agency’s
CASPER folders no less than 3
months prior to the Home Health
Compare update to allow the agency
to preview their date and contact
CMS with any potential data issues.

11. Quality Assessment Only
(QAO) Performance Reports

CMS provides both a quarterly, interim
Quality Assessments Only (QAO)
Performance Report as well as a yearend Historical Quality Assessments Only
(QAO) Performance Report. This QAO
Performance Report is based on OASIS
assessments submitted by an HHA
during the applicable reporting period as
it relates to compliance and Annual
Payment Update (APU).

Agencies can use these reports to
monitor their compliance with Home
Health pay-for-reporting
requirements.

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OASIS Guidance Manual

Appendix F

Report Title
12. Home Health Review and
Correct Reports

Report Description

Report Uses

These reports are available quarterly
and updated weekly to provide
confidential agency-level performance
for quarterly and cumulative
performance rates for the OASIS-based
publicly reported quality measures.

Agencies can use these reports in
conjunction with the other CASPER
quality measure reports to determine
if they have any data submission
errors that may affect agency-level
performance for one or more of the
quality measures.

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 items from the OASIS assessments from Medicare FFS,
Medicare Advantage, Medicaid and Medicaid Managed care. For a set of these quality measures a logistic regression
prediction model is created. Hundreds of risk factors are tested in development of the prediction models. Risk models
are measure specific. A rigorous, multi-step process is followed 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 probability of
obtaining a positive outcome (expected value) given the patient’s clinical and functional status at the start of care.
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 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 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 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 and other attributes. The method used to risk adjust home health agency
outcome measures is as follows:

•

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.

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OASIS Guidance Manual

Appendix F

•

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 for those OASIS-based outcome measures that are 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).
A subset of the OASIS-based outcome measures are risk adjusted. The OASIS-based process measures are not risk
adjusted.
Additional information on home health risk adjustment methodology is available on the CMS Home Health Quality
Initiative website and on the Home Health Compare website.

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OASIS Guidance Manual

Appendix G

APPENDIX G: DESCRIPTION OF CHANGES FROM OASIS-C2 TO OASIS-D
Table G.1 presents an overview of changes made to the OASIS items and Guidance Manual for the transition from OASIS-C2 to OASIS-D. The table columns and
headings are explained below.
1.

OASIS-C2 item number: Item number in the OASIS-C2. If an NA appears, this indicates a corresponding item did not exist in OASIS C2.

2.

OASIS-D item number: Item number in the OASIS-D. If the word “Removed” appears, this indicates the item was removed and not carried forward into
OASIS D.

3.

Item Description: A brief description of the item.

4.

Item Change: Provides an at a glance categorization of the changes in the categories explained below.

•
•
•
•
•
•

New Item – if a new item is added, “X” will appear in this column.
Time Point Versions – If the item has different time point versions an “X” will appear in this column.
Item Text – if the item text is changed, “X” will appear in this column.
Response Option(s) – if the response option(s) is changed, “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 Patterns - If the skip instructions (for example, [Go to M2401]) have changed, “X” will appear in this column.

5.

Change Description: This column contains a brief description of the changes that have been made to each item.

6.

Guidance Manual Change: provides an at a glance categorization of the changes in the Guidance Manual using the 5 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.
Examples - If new examples were added or examples were updated, an “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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Appendix G-1

OASIS Guidance Manual

Appendix G

Table G.1: Description of Changes from OASIS-C2 to OASIS-D
Item
Information

Item
Change

OASIS-C2 OASIS-D
New
Item Description
Item #
Item #
Item

M0080

M0080

M0090

M0090

M0102

M0102

M1000

M1000

M1011

Removed

M1017
M1018
M1021
M1023
M1025

Item Change
Description

Time
(-) Dash is
Item Response
Skip
Point
a Valid
Text Option(s)
Pattern
Versions
Response

Change(s)

Discipline of
Person
Completing
Assessment
Date Assessment
Completed
Date of
Physicianordered
SOC/ROC*

Guidance
Manual Change
Item
Intent

Active Diagnoses

M1034
M1036

Removed
Removed

M1046

M1046

Overall Status
Risk Factors
Influenza
Vaccine
Received

M1051

M1051

Pneumococcal
Vaccine

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Data
Sources
and
Resources
X

X

X

X

X

Skip pattern
changed due to
M1017 item
removal

Inpatient
Diagnosis
Diagnoses,
Removed
Treatment
Regimen Change
Removed Conditions Prior
Primary
M1021
Diagnosis
M1023 Other Diagnoses
Optional
Removed
Diagnoses
M1028

Response
Specific
Examples
Instructions

X

Inpatient
Facilities

M1028

Time
Points
Collected

X
X

X

Added “none of
the above”
response option

X

X

X

X

X

X

Skip Pattern
changed due to
M1501, M1230
item removals

Appendix G-2

OASIS Guidance Manual

Appendix G

Item
Information
OASIS-C2 OASIS-D
New
Item Description
Item #
Item #
Item

M1056

M1056

M1060

M1060

M1210

Removed

M1220

Removed

M1230

Removed

M1240
M1300

Removed
Removed

M1302

Removed

Item
Change
Time
(-) Dash is
Item Response
Skip
Point
a Valid
Text Option(s)
Pattern
Versions
Response

Item Change
Description
Change(s)

Guidance
Manual Change
Item
Intent

Reason
Pneumococcal
Vaccine not
received
Height and
Weight
Ability to Hear
Understanding
Verbal Content
Speech and Oral
Expression
Pain Assessment
PU* Assessment
Risk of
Developing PUs*

Time
Points
Collected

Response
Specific
Examples
Instructions

Data
Sources
and
Resources

X

X

Added the words
“injury/ Injuries”
M1306

M1306

Unhealed
Pressure
Ulcer/Injury at
Stage 2 or Higher

M1307

M1307

Oldest Stage 2
PU

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X

Changed
“excludes healed
Stage 2” to
“excludes…all
healed PUs “

X

X

X

Appendix G-3

OASIS Guidance Manual

Appendix G

Item
Information
OASIS-C2 OASIS-D
New
Item Description
Item #
Item #
Item

Item
Change

Item Change
Description

Time
(-) Dash is
Item Response
Skip
Point
a Valid
Text Option(s)
Pattern
Versions
Response

Change(s)

Guidance
Manual Change
Item
Intent

Time
Points
Collected

Response
Specific
Examples
Instructions

Data
Sources
and
Resources

Different versions
of this item
available for
SOC/ROC*, FU*
and DC*

M1311

M1311

Current Number
of Unhealed
Pressure
Ulcers/Injuries at
Each Stage

X

X

X

X

Added
“injury/injuries”;
added “device” to
non-removable
dressing;
removed
“suspected…in
evolution” from
deep tissue injury

X

X

X

Dash is a valid
response for
discharge time
point only
Modified skip
language to “Go
to”
M1313
M1320
M1322

M1324

M1332
M1334

Worsening in PU
Status
Status of Most
Removed
Problematic PU
Current Number
M1322
of Stage 1
Pressure Injuries
Stage of Most
Problematic
Unhealed
M1324
Pressure
Ulcer/Injury
Current Number
M1332
of Stasis Ulcer(s)
Status Most
Problematic
M1334
Stasis Ulcer
Removed

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X

Replaced “ulcers”
with “injuries”

X

X

Added the word
“injury”

X

X

X

X

X
X

X

Appendix G-4

OASIS Guidance Manual

Appendix G

Item
Information
OASIS-C2 OASIS-D
New
Item Description
Item #
Item #
Item

M1340

M1340

M1342

M1342

M1350

Removed

M1410

Removed

M1501

Removed

M1511

Removed

M1610

M1615

M1730
M1750
M1800
M1810
M1820
M1830
M1840
M1845
M1850

M1610

Item
Change

Item Change
Description

Time
(-) Dash is
Item Response
Skip
Point
a Valid
Text Option(s)
Pattern
Versions
Response

Surgical Wound?

X

Change(s)

Guidance
Manual Change
Item
Intent

Time
Points
Collected

Skip pattern
changed due to
M1350 item
removal

When does
Urinary
Removed
Incontinence
occur?
Depression
M1730
Screening
Psychiatric
Removed
Nursing Services
M1800
Grooming
Dress Upper
M1810
Body
Dress Lower
M1820
Body
M1830
Bathing
Toilet
M1840
Transferring
M1845 Toileting Hygiene
M1850
Transferring

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X

X

Data
Sources
and
Resources

X

Status Most
Problematic
Surgical Wound
Skin Lesion or
Open Wound
Respiratory
Treatments
Symptoms in
Heart Failure
Patients
Heart Failure
Follow-up
Urinary
Incontinence or
Urinary Catheter

Response
Specific
Examples
Instructions

Skip pattern no
longer required
due to M1615,
M1620 item
removals

X

X

X

X

X
X
X
X
X
X
X

Appendix G-5

OASIS Guidance Manual

Appendix G

Item
Information
OASIS-C2 OASIS-D
New
Item Description
Item #
Item #
Item
M1860
M1870
M1880
M1890
M1900
M1910

M2001

M2003
M2005
M2010
M2016
M2020
M2030
M2040

Item
Change

Item Change
Description

Time
(-) Dash is
Item Response
Skip
Point
a Valid
Text Option(s)
Pattern
Versions
Response

Change(s)

Ambulation/Locomotion
Feeding or
M1870
Eating
Ability to Plan
and Prepare
Removed
Light Meals
Ability to Use
Removed
Telephone
Removed Prior Functioning
Falls Risk
M1910
Assessment

Guidance
Manual Change
Item
Intent

Time
Points
Collected

M1860

M2001

Drug Regimen
Review

Medication
Follow-up
Medication
M2005
Intervention
High-risk drug
M2010
education
Patient/Caregiver
M2016
Drug Education
Management of
M2020
Oral Medications
Management of
Injectable
M2030
Medications
Prior Medication
Removed
Management
M2003

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Response
Specific
Examples
Instructions

Data
Sources
and
Resources

X
X

X

Skip Pattern
changed due to
M2040 item
removal

X

X

X

X

X

X

X

X

X

X

X

X

X
X

X

X

X
X

X

X
X

X

Appendix G-6

OASIS Guidance Manual

Appendix G

Item
Information

Item
Change

OASIS-C2 OASIS-D
New
Item Description
Item #
Item #
Item

Item Change
Description

Time
(-) Dash is
Item Response
Skip
Point
a Valid
Text Option(s)
Pattern
Versions
Response

Change(s)

Guidance
Manual Change
Item
Intent

Time
Points
Collected

Response
Specific
Examples
Instructions

Data
Sources
and
Resources

Different versions
of this item
available for
SOC/ROC and
DC
M2102

M2110

M2250
M2301

M2102

Types and
Sources of
Assistance

X

Removed rows:
(b) “IADL*
assistance”
(e) “Management
of Equipment”
(g) “Advocacy or
facilitation”

X

How Often does
the patient
Removed
receive ADL* or
IADL assistance
Plan of Care
Removed
Synopsis
M2301
Emergent Care

M2310

M2310

Reason for
Emergent Care

M2401

M2401

Intervention
Synopsis

X

X
Removed 15 of
19 response
options

X

X
X

M2410

M2410

Inpatient Facility

X

M2420

M2420

Discharge
Disposition

X

M2430

Removed

M0903

Removed

X

X

Skip pattern no
longer required
due to M2430,
M0906 item
removals
Skip pattern no
longer required
due to M2430
item removal

Reason for
Hospitalization
Date of Last
Home Visit

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Appendix G-7

OASIS Guidance Manual

Appendix G

Item
Information

Item
Change

OASIS-C2 OASIS-D
New
Item Description
Item #
Item #
Item
NA
NA

GG0100
GG0110

Prior Functioning
Prior Device Use

Item Change
Description

Time
(-) Dash is
Item Response
Skip
Point
a Valid
Text Option(s)
Pattern
Versions
Response

X
X

Change(s)

X
X

NA

GG0130

Self-Care

X

X

X

NA

GG0170

Mobility

X

X

X

NA
NA

J1800
J1900

Any Falls
Number of Falls

X
X

X
X

Different versions
of this item
available for
SOC/ROC, FU
and DC
Different versions
of this item
available for
SOC/ROC, FU
and DC

Guidance
Manual Change
Item
Intent

Time
Points
Collected

X
X

X
X

X
X

X
X

Data
Sources
and
Resources
NA
NA

X

X

X

X

NA

X

X

X

X

NA

X
X

X
X

X
X

X
X

NA
NA

Response
Specific
Examples
Instructions

*Notes: SOC - Start of Care; ROC - Resumption of Care; PU/PUs - Pressure Ulcer, Pressure Ulcers; FU - Follow-up; DC - Discharge; IADL - Instrumental Activity of Daily Living; ADL
- Activity of Daily Living; NA - not applicable

OASIS-D Guidance Manual
Effective 1/1/2019
Centers for Medicare & Medicaid Services

Appendix G-8


File Typeapplication/pdf
File TitleOutcome and Assessment Information Set OASIS-D Guidance Manual
SubjectOASIS, OASIS-D, OASIS guidance, OASIS Guidance Manual
AuthorCenters for Medicare & Medicaid Services
File Modified2018-08-21
File Created2018-06-20

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