Medicare and Medicaid Programs OASIS Collection Requirement (Training)

Outcome and Assessment Information Set
OASIS-E Manual

Effective January 1, 2023
Centers for Medicare and Medicaid Services

Table of Contents
CHAPTER 1: OASIS GUIDANCE MANUAL INTRODUCTION ...................................................................................... 3
CHAPTER 2: DATA ACCURACY AND CORRECTION OF THE OASIS ASSESSMENTS ................................................... 9
CHAPTER 3: ITEM-BY-ITEM GUIDE TO THE OASIS ASSESSMENT INSTRUMENT ................................................... 13
SECTION A: ADMINISTRATIVE INFORMATION - PATIENT TRACKING ................................................................... 15
SECTION A: ADMINISTRATIVE INFORMATION ...................................................................................................... 30
SECTION B: HEARING, SPEECH, AND VISION ........................................................................................................ 56
SECTION C: COGNITIVE PATTERNS........................................................................................................................ 62
SECTION D: MOOD ................................................................................................................................................ 93
SECTION E: BEHAVIOR......................................................................................................................................... 105
SECTION F: PREFERENCES FOR CUSTOMARY ROUTINE ACTIVITIES ................................................................... 107
SECTION G: FUNCTIONAL STATUS ...................................................................................................................... 113
SECTION GG: FUNCTIONAL ABILITIES AND GOALS ............................................................................................. 123
SECTION H: BLADDER AND BOWEL..................................................................................................................... 160
SECTION I: ACTIVE DIAGNOSES ........................................................................................................................... 164
SECTION J: HEALTH CONDITIONS........................................................................................................................ 170
SECTION K: SWALLOWING/NUTRITIONAL STATUS ............................................................................................. 185
SECTION M: SKIN CONDITIONS ........................................................................................................................... 192
SECTION N: MEDICATIONS.................................................................................................................................. 212
SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS................................................................ 230
SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL SETTING.................................................................... 240
APPENDIX A: GLOSSARY AND COMMON ACRONYMS ........................................................................................ 243
APPENDIX B: OASIS-E ITEMS, TIME POINTS, AND USES ..................................................................................... 261
APPENDIX C: OASIS-E INSTRUMENTS ................................................................................................................. 267
APPENDIX D: DESCRIPTION OF CHANGES FROM OASIS-D TO OASIS-E .............................................................. 372
APPENDIX E: REFERENCES AND RESOURCES ...................................................................................................... 382
APPENDIX F: OASIS AND QUALITY IMPROVEMENT ............................................................................................ 386

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OASIS Guidance Manual Introduction

CHAPTER 1: OASIS GUIDANCE MANUAL INTRODUCTION
The Outcome and Assessment Information Set (OASIS) is a group of standard data elements home health
agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers
for Medicare & Medicaid Services (CMS).

1.1 Purpose of the Manual
This manual provides guidance for home health agencies (HHAs) on how to ensure the collection of highquality (accurate) OASIS data. It includes both general data collection conventions and item-specific guidance,
as well as links to resources for agencies.

1.2 Organization of the Manual
This manual includes the following content:
•

Chapter 1 – Introduction to the OASIS Manual, including the manual purpose, structure and content, and
description of the OASIS requirements and conventions. The manual summarizes the statutory authority
for OASIS data collection, and describes the background on the development of OASIS, and its version
history.

•

Chapter 2 – The importance of Data Accuracy, and how HHAs may audit OASIS data to minimize errors.
This chapter briefly describes OASIS data correction and implications for reporting.

•

Chapter 3 – Item-specific guidance, subdivided into sections

•

Appendix A – Glossary and Common Acronyms

•

Appendix B – OASIS items, Time Points and Uses table

•

Appendix C – OASIS Instruments (All Items, and all Time Points versions)

•

Appendix D – Description of Changes from OASIS-D to OASIS-E table

•

Appendix E – References and Resources

•

Appendix F – OASIS and Quality Improvement

1.3 Background
In the early 1990s the Health Care Financing Administration (renamed to the Centers for Medicare & Medicaid
Service [CMS] in 2001) and the Robert Wood Johnson Foundation funded research at the University of
Colorado (Denver) Health Sciences Center to develop, test and refine a system of outcome quality measures
that Medicare and home health agencies (HHAs) could use to continuously improve the effectiveness of home
health care 1. Through multiple phases of testing and revision researchers developed and refined a core group of
data elements to uniformly measure and risk adjust outcomes quality measures. The data set, called the
Outcomes and Assessment Information Set (OASIS), measured quality across all HHAs, to produce outcome
measures and reports and serve as the basis of outcomes-based quality improvement (OBQI). Selected OASIS
items were later identified for use in payment determination in the Prospective Payment System (PPS).

1 Shaughnessy PW, Crisler KS, Schlenker RI, Arnold AG, Kramer AM, Powell MC, and Hittle DF. (1994), Fall. Measuring and assuring the quality
of home health care. Health Care Financing Review, 16(1):35-67.

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OASIS and its associated Guidance Manual are periodically revised based on CMS’s addition or removal of
quality measures from the Home Health Quality Reporting Program (HHQRP) or for other program
requirements. Table 1 lists the version history of OASIS.

1.4 Changes from OASIS-D to OASIS-E
Currently the main reason for revising OASIS is to increase standardization across post-acute care (PAC)
settings to uniformly collect social determinants of health data and to enable calculation of standardized, crosssetting quality measures (QMs), pursuant to the provisions of the Improving Medicare Post-Acute Care
Transformation (IMPACT) Act. Standardized assessment data elements are assessment items and response
options that are harmonized across four PAC assessment instruments, and to which aligned standards and
definitions apply.

1.4.1 What’s new with the OASIS instrument?
•

New sections and items are added

•

Different time point versions of some items

•

Removal of some items

•

Revision of some items

•

Updated skip patterns

Refer to the Chapter 3 Introduction and Appendix D for a more detailed summary of instrument and
guidance changes.

1.5 OASIS Requirements
This section provides a basic overview of collecting OASIS data. Refer to Chapter 3 of this manual for more
detail on strategies for completing the OASIS as part of a comprehensive assessment.

1.5.1 Who does OASIS data collection apply to?
OASIS data are collected for skilled Medicare and Medicaid patients, 18 years and older, except for patients
receiving services for pre- or postnatal conditions. Those receiving only personal care, homemaker, or chore
services are excluded from OASIS data collection and submission requirements.

1.5.2 OASIS and the comprehensive assessment
OASIS data are collected as part of the comprehensive assessment required by the Medicare Conditions of
Participation. 2 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 may rearrange OASIS item sequence in a way that permits
logical ordering within their own forms and electronic records, as long as the actual item content, and OASIS
number and formatting remain the same, and maintaining the same skip logic. The comprehensive assessment
forms the basis of the physician-ordered Plan of Care. Thus, there should be congruence between the overall
comprehensive assessment and the Plan of Care.
Agencies may have the comprehensive assessment including OASIS, if applicable, 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

2

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-484

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multiple clinicians will be documented within the clinical record, ensuring compliance with applicable
requirements, and accepted standards of practice.

1.5.3 When is OASIS Completed? (Time Points)
OASIS data are collected at the time points listed in the table below, and within the required assessment
timeframe. Not all OASIS items are completed at every assessment time point. All OASIS assessments, except
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 and death at home time points require collection
of limited OASIS data (most of which may be obtained through a telephone call). OASIS data should be
collected at each time point based on a unique patient assessment, not simply carried over from a previous
assessment.
Reason for Assessment
(RFA, M0100)
1. Start of care – further
visits planned

Within 5 calendar days after the SOC date (SOC
= Day 0)

Resumption of care (ROC)

3. Resumption of care
(after inpatient stay)

Within 2 calendar days of the facility discharge
date or knowledge of patient’s return home

Follow-up (FU)

4. Recertification
(follow-up) assessment

The last 5 days of every 60 days i.e., days 56-60
of the current 60-day period

5. Other follow-up

Within 2 calendar days of significant change of
patient’s condition

Transferred to an
inpatient facility –
patient not discharged
from agency

Within 2 calendar days of disch/trans/death date
or knowledge of a qualifying transfer to inpatient
facility

Transferred to an
inpatient facility –
patient discharged from
agency

Within 2 calendar days of disch/trans/death date
or knowledge of a qualifying transfer to inpatient
facility

Death at home (DAH)

Within 2 calendar days of disch/trans/death date

Discharge from agency
(DC)

Within 2 calendar days of disch/trans/death date.

Time Point
Start of care (SOC)

Transfer to an Inpatient
Facility (TRN)

Discharge from Agency – not
to an inpatient facility (DC)

Assessment Timeframe

1.5.4 Who Completes OASIS?
As identified in (M0080) Discipline of Person Completing Assessment, the comprehensive assessment
including OASIS data collection, if applicable, is 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
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therapist assistant (PTA), occupational therapy assistant (OTA), medical social worker (MSW), or Aide may
not be responsible for completing the comprehensive assessment and OASIS.
In cases involving nursing, the RN is responsible for completing the SOC comprehensive assessment, including
OASIS if applicable. For a Medicare therapy-only case, the PT or SLP may conduct the SOC comprehensive
assessment including OASIS. Effective January 1, 2022, OTs may conduct the SOC comprehensive
assessments including OASIS for Medicare patients when the physician’s referral order does not include skilled
nursing, but does include PT and/or SLP, along with OT. Any discipline qualified to perform OASIS
assessments (RN, PT, SLP, OT) may complete subsequent OASIS assessments (e.g., transfers, recertifications,
resumptions of care, discharge) after the SOC.
Note: Services which establish eligibility for the Medicare home health benefit include skilled nursing, PT and
SLP. The change allowing OT to conduct SOC comprehensive assessments did not alter Medicare’s criteria for
establishing initial eligibility (i.e., the need for OT does not establish the initial eligibility for the HH benefit).
The Medicare home health patient who initially qualifies for the home health benefit by requiring skilled
nursing, PT or SLP, can retain eligibility if, over time, occupational therapy is the only remaining skilled
discipline providing care. OT may conduct all subsequent comprehensive assessments with OASIS, if
applicable.
Multidisciplinary cases may have multiple points of discipline-specific discharge, though there is only one
HHA discharge, which must include completion of the comprehensive discharge assessment including OASIS if
applicable. Other non-OASIS required documentation for admission, recertification and discharge are specified
in the Condition of Participation: Comprehensive Assessment of Patients. 3

1.5.5 Conventions for Completing OASIS
This section lists conventions, or general rules, to follow when completing OASIS. Item-specific guidance is
provided in Chapter 3. It is not possible to address all situations and exceptions that may arise in clinical
practice. Each patient scenario, clinical status, and social and environmental situation requires the clinician to
consider available guidance and allows use of professional judgment and interdisciplinary collaboration for
assessment.
The OASIS guidance is updated periodically through the CMS Quarterly OASIS Q&As, based on questions
received by the Home Health Quality Help Desk. In the event you cannot resolve your understanding of the
OASIS item guidance by reviewing the OASIS Guidance Manual and/or the Q&A documents, consider
submitting your question to the Home Health Quality Help Desk (a link to the OASIS Q&As and the email
address for the Home Health Quality Help Desk can be found in Appendix E. References and Resources).
1.5.5.1 General OASIS Item Conventions
1. Understand the time period under consideration (look back) 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, Death at Home, and Discharge assessment) to be considered a complete
quality episode.

3

https://www.ecfr.gov/current/title-42/part-484

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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 time period under consideration, 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 and report 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. Assessment strategies to complete any and all OASIS items include observation, interview,
collaboration with other agency staff and other relevant strategies, 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.
13. The comprehensive assessment includes the OASIS items and is part of the patient’s legal home health
agency clinical record.
14. While only the assessing clinician is responsible for accurately completing and signing a comprehensive
assessment, they 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, is the last
date that information used to complete the comprehensive assessment and determine OASIS coding was
gathered by the assessing clinician and documentation of the specific information/responses was
completed. When used, collaboration must occur within the assessment timeframe and be consistent
with data collection guidance. Any exception to this general convention concerning collaboration is
identified in item-specific guidance.
15. The use of the term “specifically,” means scoring of the item should be limited to only the
circumstances listed. The use of “for example,” means the clinician may consider other relevant
circumstances or attributes when scoring the item.
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16. Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act amended section
1861(aa)(5) of the Act, allowing nurse practitioners (NPs), clinical nurse specialists (CNSs), and
physician assistants (PAs) to certify eligibility and provide orders for home health services, where not
prohibited by State Law. Accordingly, when coding OASIS items where the presence of a physician’s
order affects the item coding, orders from these allowed practitioners would satisfy the condition of
having a physician’s order.
1.5.5.2 Conventions Specific to OASIS M1800 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. Assistance includes verbal cues, reminders, supervision and/or stand-by or hands-on
assistance.
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 to determine and report the level
of assistance 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/allowed
practitioner has ordered activity restrictions, consider this when selecting the best response to functional
items related to ambulation, transferring, bathing, etc.

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Data Accuracy and Correction of the OASIS Assessments

CHAPTER 2: DATA ACCURACY AND CORRECTION OF THE OASIS
ASSESSMENTS
2.1 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 Care
Compare website, and to determine payment. Thus, it is imperative that the OASIS data that HHAs collect and
submit be accurate and complete. Regulatory language specifying accuracy of OASIS data can be found in the
Medicare Conditions of Participation Accuracy of Encoded OASIS Data found in Section 484.55 of the
Conditions of Participation (See Appendix E). This language stipulates that the encoded OASIS data must
accurately reflect the patient’s status at the time the information is collected. The State survey process for
HHAs may include review of OASIS data collected versus data encoded and transmitted to the CMS.

2.2 Data Auditing
It follows that minimizing data errors that could affect accuracy of clinical data or outcome analyses is a
necessary condition. This is the responsibility of the agency since, ultimately, agency-level quality reports
reflect the data agencies input into the system. Internal staff development and training should focus on data
accuracy, not only at the start-up of OASIS data collection, but on a continuing basis. Once the qualified skilled
professional (specifically, RN, PT, SLP/ST, or OT) completes the assessment, the HHA should develop internal
systems for monitoring data accuracy to ensure that the OASIS data transmitted to CMS exactly reflects the
data collected by the skilled professional. Processes to promote data accuracy may include clinical record
audits, data entry audits, reports produced from electronic health record systems or other activities. Routine
agency OASIS data audits are recommended, with audit frequency determined by the agency. Some data audit
activities might be conducted monthly, while others conducted at less frequent intervals, such as quarterly.
The following guidelines offer examples of approaches for monitoring the quality of OASIS 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. Use of these approaches are not mandated by CMS, nor do they ensure
regulatory compliance. If problems are identified, it is also recommended that the agency develop and
implement a plan to correct data quality problems. Table 1 displays the data quality audit approaches discussed
and summarizes the purpose, frequency, and procedures for each.

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Table 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

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 on a
team or within the agency, a
supervisor or peer auditor attends the
SOC visit. The auditor completes
OASIS items while the assessing
clinician conducts the assessment and
completes SOC paperwork. OASIS
item codes are compared for
consistency between auditor and care
provider. Consider similar auditing
efforts for the additional time points
after the SOC.

QI
Coordinator,
Clinical
Supervisor,
or Clinical
Staff

2.21 Clinical Record Audits
Clinical record audits allow an agency to monitor the validity of OASIS data. This quality check assesses the
congruence of OASIS data with other patient status information found in the clinical record.
To complete 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. In the event that the agency has fewer than five patients admitted to or discharged from the agency,
review all records. It should be noted that many agencies may choose to audit a larger sample and some may
audit 100% of records.

2.22 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 would be compared. Reviewers
would 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, payment source or birth date) in addition to discrepancies in clinical
assessments (ICD-10-CM codes, all clinical assessment OASIS items).
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The records for discharged patients could be reviewed in the same manner. All discharge OASIS patient status
items would 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 unexpected/unexplainable differences in
descriptions of the patient, a potential data quality problem may exist.
If differences are found that cannot be explained by other documentation in the clinical record, the care provider
who completed the OASIS would 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 is 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.

2.23 Clinical Audit Visits
Clinical audit visits provide an opportunity to verify the quality of patient status data collected by assessing
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, as well
as at other time points based on agency needs and goals. Within a one-year period, each clinical staff member of
an average-sized agency or agency’s team thus can receive an audit visit. The supervisor or peer auditor should
complete the OASIS items while observing the assessing clinician conducting the assessment visit. The
assessing clinician and auditor should not discuss OASIS items between themselves during the visit. The QI
coordinator (or designated person) then compares each code on the OASIS items completed by the assessing
clinician to the OASIS codes completed by the auditor. Discrepancies should be noted. Any differences
between OASIS coding should be discussed jointly by the assessing clinician and auditor to determine the
reasons for the differences and to ensure that assessing clinicians fully understand the OASIS items and related
guidance. 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 assessing clinicians are represented.

2.3 Summarizing Audit Activities
Agencies would 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 would 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.

2.4 Data Correction and Reporting Implications
All HHA users are expected to submit required OASIS records to CMS via the internet Quality Improvement
and Evaluation System (iQIES). An automated correction policy exists related to submission of modification
and inactivation records when the current OASIS record in the iQIES database is erroneous. The following two
processes have been established to correct records that have been accepted into iQIES:
•

A Modification record should be used when a record has been accepted into iQIES, but the information in
the record contains clinical errors or errors to non-key fields.

•

An Inactivation record should be used when a record has been accepted into iQIES but the corresponding
event did not occur or information in ANY of the key fields are erroneous.

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Users are not allowed to change data in key fields. If data in the key fields in the current record are inaccurate,
the current record must be inactivated and a new replacement record should be submitted.
Effective January 1, 2020, HHAs have 24 months from the assessment target date to submit, modify or
inactivate OASIS records. For additional details including the list of key fields, please reference the QIES
Technical Support Office for HH Providers (See Appendix E).
Additionally, online help is available in iQIES for those users who take advantage of the assessment data entry
software within iQIES. To access this online support authorized users would log into iQIES, select the Help
link from the bottom of the page, and select the Assessments tab.
Before data is publicly reported on Care Compare, HH providers have an opportunity to review and correct, as
well as preview, their data. A Review and Correct Report is available for providers to access in the iQIES CMS
reporting system. The Review and Correct Report will assist providers in identifying whether there are any
issues with the data already collected and submitted before the applicable quarterly data submission deadlines.
Correction of any errors identified by the agency must be submitted by the final submission deadlines, which
can be found on the CMS HH QRP Data Submission Deadlines web page. Only updates/corrections to the
underlying assessment data submitted before the data correction deadline will be reflected in the publicly
reported data on Care Compare.
If a provider corrects assessment data after the data correction deadline, the corrected data will only be reflected
in the QM agency- and patient-level reports. Corrections will not be reflected in the Provider Preview Reports
or on the Care Compare website.
A quarterly Provider Preview Report issued by CMS displays the data that will be publicly reported. This report
is available approximately 3 months prior to display on Care Compare. It provides an opportunity to review
agency-level assessment and claims-based QM data for measures that will be publicly reported on the Care
Compare website for that reporting period.

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Chapter 3

Item-by-Item Guide to the OASIS Assessment Instrument

CHAPTER 3: ITEM-BY-ITEM GUIDE TO THE OASIS ASSESSMENT
INSTRUMENT
3.1 Overview
This chapter provides item-by-item coding instructions for HH assessing clinicians to complete each section of
the OASIS-E instrument. The goal of this chapter is to provide HH staff with the rationale and guidance
necessary to accurately complete each item of the OASIS Assessment.
OASIS-E is a major revision to the OASIS instrument and guidance manual resulting in significant instrument
redesign and manual reorganization. To align the items and guidance across the PAC settings, multiple new
standardized items have been added to OASIS-E, new sections have been added or renamed, items have been
reorganized within the sections, and the format for item specific guidance has changed.

3.2 OASIS-E Sections
OASIS-E includes the following sections:
Section
A

Title
Administrative Information
•

Section

Title

H

Bowel and Bladder

Patient Tracking

B

Hearing, Speech, and Vision

I

Active Diagnoses

C

Cognitive Patterns

J

Health Conditions

D

Mood

K

Swallowing/Nutritional Status

E

Behavior

M

Skin Conditions

F

Preferences for Customary Routine
Activities

N

Medications

G

Functional Status

O

Special Treatments, Procedures and
Programs

Functional Status: Functional
Abilities and Goals

Q

Participation in Assessment and Goal
Setting

GG

3.3 Using This Chapter
Item-specific guidance has been included for all new items introduced in OASIS-E and for those retained from
OASIS-D. Each section begins with a brief introduction describing the items found in the section. The sources
of information clinicians use to respond to items are now located in the first bullet under Response-Specific
Instructions, and the OASIS-D Section “Data Sources/Resources” has been removed. Dash language has been
added to each item indicating whether a Dash is an acceptable response or not. General formatting and
organization changes have been made to improve clarity and remove redundancy.
Throughout this chapter, the sections of OASIS-E are presented using a standard format for ease of review by
HH staff. The layout and text color for headings varies from OASIS-D. Item-specific guidance includes
additional headings to convey information, for example, Coding Instructions, Coding Tips and Examples where
appropriate, the order of information for all items in each section of the OASIS-E is presented as follows:
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Item-by-Item Guide to the OASIS Assessment Instrument

•

Item Display. Item-specific guidance begins with a screen shot, which displays the item from the
OASIS-E instrument.

•

Intent. States the reason(s) for including this item in the OASIS-E.

•

Time Point(s) Items Completed. Lists when the information for the data element is to be collected
during the patient’s home health episode of care.

•

Item Rationale. Explains the purpose, meaning or importance of the item; the reason why the item is
needed.

•

Response Specific Instructions. General instructions for how to complete the item, that apply to
most, if not all, situations; how users are intended to collect information to complete the item.

•

Coding Instructions. Provides additional information to supplement the instructions found in the data
element.

•

Coding Tips. Any special situations, outliers or uncommon scenarios; or any tips to clarify confusing or
equivocal circumstances when coding each OASIS-E item.

•

Examples. Illustrates examples of appropriate coding for several of the OASIS-E sections/items

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SECTION A: ADMINISTRATIVE INFORMATION - PATIENT TRACKING
Introduction

This section includes items for patient tracking and general administrative information.
Items in this section only need to be revised if the patient information changes during the episode. For each
item, the first bullet under Response-Specific Instructions includes data sources and resources that may be used
to respond to the item.

M0018: National Provider Identifier (NPI)

Item Intent
Identifies the physician/allowed practitioner who will sign the Plan of Care.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•
•
•

Agency medical records department could be consulted for this item.
For more information see the link for NPI registry in Appendix E of this manual.
The NPI is a ten-digit numeric identifier.

Coding Instructions
•

Dash is not a valid response for this 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
Start of Care

Response-Specific Instructions
• Agency administrative and billing staff could be consulted for this item.
• Enter the agency’s CMS certification (Medicare provider) number.
• If agency is not Medicare-certified, leave blank.
• This is NOT the Provider’s NPI number.
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Preprinting this number on clinical documentation is allowed and recommended.

Coding Instructions
•

Dash is not a valid response for this item.

M0014: Branch State

Item Intent
Specifies the State where the agency branch office is located.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
• Agency administrative and billing staff could be consulted for this item.
• 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.

Coding Instructions
•

Dash is not a valid response for this item.

M0016: Branch ID Number

Item Intent
Specifies the branch identification code, as assigned by CMS.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•
•

Agency administrative and billing staff could be consulted for this item.
Enter the Federal branch identification number specified for this branch as assigned by CMS.

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Section A: Administrative Information – Patient Tracking

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 CMSassigned branch number.
Preprinting this number on clinical documentation is allowed and recommended.

Coding Instructions
•
•
•

Code N, if you are an HHA with no branches. The remaining 9 boxes should be blank.
Code P, if you are a parent HHA that has branches. The remaining 9 boxes should be blank.
Dash is not a valid response for this item.

M0020: Patient ID Number

Item Intent
Identifies the agency-specific patient identifier.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
Agency medical records department could be consulted for this item.
Enter the identification code the agency assigns to the patient and uses for record keeping purposes for this
episode of care.
• If there are fewer digits than boxes provided, leave boxes at the end blank.
• 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 start of care to discharge).
•
•

Coding Instructions
•

Dash is not a valid response for this item.

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M0030: Start of Care Date

Item Intent
Specifies the start of care date, which is the date that the first reimbursable service is delivered.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
Agency administrative staff may be consulted for this item.
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 day or month is only one digit, that digit should be preceded by a “0” (for example, May 4, 2021 =
05/04/2021).
• Enter all four digits for the year.
• For skilled PT or SLP to perform the start of care visit for a Medicare patient:
o the HHA is expected to have orders from the patient’s physician/allowed practitioner indicating the
need for physical therapy or SLP prior to the initial assessment visit;
o no orders are present for nursing at the start of care;
o a reimbursable service must be provided; and
o the need for this service establishes program eligibility for the Medicare home health benefit.
• For skilled OT to perform the start of care visit for a Medicare patient:
o The referral order must not include skilled nursing but does include
o occupational therapy AND
o physical therapy AND/OR speech language pathology
o Note: the above guidance does not alter Medicare’s criteria for establishing eligibility for the home
health benefit as it relates to occupational therapy.
• 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.
•
•

Coding Instructions
•

Dash is not a valid response for this item.

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M0032: Resumption of Care Date

Item Intent
Specifies the date of the first visit following an inpatient stay by a patient receiving service from the home
health agency.

Time Points Item(s) Completed
Resumption of Care

Response-Specific Instructions
Agency administrative staff may be consulted for this item.
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
• The most recent resumption of care date should be entered.
• If the day or month is only one digit, that digit is preceded by a “0” (for example May 4, 2021, =
05/04/2021).
• Enter all four digits of the year.
•
•

Coding Instructions
• Code NA, if a start of care assessment
• Dash is not a valid response for this item

M0040: Patient Name

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
Start of Care

Response-Specific Instructions
•

The data sources/resources for this item include, the patient’s Medicare card, private insurance card, HMO
identification card, etc.

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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.
•

Coding Instructions
•

Dash is not a valid response for this 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
Start of Care

Response-Specific Instructions
The data sources/resources for this item include, municipal, county, or State officials, in order to clarify
the exact (State) location of the residence, if necessary.
• 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.

•

Coding Instructions
•

Dash is not a valid response for this 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.

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Item Rationale
•

The patient’s ZIP code is used for Care Compare to determine places where your agency provides
service.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•
•
•
•

The data sources/resources for this item include the post office, to verify the ZIP code, if necessary.
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.
Be sure to use the ZIP code where the service is provided.
Enter at least five digits (nine digits if known).

Coding Instructions
•

Dash is not a valid response for this item.

M0064: Social Security Number

Item Intent
Specifies the patient’s Social Security number.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•
•
•

Review the Patient’s Social Security card.
Referral information may include the number, but it should be verified with the patient.
Include all nine numbers. Mark “UK” if unknown or not available (for example, information cannot be
obtained or patient refuses to provide information).

Coding Instructions
• Dash is not a valid response for this item.

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M0063: Medicare Number

Item Intent
This item identifies the patient’s Medicare number, including any prefixes or suffixes.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
Review the patient’s Medicare card. The referral information may include the number, but it should be
verified with the patient.
• In an effort to fight identity theft for Medicare beneficiaries, CMS replaced the Social Security number
(SSN)-based Health Insurance Claim Number (HICN) with a new Medicare Beneficiary Identifier (MBI).
o 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.
• Dash is not a valid response for this item.
•

M0065: Medicaid Number

Item Intent
Specifies the patient’s Medicaid number.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•

Review the patient’s Medicaid card or other verifying information.

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Referral information may include the number, but it should be verified with the patient. Make sure that
coverage is still in effect by 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. Include all digits and letters. If patient does not have Medicaid
coverage or Medicaid coverage is pending, mark “NA – No Medicaid.”
• Regardless of payer source for the home care episode, indicate if the patient has Medicaid.
•

Coding Instructions
• Dash is not a valid response for this item.

M0069: Gender

Item Intent
Specifies the gender of the patient.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
Interview the patient and/or caregiver. If the patient does not self-identify, referral information (including
hospital or physician office clinical data), or observation and physical assessment may be used.
• Based on the resources mentioned above, enter a response for patient’s gender.

•

Coding Instructions
•

Dash is not a valid response for this item.

M0066: Birth Date

Item Intent
Specifies the birth date of the patient, including month, day, and four digits for the year.

Time Points Item(s) Completed
Start of Care
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Response-Specific Instructions
Interview the patient and/or caregiver report, or review other legal documents (driver’s license, stateissued ID card, etc.).
• If the day or month is only one digit, that digit should be preceded by a “0” (for example, May 4, 2021=
05/04/2021).
• Enter all four digits of the year.
•

Coding Instructions
•

Dash is not a valid response for this item.

A1005: Ethnicity

Item Intent
The intent of this item is to identify the patient’s self-reported ethnicity data.

Item Rationale
•
•
•
•
•

The ability to improve understanding of and address racial and ethnic disparities in health care outcomes
requires the availability of better data related to social determinants of health, including ethnicity.
The ethnicity and race data elements use a two-question format. Collection of A1005, Ethnicity and
A1010, Race provide data granularity important for documenting and tracking health disparities and
conform to the 2011 Health and Human Services Data Standards.
Collection of ethnicity data is an important step in improving quality of care and health outcomes.
Standardizing self-reported data collection for ethnicity allows for the comparison of data within and cross
multiple post-acute care settings.
These categories are NOT used to determine eligibility for participation in any Federal program.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•

Ask the patient to select the category or categories that most closely corresponds to the patient’s ethnicity
from the list in A1005, Ethnicity.

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o Individuals may be more comfortable if this and the subsequent question are introduced by saying,
“We want to make sure that all our patients get the best care possible, regardless of their ethnic
background.”
• Respondent should be offered the option of selecting one or more ethnic designations.
• If a patient is unable to respond, a proxy response may be used.
• If neither the patient nor a proxy is able to provide a response to this item, use medical record
documentation.
• If a patient declines to respond, do not code based on proxy response or medical record documentation.
• If the patient can provide a response:
o Check all that apply
o Check the box(es) indicating the ethnic category or categories identified by the patient
• Complete as close to the time of SOC as possible

Coding Instructions
•

•

•

Code X, Patient unable to respond, if the patient is unable to respond.
o If the patient is unable to respond, a response may be determined via proxy input. If a proxy is not
able to provide a response, medical record documentation may be used.
o If the response(s) is/are determined via proxy input, and/or medical record documentation, check all
boxes that apply, including Code X - Patient unable to respond.
o If the patient is unable to respond and no other resources (proxy input or medical record
documentation) provided the necessary information, Code X – Patient unable to respond, only.
Code Y, Patient declines to respond, if the patient declines to respond.
o In the cases where the patient declines to respond, Code Y – Patient declines to respond, only.
o If the patient declines to respond, do not code based on a proxy input or medical record
documentation.
Dash is not a valid response for this item.

Examples
1. The patient had an acute CVA with mental status changes. During the SOC assessment the patient is unable
to respond to questions regarding their ethnicity. The patient’s spouse informs the nurse that they are Cuban.
Coding: A1005, Ethnicity would be coded as D - Yes, Cuban and X – Patient unable to
respond.
Rationale: If a patient is unable to respond and the proxy provides the response, code both
the proxy response and X - Patient unable to respond.
2. The patient is admitted following a THA and declines to respond to questions regarding their ethnicity.
Coding: A1005, Ethnicity would be coded as Y – Patient declines to respond.
Rationale: If a patient declines to respond to this item, then the only response option that
should be coded is Y – Patient declines to respond. No attempts should be made to use proxy
input or medical record documentation to complete A1005, Ethnicity when a patient declines
to respond.

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A1010: Race

Item Intent
The intent of this item is to identify the patient’s self-reported race data.

Item Rationale
•
•

•
•
•

The ability to improve understanding of and address racial and ethnic disparities in health care outcomes
requires the availability of better data related to social determinants of health, including race.
The ethnicity and race data elements use a two-question format. Collection of A1005, Ethnicity and
A1010, Race provides data granularity important for documenting and tracking health disparities and
conform to the 2011 Health and Human Services Data Standards.
Collection of the race data is an important step in improving quality of care and health outcomes.
Standardizing self-reported data collection for race allows for the equal comparison of data across
multiple post-acute care settings.
These categories are NOT used to determine eligibility for participation in any Federal program.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•

•

Ask the patient to select the category or categories that most closely correspond to the patient’s race from
the list in A1010, Race.
o Individuals may be more comfortable if this and the preceding question are introduced by saying
“We want to make sure that all our patients get the best care possible, regardless of their racial
background.”
Respondents should be offered the option of selecting one or more race category.

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If a patient is unable to respond, a proxy response may be used.
If neither the patient nor a proxy is able to respond to this item use medical record documentation.
If the patient declines to respond, do not code based on a proxy response or medical record
documentation.
• If the patient can provide a response:
o Check all that apply
o Check the box(es) for indicating the race category or categories identified by the patient.
• Complete as close to the time of SOC as possible
•
•
•

Coding Instructions
•

•

•
•

Code X, Patient unable to respond, if the patient is unable to respond.
o In the cases where the patient is unable to respond, a response may be determined via proxy input. If
a proxy is not able to provide a response, medical record documentation may be used.
o If the response(s) is/are determined via proxy input and/or medical documentation, check all boxes
that apply, including Code X - Patient unable to respond.
o If the patient is unable to respond and no other resources (proxy input or medical record
documentation) provided the necessary information, Code X – Patient unable to respond, only.
Code Y, Patient declines to respond, if the patient declines to respond.
o In the cases where the patient declines to respond, Code Y – Patient declines to respond, only.
o If the patient declines to respond, do not code based on proxy input or medical record documentation
to complete this item.
Code Z, None of the above, if the patient reports or it is determined from proxy or medical record
documentation that none of the listed races apply to the patient.
Dash is not a valid response for this item.

Examples
1. The patient has severe dementia with agitation. During the SOC assessment the patient is unable to
respond. The patient’s child informs the nurse that the patient is Korean and African American.
Coding: A1010 would be coded as B- Black or African American, H – Korean, and X – Patient unable
to respond.
Rationale: If a patient is unable to respond and the proxy provides the response, code both the proxy
response and X – Patient unable to respond.
2. The patient declines to provide their race during the admission assessment stating, “I’d rather not answer.”

Coding: A1010, Race would be coded as Y – Patient declines to respond.
Rationale: If a patient declines to respond to this item, then code only Y, Patient declines to respond.
No attempts should be made to use proxy input or medical record documentation to complete A1010,
Race when a patient declines to respond.
3. The patient is admitted to the HHA following a recent CVA resulting in confusion and is unable to inform
the assessing clinician which race applies to them. The proxy reports that none of the listed races apply to
the patient.
Coding: A1010, Race would be coded as X, Patient unable to respond and Z, None of the above.
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Rationale: If a patient is unable to respond, proxy input may be used to code A1010, Race. When a
patient is unable to respond but proxy input can provide the necessary information, code both the
information from the proxy input, in this case- Z, None of the above, and X, Patient unable to respond.

M0150: Current Payment Sources for Home Care

Item Intent
This item identifies payers who will be billed by your home health agency for services provided during the
home health episode.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
Review referral information and health insurance identification cards.
Exclude “pending” payment sources.
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 only those that are
known.
• Do not consider any equipment, medications, or supplies being paid for by the patient in part or in full.

•
•
•

Coding Instructions
Code 2, if the payment source is a Medicare HMO, another Medicare Advantage Plan, or Medicare Part
C.
• Code 3, if the patient is receiving services provided as part of a Medicaid waiver or home and
community-based waiver (HCBS) program.
• Code 6, if the patient is receiving services through one of the following programs:
o 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
•

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•
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to maximize the informal support provided to older Americans to enable them to remain in their
homes and communities. This program ensures that elders receive the services they need to remain
independent by providing transportation services, in-home services, and caregiver support services;
o 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;
o 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.
Code 7, if the patient is a member of a Tri-Care program.
Code 10, if the patient is self-pay for all or part of the care (for example, copayments).
Dash is not a valid response for this item.

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A1110: Language

Item Intent
The intent of this item is to identify the patient’s self-reported preferred language and need for an interpreter.

Item Rationale
•
•

Language barriers can lead to social isolation, depression, and patient safety issues.
Language barriers can interfere with accurate assessment.

Time Points Item(s) Completed
Start of Care

Response Specific Instructions
Ask for the patient’s preferred language.
Ask if the patient needs or wants an interpreter to communicate with a doctor or health care staff.
If the patient themselves – or with the assistance of an interpreter – is unable to respond to A1110A, What
is your preferred language? or A1110B, Do you need or want an Interpreter? a proxy response is
permitted.
• If neither the patient nor a proxy is able to provide a response to A1110A or A1110B, medical record
documentation may be used.
• Complete as close to the time of SOC as possible.
•
•
•

Coding Instructions for A1110A
•
•

Enter the preferred language the patient primarily speaks or understands
Dash is a valid response for this item.
o If the patient or any available source cannot or does not identify preferred language, enter a dash
(“-“) in the first box. A dash indicates “no information.” CMS expects dash use to be a rare
occurrence.

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Coding Instructions for A1110B
Code 0, No: if the patient indicates no want or need of an interpreter to communicate with a doctor or
health care staff.
o If the patient is unable to indicate the need or want of an interpreter proxy input may be used.
o If the patient is unable and a proxy response is not available, then medical record documentation
may be used.
• Code 1, Yes: if the patient indicates the need or want of an interpreter to communicate with a doctor or
health care staff. Ensure that preferred language is indicated.
o If the patient is unable to indicate the need or want of an interpreter, proxy input may be used.
o If the patient is unable and a proxy response is not available, then medical record documentation
may be used.
• Code 9, Unable to determine: if no source can identify whether the patient needs or wants an
interpreter.
• Dash is not a valid response for this item.
•

Coding Tips
•

An organized system of signing, such as American Sign Language (ASL), can be reported as the preferred
language if the patient needs or wants to communicate in this manner.

M0080: Discipline of Person Completing Assessment

Item Intent
Specifies the discipline of the clinician completing the comprehensive assessment 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
Start of Care
Resumption of Care
Follow-up
Transfer
Discharge from agency
Death at Home

Response-Specific Instructions
•

Data sources/resources for this item are agency policies.

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Section A: Administrative Information

Enter the response associated with the discipline of the individual completing the assessment (referred to
as the assessing clinician).

Coding Instructions
•

Dash is not a valid response for this item.

Coding Tips
While only the assessing clinician is responsible for accurately completing and signing a comprehensive
assessment, they may collaborate to collect data for all OASIS items, if agency policy allows.
• According to the comprehensive assessment regulation, when both the RN and PT/SLP/OT are ordered on
the initial referral, the RN must perform the SOC comprehensive assessment including OASIS. An RN,
PT, SLP, or OT may perform subsequent assessments.
• LPNs, PTAs, COTAs, MSWs, and home health aides are not 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.
•

M0090: Date Assessment Completed

Item Intent
Specifies the actual date the assessment is completed.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Transfer
Discharge from Agency
Death at Home

Response-Specific Instructions
If the day or month is only one digit, that digit should be preceded by a “0” (for example, May 4, 2021 =
05/04/2021).
• Enter all four digits of the year.

•

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Coding Instructions
•

Dash is not a valid response for this item.

Coding Tips
Date Assessment Completed cannot be before the SOC date.
The M0090 - Date Assessment Completed is the last date that information used to complete the
comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and
documentation of the specific information/responses was completed.
o Example: If the assessing clinician gathers additional information during the assessment timeframe
that results in changing the coding of one or more OASIS items (for instance, identifies functional or
cognitive information 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
by the assessing clinician and documentation of the specific information/responses was completed.
• 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.
• When completing a Transfer or Death at Home, record the date the agency completed the data collection
after learning of the event.
•
•

Comprehensive assessment, OASIS and collaboration
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 their knowledge, the document, including OASIS
responses, reflects the patient status as assessed, documented and/or supported in the patient’s clinical
record.
• Some OASIS items, for example, patient name, date of birth, or Medicare Number, 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 information
from these other sources and selecting the appropriate OASIS item response(s), within the appropriate
timeframe and consistent with data collection guidance.
•

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M0100: Assessment Reason

Item Intent
Identifies the “time point” – reason why the assessment data are being collected and reported.

Item Rationale
•

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
Start of Care
Resumption of Care
Follow-up
Transfer
Discharge from agency
Death at Home

Response-Specific Instructions
•

Consult with the agency case manager or other care team provider and/or the clinical record. Hospital or
other health care provider information may identify transfer to inpatient facility or death at home.

Coding Instructions
Enter only one response.
•
•

Code 1, Start of care, for 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.
Code 3, Resumption of care, when the patient:

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o Resumes care following an inpatient stay of 24 hours or longer for reasons other than diagnostic
tests.
o Is discharged from an inpatient facility and care is resumed within the last 5 days of the 60-day
certification period (that is, a recertification assessment is due). A ROC assessment, rather than a
recertification assessment, is completed.
• Code 4, Recertification, if the follow-up assessment is conducted during the last five days of the 60day certification period and is completed to continue the patient’s services for an additional 60-day
certification period.
• Code 5, Other follow-up, if the 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 60-day certification
period. This assessment is done to re-evaluate the patient’s condition, allowing revision to the patient’s
care plan as appropriate.
• Code 6, Transferred to an Inpatient Facility- patient not discharged from agency, if the
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. The patient is
not discharged from the agency.
 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.
• Code 7, Transferred to an Inpatient Facility- patient discharged from agency, if the 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.
 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.
• Code 8, Death at home, when the patient dies:
o At home, while receiving home health services.
o Before being treated in the emergency department, or before being admitted to an inpatient facility.
o In the emergency department.
o Less than 24 hours after being admitted to an inpatient facility.
o In outpatient surgery, or, in the care of the recovery room after outpatient surgery.
o Do not use Code 8, Death at home, when the patient dies after being admitted for a qualifying
inpatient facility stay.
 A telephone call may provide the information necessary to complete the required data items.
• Code 9, Discharge from agency, when the 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.
 The Discharge OASIS is not required when only a single visit is made in a quality episode
(SOC/ROC to TRN/DC).
• Dash is not a valid response for this item.
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M0906: Discharge/Transfer/Death Date:

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
Discharge from agency
Death at Home

Response-Specific Instructions
The data sources/resources for responding to this item include agency policy or physician/allowed
practitioner 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.
• The date of discharge is determined by agency policy or physician/allowed practitioner 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
o Including when a patient dies in the following situations:
 death while being transported to an emergency department or inpatient facility (before being
seen in the emergency department or admitted to the inpatient facility).
 death occurs less than 24 hours after being admitted to an inpatient facility,
 death in the emergency department,
 death occurring during outpatient surgery or in the care of the recovery room after outpatient
surgery.
o Exclude death that occurs after the patient has been admitted to an inpatient facility for a qualifying
inpatient stay as this situation would result in Transfer OASIS collection and would report the date
of transfer.
• If the day 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.
•

Coding Instructions
•

Dash is not a valid response for this item.

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M0102: Date of Physician-ordered Start of Care (Resumption of Care)

Item Intent
The date specified by a physician/allowed practitioner 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
Review the physician/allowed practitioner orders to initiate home care, or resume home care following
inpatient facility stay.
• Enter the date specified on the most recent physician/allowed practitioner order for the start or resumption
of home care services. If the day 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.
• If the originally ordered Start of Care (SOC)/Resumption of Care (ROC) is delayed due to the patient’s
condition or physician/allowed practitioner request (for example, extended hospitalization), then the date
specified on the revised order to start/resume home care services would be considered the date of
physician-ordered SOC/ROC.
o For example, a patient discharged home on May 15, for whom the physician/allowed practitioner
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.
• A revised physician’s ordered SOC/ROC date must be received on or before the date of the previous
physician’s ordered SOC/ROC.
• If the order to extend the physician’s ordered SOC/ROC date is received after the previous physician’s
ordered SOC/ROC date has passed, report NA for M0102 and report the original referral date in M0104.
• In order to be considered a physician-ordered SOC/ROC date, the physician/allowed practitioner must
give a specific date to initiate or resume care, not a range of dates.
o If a single date to initiate or resume services is not provided, the initial contact (via the initial
assessment visit or ROC visit) must be conducted within 48 hours of the referral or within 48 hours
of the patient’s return home from the inpatient facility.
• When coding OASIS items where the presence of a physician’s order affects the item coding, orders from
an allowed practitioner including physician assistant, nurse practitioner, or other advanced practice nurse
would satisfy the condition of having a physician’s order.
•

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Coding Instructions
•

Code N/A,
o if the initial orders did not specify a SOC or ROC date, or,
o if the order to extend the physician’s ordered SOC/ROC date is received after the date of the
previous order has passed.

M0104: Date of Referral

Item Intent
Specifies 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
The data sources/resources for responding to this item include the agency referral form; agency records
specifying the date the referral was received by the agency; and/or hospital, nursing home, or other
referring facility discharge information.
• A valid referral is considered received when the agency has received adequate information about a patient
(such as name, address/contact info, and diagnosis and/or general home care needs) to initiate patient
assessment and confirmed that the referring physician/allowed practitioner or another physician/allowed
practitioner, will provide the plan of care and ongoing orders.
o 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/allowed practitioner.
The agency will note the date the alternate or attending physician/allowed practitioner agreed to
follow the patient as the referral date (M0104) unless referral details are later updated or revised.
• Enter the date of the most recent/latest referral.
• If Start of Care or Resumption of Care is delayed due to the patient’s condition or physician/allowed
practitioner request (for example, extended hospitalization), the date the agency received the
updated/revised referral for home care services would be considered the date of referral.
o This does not include calls or documentation from others, such as assisted living facility staff or
family, who contact the agency to prepare the agency for possible admission.
• If the day 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.
•

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Coding Instructions
•

Dash is not a valid response for this item.

Coding Tips
•

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).

M0110: Episode Timing

Item Intent
Some payment sources that are not Medicare-fee-for-service payers will use this information in setting an
episode payment rate.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up

Response-Specific Instructions
• This item is not used in the Medicare PDGM payment model.
• While CMS will no longer use M0110 to influence payment under PDGM, other payers may be using this
data in their PPS-like payment model. In such cases, agencies should follow instructions from individual
payers directing data collection by patient.

Coding Instructions
Code 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 payment episodes.
• Code 2, Later, if this episode is the third or later episode of care in a current sequence of adjacent
payment episodes.
• Code UK, Unknown, if the placement of this payment episode in the sequence of adjacent episodes is
unknown.
• Code NA, Not Applicable, where the data is not required for the patient’s payer (including all Medicare
FFS assessments).
• Dash is not a valid response for this item.
•

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A1250: Transportation
A1250. Transportation (NACHC ©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X. Patient unable to respond
Y. Patient declines to respond
Adapted from: NACHC© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health
Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use
by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part or whole without written consent from
NACHC.
↓

Item Intent
Access to transportation for ongoing health care and medication access needs is essential to effective care
management.
Understanding patient transportation needs can help organizations assess barriers to care and facilitate
connections with available community resources.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Ask the patient:
o “In the past six months to a year, has lack of transportation kept you from medical appointments or
from getting your medications?”
o “In the past six months to a year, has lack of transportation kept you from non-medical meetings,
appointments, work, or from getting things that you need?”
• Patient should be offered the option of selecting more than one yes designation, if applicable.
• If the patient is unable to respond, a proxy response may be used.
• If neither the patient nor a proxy is able to provide a response to this item, medical record documentation
may be used.
• If the patient declines to respond, do not code based on proxy input or medical record documentation.
• Complete as close to the time of SOC/ROC as possible and within three days of discharge.
• Check all that apply
•

Coding Instructions
•

Code A, Yes, if the patient indicates that lack of transportation has kept the patient from medical
appointments or from getting medications.

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•
•
•

•

•

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Code B, Yes, if the patient indicates that lack of transportation has kept the patient from non-medical
meetings, appointments, work, or from getting things that the patient needs.
Code C, No, if the patient indicates that a lack of transportation has not kept the patient from medical
appointments, getting medications, non-medical meetings, appointments, work, or getting things that the
patient needs.
Code X, Patient unable to respond, if the patient is unable to respond.
o In the cases where the patient is unable to respond, a response may be determined via proxy input. If
a proxy is not able to provide a response, medical record documentation may be used.
o If the response(s) is/are determined via proxy input and/or medical record documentation, check all
boxes that apply, including Code X - Patient unable to respond.
o If the patient is unable to respond and no other resources (proxy or medical record documentation)
provided the necessary information, Code X – Patient unable to respond, only.
Code Y, Patient declines to respond, if the patient declines to respond.
o In the cases where the patient declines to respond, Code Y – Patient declines to respond, only.
o If the patient declines to respond do not code based on proxy input or medical record
documentation to complete this item.
Dash is not a valid response for this item.

Example
1. The patient has Multiple Sclerosis. During the SOC assessment the patient is confused and unable to
understand when asked if they have had a lack of transportation that has kept them from medical
appointments, meetings, work, or from getting things needed for daily living. No proxy with related
information is available, but the patient’s medical record indicates that their sibling uses their car to
transport the patient wherever the patient needs to go.
Coding: A1250, Transportation would be coded as Code C – No and Code X – Patient unable to
respond.
Rationale: If neither the patient nor a proxy is able to provide a response, but the medical record
documentation can provide the necessary information, code both the information in the medical record,
and Code X, Patient unable to respond.

M1000: Inpatient Facilities

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Item Intent
Identifies whether the patient has been discharged from one or more inpatient facilities within the 14 days
immediately preceding the Start of Care/Resumption of Care date.

Item Rationale
•

The purpose of this item is to establish the patient’s recent health care history before formulating the Plan
of Care.

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

Response-Specific Instructions
Interview the patient and/or caregiver and review referral information. Home health providers may access
Medicare’s Common Working File (CWF) (for Medicare patients) 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.
• Mark all that apply. For example, patient may have been discharged from both a hospital and a
rehabilitation facility within the past 14 days.
• The “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.
• An inpatient facility discharge that occurs on Day 0 should be included.
• Facility type is determined by the facility’s state license.
•

Coding Instructions
•
•

•
•

Code 1, Long-term nursing facility, 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.
Code 2, Skilled nursing facility, includes (a) a Medicare certified nursing facility where the patient
received a skilled level of care under the Medicare Part A benefit, or (b) a transitional care unit (TCU)
within a Medicare-certified nursing facility. Code 2, Skilled nursing facility if the answer to all three
questions below is “Yes.”
o Was the patient discharged from a Medicare-certified skilled nursing facility?
o While in the skilled nursing facility was the patient receiving skilled care under the Medicare Part A
benefit?
o 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?
Code 3, Short-stay acute hospital applies to most hospitalizations.
Code 4, Long-term care hospital applies to a hospital that has an average inpatient length of stay of
greater than 25 days.

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Code 5, Inpatient rehabilitation hospital or unit (IRF) means a freestanding rehab hospital or a
rehabilitation bed in a distinct rehabilitation unit of a general acute care hospital.
• Code 7, Other, if the patient was discharged from other than the listed inpatient facilities.
• Dash is not a valid response for this item.
•

Coding Tips
•

•

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.
Intermediate care facilities for individuals with intellectual disabilities (ICF/IID) are considered “Other”
(Response 7) for the purpose of this item

M1005: Inpatient Discharge Date

Item Intent
Identifies the date of the most recent discharge from an inpatient facility that occurred within the 14 days
immediately preceding the Start/Resumption of Care date.

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

Response-Specific Instructions
Interview the patient and/or caregiver interview and review referral information. Home health providers
may access Medicare’s Common Working File (CWF) 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.
• The “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.
• An inpatient facility discharge that occurs on Day 0 should be included.
• Use the most recent date of discharge from any inpatient facility, even though the patient may have been
discharged from more than one facility in the 14 days immediately preceding the Start/Resumption of
Care date.
• If the day 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.
•

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Coding Instructions
•

Dash is not a valid response for this item.

M2301: Emergent Care

Item Intent
Identifies whether the patient was seen in a hospital emergency department at or since the most recent
SOC/ROC assessment, with or without a hospital admission.

Time Points Item(s) Completed
Transfer
Discharge from agency

Response-Specific Instructions
Interview the patient and/or caregiver. Review the clinical record and the hospital emergency department
discharge information. Check with the physician and/or the hospital emergency department staff.
• This item is coded whether the patient independently decides to seek care at a hospital emergency
department or was advised to go by the physician, the home health agency or other health care provider.
• This item excludes urgent care services not provided in a hospital emergency department, including care
provided in a doctor’s office, by an ambulance crew, or at an urgent care facility.
•

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Coding Instructions
Code 0, No, if the patient:
o Was directly admitted to the hospital, without being evaluated or treated first in the hospital
emergency department
o Was not seen in a hospital emergency department at any time during the episode, at or since the most
recent SOC/ROC
• Code 1, Yes, used hospital emergency department WITHOUT hospital admission, if the
patient:
o Went to a hospital emergency department, was “held” at the hospital for observation, then released
 The time period that a patient can be “held” without admission can vary. “Holds” can be
longer than 23 hours.
 Emergent care should be reported regardless of the length of the observation “hold.”
• Code 2, Yes, used hospital emergency department WITH hospital admission, if the patient:
o Was seen at a hospital emergency department, and was then admitted to the hospital (See Definition
– Hospital Admission)
• Dash is not a valid response for this item.
•

M2310: Reason for Emergent Care

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
Discharge from agency

Response-Specific Instructions
•
•
•
•

Interview the patient/caregiver/family. Review the clinical record and hospital emergency department
discharge information. Check with the physician and/or the hospital emergency department staff.
This item excludes urgent care services not provided in a hospital emergency department, including care
provided in a doctor’s office, by an ambulance crew, or in an urgent care facility.
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.
If more than one reason contributed to the hospital emergency department visit, mark all appropriate
responses.

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o For example, if a patient received care for a fall at home and was found to have medication side
effects, use both Code 19, Other than above reasons (for the fall), and Code 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.
o For example, the patient was sent to a hospital emergency department for suspected DVT but
diagnostic testing and evaluation were negative for DVT – use Code 19 – Other than above reasons.

Coding Instructions
•

Dash is not a valid response to this item.

M2410: Inpatient Facility

Item Intent
Identifies the type of inpatient facility to which the patient was admitted.

Time Points Item(s) Completed
Transfer
Discharge from agency

Response-Specific Instructions
Interview the patient and/or family (for agency discharge); contact the family or caregiver by telephone if
the patient was transferred, and/or contact the receiving facility.
• 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).

•

Coding Instructions
•

•
•

Code NA, No inpatient facility admission, when completing a Discharge from Agency – Not to an
Inpatient Facility.
o This response is available on the Discharge OASIS assessment. The NA response is not included on
the Transfer OASIS assessment.
Code 1, Hospital, when a patient:
o Is admitted to inpatient drug rehabilitation whether it was a freestanding drug rehabilitation unit or a
distinct drug rehabilitation unit that is part of a short-stay acute hospital.
Code 2, Rehabilitation facility, when the patient is admitted 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.

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Code 3, Nursing home, when the patient is admitted 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.
• Dash is not a valid response for this item.

•

M2420: Discharge Disposition

Item Intent
Identifies where the patient resides after discharge from the home health agency.

Time Points
Discharge from agency

Response-Specific Instructions
•

Interview the patient/family and/or caregiver. Check with the physician and with community resources.

Coding Instructions
•

•

•
•

Code 1, Patient remained in the community (without formal assistive services), if, after
discharge from your agency the patient remained in a non-inpatient setting, either with no assistive
services, or with any assistive services EXCEPT:
1. Skilled services from another Medicare certified home health agency, or
2. Hospice care from a non-institutional (“home”) hospice provider.
Code 2, Patient remained in the community (with formal assistive services), if, after
discharge from your agency the patient remained a non-inpatient setting, receiving skilled services from
another Medicare certified home health agency, (with or without other assistive services), or when an
agency completes a discharge and new SOC OASIS due to a pay source change for a patient.
Code 3, Patient transferred to a non-institutional hospice, if, after discharge from your agency,
the patient remained in a non-inpatient setting receiving hospice care from a non-institutional (“home”)
hospice provider.
Dash is not a valid response for this item.

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A2120 and A2121: Provision of Current Reconciled Medication List to
Subsequent Provider at Transfer and Discharge

Special Note: The guidance for items A2120 and A2121 is the same, except that one item is used for home

health transfers and the other one for discharges. The guidance is combined here, with specific instructions for
either transfer or discharge as needed.

Item Intent
The intent of these items is to identify if the home health agency provided a current reconciled medication list to
the subsequent provider.

Item Rationale
•

The transfer of a current reconciled medication list at the time of discharge or transfer, can improve care
coordination, quality of care, help subsequent providers reconcile medications and may mitigate adverse
outcomes related to medications. Communication of medication information at discharge/transfer is
critical to ensure safe and effective transitions from one health care setting to another.

Time Points Item(s) Completed
Transfer (A2120)
Discharge from agency (A2121)
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Response Specific Instructions
For Home Health at Transfer: Complete A2120 only if:
• M0100, This Assessment is Currently Being Completed for the Following Reason =
6. Transferred to an inpatient facility – patient not discharged from agency
- Or 7. Transferred to an inpatient facility – patient discharged from agency
For Home Health at Discharge: Complete A2121 only if:
• M0100, This Assessment is Currently Being Completed for the Following Reason =
9. Discharge from Agency, and
• M2420, Discharge Disposition =
2. Patient remained in the community (with formal assistive services) - or 3. Patient transferred to a non-institutional hospice

Coding Instructions

Code 0, No, if at transfer or discharge to a subsequent provider, your agency did not provide the
patient’s current reconciled medication list to the subsequent provider.
• Code 1, Yes, if at transfer or discharge to a subsequent provider, your agency did provide the patient’s
current reconciled medication list to the subsequent provider.
• A2120 only: Code 2, NA, if at transfer to a subsequent provider, your agency was not made aware of
the transfer timely and was, therefore, unable to provide the patient’s current reconciled medication list to
the subsequent provider.
• Dash is not a valid response for this item.
•

Coding Tips
At the time of transfer/discharge – This is the period of time as close to the actual time of transfer or
discharge as possible. This time may be based on agency, State, or Federal guidelines for data collection at
discharge.
• At Transfer- A subsequent provider is identified when the patient has transferred to any inpatient facility
(M0100, RFA 6 or 7)
• At Discharge – A subsequent provider is identified when the patient has been discharged to home under
the care of a home health agency (M2420 response 2) or home hospice (M2420 response 3)
• While the patient may receive care from other providers after discharge from your agency, such as
primary care providers, other outpatient providers, and residential treatment centers, these locations are
not considered to be a subsequent provider for the purpose of coding this item.
• Current Reconciled Medication list -This refers to a list of the patient’s current medications at the time
of discharge that was reconciled by the agency prior to the patient’s discharge.
• Your agency should be guided by current standards of care and any applicable regulations and guidelines
(e.g., Conditions of Participation) in determining what information should be included in a current
reconciled medication list.
•

Additional Considerations for Important Medication List Content
Defining the completeness of that medication list is left to the discretion of the providers and patient who are
coordinating this care.
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An example of items that could be on a reconciled medication list can be but are not limited to a list of the
current prescribed and over-the-counter medications, nutritional supplements, vitamins, and/or homeopathic and
herbal products administered by any route at the time of discharge or transfer. A reconciled medication list
could also include important information about: (1) the patient, including their name, date of birth, active
diagnoses, known medication and other allergies, and known drug sensitivities and reactions; and (2) each
medication, including the name, strength, dose, route of medication administration, frequency or timing,
purpose/indication, and/or any special instructions. However, this information serves as guidance and as stated
prior, the completeness of the medication list is left to the discretion of the providers and patient.
Documentation sources for reconciled medication list information include electronic and/or paper records.
Some examples of such records are discharge summary records, a Medication Administration Record, an
Intravenous Medication Administration Record, a home medication list, and physician orders.

Examples
1. The patient is being transferred from home health to an acute care hospital in the same healthcare system
which uses the same electronic health record (EHR), also sometimes referred to as an electronic medical
record (EMR) (see definition of EHR/EMR in Appendix A). The patient’s current reconciled medication list
at the time of transfer from the agency is accessible to the subsequent acute care hospital staff admitting
them and this is how the medication list is shared.
Coding: A2120 would be coded 1, Yes.
Rationale: Having access to the patient’s medication list through the same EHR system is one way to
transfer a medication list. This code of 1, Yes, is used for this passive means of transferring the
medication list when the sending and receiving provider can access the same EHR system.
2. A patient is not taking any prescribed or over the counter medications at the time of discharge.
Coding: If the lack of any medications for a patient is clearly documented and communicated to the
subsequent provider when the patient is discharged, code 1, Yes, that the medication list was transferred.
If this information is not communicated to the subsequent provider, code 0, No.
Rationale: Information confirming that the patient is not taking any medications at discharge is given
to the subsequent provider and meets the item intent of providing the patient’s current reconciled
medication list to the subsequent provider.
3. When the nurse visited a patient for their monthly Foley catheter change, the patient informed the nurse that
they had been admitted to the hospital last week for a urinary tract infection.
Coding: Code A2120, 2, NA - the agency was not made aware of this transfer timely.
Rationale: When a home health agency is not made aware of a transfer to an inpatient setting timely,
they are unable to provide the current reconciled medication list to the subsequent provider timely.

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A2123: Provision of Current Reconciled Medication List to Patient at
Discharge

Item Intent
The intent of this item is to identify if the home health agency provided a current reconciled medication list to
the patient, family, and/or caregiver at discharge.

Item Rationale
•
•

Communication of medication information to the patient at discharge is critical to ensuring safe and
effective discharges. The item, collected at the time of discharge, can improve care coordination, quality
of care, aids in medication reconciliation, and may mitigate adverse outcomes related to medications.
It is recommended that a reconciled medication list that is provided to the patient, family, or caregiver use
consumer-friendly terminology and plain language to ensure that the information provided to patients and
caregivers is clear and understandable.

Time Points Item(s) Completed
Discharge

Response-Specific Instructions
For Home Health at Discharge: Complete A2123 only if:
•
•

M0100, This Assessment is Currently Being Completed for the Following Reason =
o 9. Discharge from Agency – and –
M2420, Discharge Disposition =
o 1. Patient remained in the community (without formal assistive services) – or –
o 4. Unknown, because patient moved to a geographic location not served by this agency – or –
o UK. Other unknown

Coding Instructions
Code 0, No, if at discharge to a home setting, your agency did not provide the patient’s current
reconciled medication list to the patient, family, and/or caregiver.
• Code 1, Yes, if at discharge to a home setting, your agency did provide the patient’s current reconciled
medication list to the patient, family, and/or caregiver.
• Dash is not a valid response for this item.
•

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Coding Tips
•
•

At the time of discharge – This is the period of time as close to the actual time of discharge as possible.
This time may be based on facility/agency, State, or Federal guidelines for data collection at discharge.
Patient/family/caregiver – The recipient of the current reconciled medication list can be the patient
and/or a family member and/or other caregiver in order to code 1, Yes, a current reconciled medication list
was transferred. It is not necessary to provide the current reconciled medication list to all of these
recipients in order to code 1, Yes.

Examples
1. A patient will not be taking any prescribed or over the counter mediations at the time of discharge.
Coding: If it is clearly documented that the patient is taking no medications and this is then clearly
communicated to the patient, family, and/or caregiver when the patient is discharged, A2123 would be
coded 1, Yes, that the medication list was transferred. If this information is not communicated to the
patient, family and/or caregiver, code 0, No.
Rationale: Information confirming that the patient is not taking any medications at discharge is
provided to the patient, family, and/or caregiver and meets the item intent of providing the patient’s
current reconciled medication list to patient, family, and/or caregiver.

A2122 and A2124: Route of Current Reconciled Medication List
Transmission to Subsequent Provider and Patient
A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Route of Transmission
A.

Electronic Health Record

B.

Health Information Exchange

C.

Verbal (e.g., in-person, telephone, video conferencing)

D.

Paper-based (e.g., fax, copies, printouts)

E.

Other Methods (e.g., texting, email, CDs)

↓

Check all that apply

↓

After completing A2122, Skip to B1300, Health Literacy at Discharge

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Special Note: The guidance for items A2122 and A2124 is the same, except that one item is used for the

subsequent provider at transfer/discharge and the other one at discharge for the patient, family, and/or caregiver.
The guidance addresses coding the route(s) of transmission to the subsequent provider at transfer (A2120) and
at discharge (A2121) and to the patient (A2123). The guidance is combined here, with specific instructions for
either transfer or discharge as needed.

Item Intent
The intent of these items is to identify all routes used in the transmission of the current reconciled medication
list to the subsequent provider at transfer or discharge or to the patient.

Item Rationale
•

These items collect important data to monitor how medication lists are transmitted at transfer/discharge to
the subsequent provider and at discharge to the patient, family, and caregiver.

Time Points Item(s) Completed
Transfer (A2122)
Discharge from agency (A2122 and 2124)

Response Specific Instructions
For Home Health at Transfer: Complete A2122 only if:
• M0100, This Assessment is Currently Being Completed for the Following Reason =
6. Transferred to an inpatient facility – patient not discharged from agency
- Or 7. Transferred to an inpatient facility – patient discharged from agency
For Home Health at Discharge:
Complete A2122 only if:
• M0100, This Assessment is Currently Being Completed for the Following Reason =
9. Discharge from Agency, and
• M2420, Discharge Disposition =
2. Patient remained in the community (with formal assistive services) - or 3. Patient transferred to a non-institutional hospice
Complete A2124 only if:
• M0100, This Assessment is Currently Being Completed for the Following Reason =
9. Discharge from Agency, and
• M2420, Discharge Disposition =
o 1. Patient remained in the community (without formal assistive services) – or –
o 4. Unknown, because patient moved to a geographic location not served by this agency – or –
o UK. Other unknown

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Coding Instructions
•

Code A2122A/A2124A, Electronic Health Record, if your agency has an EHR and used it to
transmit or provide access to the reconciled medication list to the subsequent provider, patient, family,
and/or caregiver. This would include situations where both the discharging and receiving provider have
direct access to a common EHR system. This could also include providing the patient with direct access to
their EHR medication information through a patient portal. Checking this route does not require
confirmation that the patient has accessed the medication list from the portal or the subsequent provider
has accessed the common EHR system for the medication list.

Code A2122B/A2124B, Health Information Exchange, if your agency participates in a Health
Information Exchange (HIE) and used the HIE to electronically exchange the current reconciled
medication list with the subsequent provider, patient, family, and/or caregiver.
• Code A2122C/A2124C, Verbal, if the current reconciled medication list information was verbally
communicated (e.g., in-person, telephone, video conferencing) to the subsequent provider, patient, family,
and/or caregiver.
• Code A2122D/A2124D, Paper-Based, if the current reconciled medication list was transmitted to the
subsequent provider, patient, family, and/or caregiver using a paper-based method such as a printout, fax
or efax.
• Code A2122E/A2124E, Other Methods, if the current reconciled medication list was transmitted to
the subsequent provider, patient, family, and/or caregiver using another method, not listed above (e.g.,
texting, email, CDs).
• Dash is not a valid response for this item.
•

Examples
1. A patient receives a paper copy of their medication list, receives education about their medications by the
home health nurse at discharge, and is notified that the home health patient portal is another means that the
patient can obtain their discharge medication list.
Coding: Code Electronic Health Record (A), Verbal (C), and Paper-based (D) for A2124.

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Rationale: The copy of the medication list is paper-based (D). The information about the patient’s
medication list was also communicated verbally by the nurse at the time of discharge (C). The patient
portal uses the agency’s EHR to provide access to the medication list (A). It is not necessary to confirm
that the patient is a registered user of and accessed the patient portal in order to code EHR (A) as a route.
2. A PAC provider participates in a regional HIE as does a local acute care hospital. When patients are
transferred to this acute care hospital, the PAC provider’s medication list is included in the medications
section of a transfer summary document from their EHR which is electronically exchanged through the HIE.
The acute care hospital is then able to obtain and integrate the medication information into their EHR.
Coding: Code Electronic Health Record (A) and Health Information Exchange (B) for A2122.
Rationale: The medication information is exchanged by the regional HIE through health IT standards.
Sending the medication information in transfer summary allows the acute care hospital to integrate the
medication information into their EHR. Code as EHR (A) since it was used to generate and exchange
the information, and as HIE (B) since it is the means through which information exchange is possible
with external providers.
3. A home health agency has developed an interface that allows documents from their EHR to be
electronically faxed to the subsequent provider.
Coding: Code Check Paper-Based (D) for A2122.
Rationale: Faxing information is considered paper-based as faxed documents are comparable to hard
copy documents, and not computable.
4. A home health agency created a process to automatically send a patient summary document containing
medications and other information using Direct Messaging (Direct Exchange) to the receiving acute care
hospital’s EHR when a patient is transferred to this hospital. The EHR vendors are members of a health
information service provider, or HISP, and are in compliance with DirectTrust requirements 4.The hospital
clinicians can readily access the latest medication and other medical information which is ‘pushed’ or sent
to their EHR.
Coding: Code Electronic Health Record (A) and Health Information Exchange (B) for A2122.
Rationale: Direct Messaging is interoperable exchange through a HIE such as a HISP and EHR (A)
was used to generate and initiate the exchange of the information.

4

DirectTrust | HIMSS

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Section B: Hearing, Speech, And Vision

SECTION B: HEARING, SPEECH, AND VISION
Introduction
The items in this section assesses the degree to which individuals have the capacity to obtain, process, and
understand basic health information needed to make appropriate health decisions.

B0200. Hearing

Item Intent
Identifies the patient’s ability to hear (with assistive devices, if they are used).

Item Rationale
Problems with hearing can contribute to sensory deprivation, social isolation, and mood and behavior
disorders.
• Unaddressed communication problems related to hearing impairment can be mistaken for confusion or
cognitive impairment.

•

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
Ensure that the patient is using their normal hearing appliance, if they have one. Hearing devices may not
be as conventional as a hearing aid. Some patients by choice may use hearing amplifiers or a microphone
and headphones as an alternative to hearing aids. Ensure the hearing appliance is operational.
• Interview the patient and ask about hearing function in different situations (e.g., hearing staff or family
members, talking to visitors, using telephone, watching TV, participation in group discussion).
• Observe the patient during your verbal interactions and when interacting with others.
• Review the clinical record or other available documentation.
• Consult the patient’s family/caregiver, and/or speech or hearing specialists.
•

Coding Instructions
Complete as close to the time of SOC as possible.
•
•

Code 0, Adequate, No difficulty hearing in normal conversation, social interaction, or listening to TV.
The patient hears all normal conversational speech and telephone or group conversations.
Code 1, Minimal difficulty, Difficulty in some environments (e.g., when a person speaks softly or the
setting is noisy). The patient hears speech at conversational levels but has difficulty hearing when not in

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•
•

•

Section B: Hearing, Speech, And Vision

quiet listening conditions or when not in one-on-one situations. The patient’s hearing is adequate after
environmental adjustments are made, such as reducing background noise by moving to a quiet room or by
lowering the volume on television or radio.
Code 2, Moderate difficulty, Speaker has to increase volume and speak distinctly. Although hearingdeficient, the patient compensates when the speaker adjusts tonal quality and speaks distinctly; or the
patient can hear only when the speaker’s face is clearly visible.
Code 3, Highly impaired, Absence of useful hearing. The patient hears only some sounds and
frequently fails to respond even when the speaker adjusts tonal quality, speaks distinctly, or is positioned
face-to-face. There is no comprehension of conversational speech, even when the speaker makes
maximum adjustments.
Dash is a valid response when coding this item.
o A dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
•

Patients who are unable to respond to a standard hearing assessment due to cognitive impairment will
require alternate assessment methods. The patient can be observed in their normal environment. Do they
respond (e.g., turn their head) when a noise is made at a normal level? Does the patient seem to respond
only to specific noise in a quiet environment? Assess whether the patient responds only to loud noise or do
they not respond at all.

Examples
1. When asked about whether they can hear normal conversation without difficulty, patient responds, “When
I’m at home, I usually keep the TV on a low volume and hear it just fine. When I have visitors, I can hear
people from across the room.”
Coding: B0200, Hearing, would be coded as 0, Adequate
Rationale: Patient hears normal conversational speech.
2. “Sitting at the dinner table, I can hear people who are sitting closer to me (e.g., within 5 feet) but not from
farther across the table (e.g., 8 feet) speaking at a normal volume.”
Coding: B0200, Hearing, would be coded as 1, Minimal difficulty
Rationale: Patient has difficulty in some situations (when someone is sitting farther away) but can hear
clearly when someone is sitting close.
3. “I have trouble following normal conversations, especially when a lot of different people are talking at the
same time. I can usually make out what someone is saying if they talk a little louder and make sure they
speak clearly and I can see their face when they are talking to me.”
Coding: B0200, Hearing, would be coded as 2, Moderate difficulty
Rationale: Patient has difficulty hearing people in conversation, but comprehension is improved when
the speaker makes adjustments like speaking at high volume, speaking clearly, and sitting close by so
that the speaker’s face is visible.

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4. “I cannot hear one person speaking, even at a high volume, if others are speaking at the same time. I tend to
listen to the TV at a high volume even if I am alone and I still struggle to hear what is being said. People
complain that they need to scream at me for me to hear anything.”
Coding: B0200, Hearing, would be coded as 3, Highly impaired
Rationale: Patient cannot hear people in conversation even if the speaker is making maximum
adjustments of speaking at high volume and sitting close.

B1000: Vision

Item Intent
Identifies the patient’s ability to see objects nearby in their environment, in adequate light, and with glasses or
other visual appliances.

Item Rationale
•
•
•

A person’s reading vision often diminishes over time.
If uncorrected, vision impairment can limit the enjoyment of everyday activities such as reading
newspapers, books, or correspondence, and maintaining and enjoying hobbies and other activities. It also
limits the ability to manage personal business, such as reading and signing consent forms.
Moderate, high, or severe impairment can contribute to sensory deprivation, social isolation, and
depressed mood.

Time Points Item(s) Completed
Start of Care

Response-Specific Instructions
•
•

Ask the patient, family, caregivers and/or staff if possible about the patient’s usual vision patterns (e.g., is
the patient able to see newsprint, menus, greeting cards?).
Ensure that the patient’s customary visual appliance for close vision is in place (e.g., eyeglasses,
magnifying glass).

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•
•

Section B: Hearing, Speech, And Vision

Ensure adequate lighting.
Ask the patient to look at regular-size print in a book or newspaper. Then ask the patient to read aloud,
starting with larger headlines and ending with the finest, smallest print. If the patient is unable to read a
newspaper, provide material with larger print, such as a flyer or large textbook.
When the patient is unable to read out loud (e.g., due to aphasia, illiteracy), you should test this by another
means such as, but not limited to:
o Substituting numbers or pictures for words that are displayed in the appropriate print size (regularsize print in a book or newspaper)

Coding Instructions
Complete as close to the time of SOC as possible.
•
•
•
•
•
•

Code 0, Adequate, if the patient sees fine detail, including regular print in newspapers/books.
Code 1, Impaired, if the patient sees large print, but not regular print in newspapers/books.
Code 2, Moderately impaired, if the patient has limited vision and is not able to see newspaper
headlines but can identify objects nearby in their environment.
Code 3, Highly impaired, if the patient’s ability to identify objects nearby in their environment is in
question, but the patient’s eye movements appear to be following objects (especially people walking by).
Code 4, Severely impaired, if the patient has no vision, sees only light, colors or shapes, or does not
appear to follow objects with eyes.
Dash is a valid response when coding this item.
o A dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
Some patients have never learned to read or are unable to read English. In such cases, ask the patient to
read numbers, such as dates or page numbers, or to name items in small pictures. Be sure to display this
information in two sizes (equivalent to regular and large print).
• If the patient is unable to communicate or follow your directions for testing vision, observe the patient’s
eye movements to see if their eyes seem to follow movement and objects. Though these are gross
measurements of visual acuity, they may assist you in assessing whether or not the patient has any visual
ability. For patients who appear to do this, code 3, highly impaired.

•

Examples
1. When asked about whether they can see fine detail, including regular print in newspaper/books, patient
responds, “When I wear my glasses, I can read the paper fine. If I forget to wear glasses, it is harder to see
unless I hold the paper a little closer.”
Coding: B1000, Vision, would be coded as 0, Adequate
Rationale: The patient can read regular print when wearing glasses.
2. The assessor asks the patient to read aloud from a newspaper, starting with larger headlines and then the
smaller print. The patient is able to read the headlines but not the regular newspaper print.
Coding: B1000, Vision, would be coded as 1, Impaired
Rationale: The patient sees large print, but not regular print in newspapers/books.
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3. “I cannot read the newspaper headlines, even with glasses.” When the assessor presents the patient with
newspaper text, while wearing glasses, the patient is not able to correctly read the headlines. The patient can
identify objects in their environment.
Coding: B1000, Vision, would be coded as 2, Moderately impaired
Rationale: Patient cannot read newspaper headlines.
4. “I can’t see much of anything at this point. I can see blurry shapes and I can tell what things are, but I can’t
read books anymore – even the ones with giant print. I do okay recognizing my caregivers by their voices,
but I couldn’t tell you what they look like. Everyone’s just a blob of color, even with my glasses on.” The
patient’s eyes appear to follow the assessor when they move about the room. When the assessor presents the
patient with newspaper text, while wearing glasses, the patient is able to appropriately reach for and
successfully hold the paper, but is not able to correctly read the headlines.
Coding: B1000, Vision, would be coded as 3, Highly impaired
Rationale: Patient is able to follow objects and track movement in the environment (e.g., people
moving throughout the room), but is unable to see people or objects in detail.

B1300: Health Literacy

Item Intent
The intent of this item is to identify the patient’s self-reported health literacy.

Item Rationale
•
•

Similar to language barriers, low health literacy interferes with communication between provider and
patient.
Health literacy can also affect the ability for patients to understand and follow treatment plans, including
medication management.

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Section B: Hearing, Speech, And Vision

Poor health literacy is linked to lower levels of knowledge of health, worse outcomes, and the receipt of
fewer preventive services, higher medical costs and rates of emergency department use

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
This item is intended to be a patient self-report item. No other source should be used to identify the
response.
• Ask the patient, “How often do you need to have someone help you when you read instructions,
pamphlets, or other written material from your doctor or pharmacy?”

•

Coding Instructions
Complete as close to the time of SOC/ROC as possible and within three days of discharge.
Code 0, Never, if the patient indicates never needing help reading instructions, pamphlets, or other
written materials from doctors or pharmacies.
• Code 1, Rarely, if the patient indicates rarely needing help reading instructions, pamphlets, or other
written materials from doctors or pharmacies.
• Code 2, Sometimes, if the patient indicates sometimes needing help reading instructions, pamphlets, or
other written materials from doctors or pharmacies.
• Code 3, Often, if the patient indicates often needing help reading instructions, pamphlets, or other
written materials from doctors or pharmacies.
• Code 4, Always, if the patient indicates always needing help reading instructions, pamphlets, or other
written materials from doctors or pharmacies.
• Code 7, Patient declines to respond, if the patient declines to respond.
• Code 8, Patient unable to respond, if the patient is unable to respond.
• Dash is not a valid response for this item.
•

Example
1. When asked how often they need help when reading the instructions provided by their doctor, the patient
reports that they never need help. The patient’s son is present and shares that a family member must always
accompany the patient to doctors’ visits and that the patient often needs someone to explain the written
materials to them multiple times before they understand, providing examples of needing to frequently
explain to the patient why they are on a special diet and why and how to take some of their medications.
Coding: B1300, Health Literacy is coded as Code 0, Never.
Rationale: The patient indicated they never need help reading instructions from their doctor or
pharmacist. B1300, health literacy is intended to be a patient self-report item and no other sources,
including proxy/caregivers, should be used to identify the response to this item.

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Section C: Cognitive Patterns

SECTION C: COGNITIVE PATTERNS
Introduction
This section contains guidance for nine items that assess cognitive function including the Brief Interview for
Mental Status (BIMS) and Signs and Symptoms of Delirium from CAM©.
There is general guidance for C0200 – C0500, including basic BIMS interview instruction and cue cards for
administering the BIMS in written format, as well as specific guidance on the individual items.

C0100. Should Brief Interview for Mental Status be Conducted?

Item Intent
The intent of this item is to identify if the Brief Interview for Mental Status (BIMS), a structured cognitive
interview, should occur.

Item Rationale
•
•

Most patients are able to attempt the Brief Interview for Mental Status (BIMS). The BIMS is a structured
cognitive interview.
A structured cognitive test is more accurate and reliable than observation alone for observing cognitive
performance.
o Without an attempted structured cognitive interview, a patient might be mislabeled based on their
appearance or assumed diagnosis.
o Structured interviews will efficiently provide insight into the patient’s current condition that will
enhance good care.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Interact with the patient using their preferred language. Be sure the patient can hear you and/or has access
to their preferred method for communication. If the patient appears unable to communicate, offer
alternatives such as writing, pointing, sign language, or cue cards.
• Determine if the patient is rarely/never understood verbally, in writing, or using another method. If
rarely/never understood: skip items C0200-C0500.

•

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Coding Instructions
If SOC/ROC assessment, complete as close to the time of SOC/ROC as possible. If discharge assessment,
complete as close to the time of discharge as possible.
•
•
•

Code 0, No, if the interview should not be conducted because the patient is rarely/never understood;
cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available.
Skip items C0200-C0500.
Code 1, Yes, if the interview should be conducted because the patient is at least sometimes understood
verbally, in writing, or using another method, and if an interpreter is needed, one is available. Proceed to
C0200, Repetition of Three Words.
Dash is a valid response for this item.
o A dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
•

Attempt to conduct the interview with ALL patients.

C0200-C0500: Brief Interview for Mental Status (BIMS)

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Item Intent
The intent of this item is to determine the patient’s attention, orientation and ability to register and recall

information.

Item Rationale
•
•
•
•

Direct or performance-based testing of cognitive function decreases the chance of incorrect labeling of
cognitive ability and improves detection of delirium.
Cognitively intact patients may appear to be cognitively impaired because of a language barrier, hearing
impairment, or lack of social interaction.
Some patients may appear to be more cognitively intact than they actually are.
If cognitive impairment is incorrectly diagnosed or missed, appropriate communication, worthwhile
activities and therapies may not be offered.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from Agency
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Basic Interview Instructions for BIMS (C0200-C0500)
•
•
•

•
•
•
•
•

Interview any patient not screened out by item C0100, Should Brief Interview for Mental Status Be
Conducted?
Conduct the interview in a private setting, if possible.
Be sure the patient can hear you.
o Patients with a hearing impairment should be tested using their usual communication
devices/techniques, as applicable.
o Try an external assistive device (headphones or hearing amplifier) if you have any doubt about
hearing ability.
o Minimize background noise.
Sit so that the patient can see your face. Minimize glare by directing light sources away from the patient’s
face.
Give an introduction before starting the interview. Suggested language: “I would like to ask you some
questions. We ask everyone these same questions. This will help us provide you with better care. Some of
the questions may seem very easy, while others may be more difficult.”
If the patient expresses concern that you are testing their memory, they may be more comfortable if you
reply: “We ask these questions of everyone so we can make sure that our care will meet your needs.”
Directly ask the patient each item in C0200 through C0400 at one sitting and in the order provided.
If the patient chooses not to answer a particular item, accept their refusal and move on to the next
questions. For C0200 through C0400, code refusals as incorrect/no answer or could not recall.

Instructions for BIMS When Administered in Writing
• Interview any patient not screened out by Should Brief Interview for Mental Status Be Conducted? item
(C0100).
• Conduct the interview in a private setting, if possible.
o Patients with visual impairment should be tested using their usual visual aids.
o Minimize glare by directing light sources away from the patient’s face and from written materials.
• Provide a written introduction before starting the interview.
• Suggested language: “I would like to ask you some questions, which I will show you in a moment. We ask
everyone these same questions. This will help us provide you with better care. Some of the questions may
seem very easy, while others may be more difficult. We ask these questions of everyone so we can make
sure that our care will meet your needs.”
• Directly provide the written questions for each item in C0200 through C0400 at one sitting and in the order
provided.
o For each BIMS question, show the patient a sheet of paper or card with the instruction for that
question from the form clearly written in a large enough font to be easily seen.
o The patient may respond to any of the BIMS questions in writing.
o Show separate sheets or cards for each question or statement.
o For C0200 items, instructions should be written as:
 I have written 3 words for you to remember. Please read them. Then I will remove the card
and ask you repeat or write down the words as you remember them.

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Category cues should be provided to the patient in writing after the patient’s first attempt to
answer. Written category cues should state: “sock, something to wear; blue, a color; bed, a
piece of furniture.”
o For C0300 items, instructions should be written as:
 C0300A: “Please tell me what year it is right now.”
 C0300B: “What month are we in right now?”
 C0300C: “What day of the week is today?”
o For C0400 items, instructions should be written as:
 Let’s go back to an earlier question. What were those three words that I asked you to repeat?”
 If the patient is unable to remember a word, provide Category cues again, but without using
the actual word. Therefore, Category cues for:
1. C0400A should be written as “something to wear,”
2. C0400B should be written as “a color,” and
3. C0500C should be written as “a piece of furniture.”
• If the patient chooses not to answer a particular item, accept their refusal and move on to the next question.
For C0200 through C0400C, code refusals as incorrect/no answer or could not recall.
• Rules for stopping the interview are the same as for administering the BIMS verbally, see Coding Tips.
The agency may develop their own signs for this process. If the agency develops their own, they must use
the exact language as that used in the item set.


Coding Instructions
See coding instructions for individual items. If SOC/ROC assessment, collect as close to the time of SOC/ROC as
possible. If discharge assessment, complete as close to the time of discharge as possible.
•

Dash is a valid response for this item.
o A dash indicates “no information”. CMS expects dash use to be a rare occurrence.

Coding Tips
Nonsensical responses, incorrect answers, and questions the patient chooses not to answer should be
coded as zero.
o The assessing clinician should track the reason for coding answers as zero because this information
will be used later for the coding of the summary score in C0500.
• Rules for stopping the BIMS interview before it is complete:
o Stop the interview after completing (C0300C) “Day of the Week” if:
 All responses have been nonsensical (i.e., any response that is unrelated, incomprehensible,
or incoherent; not informative with respect to the item being rated), OR
 there has been no verbal or written response to any of the questions up to this point, OR
 there has been no verbal or written response to some questions up to this point and for all
others, the patient has given a nonsensical response.
o If the interview is stopped, do the following:
 Code “-” (dash) in C0400A, C0400B, and C0400C.
 Code 99 in the summary score in C0500.
• If all responses to C0200, C0300A, C0300B, and C0300C are 0 because answers are incorrect, continue
interview.
•

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Examples of Incorrect Answers, Refusals, and Nonsensical Responses
Code 0 is used to represent three types of responses: incorrect answers (unless the item itself provides an
alternate response code), nonsensical responses, and questions the patient chooses not to answer (or “refusals”).
Since zeros resulting from these three situations are treated differently when coding the summary score in
C0500, the assessing clinician may find it valuable to track the reason for the zero reponse to aid in accurately
calculating the summary score.
1. Assessing clinician asks patient to state the year. The patient replies that it is 1935. This answer is incorrect
but related to the question.
Coding: This answer is coded 0, incorrect but would NOT be considered a nonsensical response.
Rationale: The answer is wrong, but it is logical and relates to the question.
2. Assessing clinician asks patient to state the year. The patient says, “Oh what difference does the year make
when you’re as old as I am?” The clinician asks the patient to try to name the year, and the patient shrugs.
Coding: This answer is coded 0, incorrect but would NOT be considered a nonsensical response.
Rationale: The answer is wrong because refusal is considered a wrong answer, but the patient’s
comment is logical and clearly relates to the question.
3. Assessing clinician asks the patient to name the day of the week. Patient answers, “blue, that’s my favorite
color.” The clinician asks the patient the question again to confirm the patient is not hearing the question
incorrectly, and the patient answers with the same response.
Coding: The answer is coded 0, incorrect; the response is illogical and nonsensical.
Rationale: The answer is wrong, and the patient’s comment clearly does not relate to the question; it is
nonsensical.

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Cue Cards for BIMS
Written Introduction Card – BIMS – Items C0200-C0400

I would like to ask you some questions,
which I will show you in a moment.
We ask everyone these same questions.
This will help us provide you with better
care.
Some of the questions may seem very
easy, while others may be more difficult.
We ask these questions so that we can
make sure that our care will meet your
needs.
Written Instruction Cards – Item C0200 – Repetition of Three Words

I have written 3 words for you to remember.
Please read them.
Then, I will remove the card and ask you to
repeat or write down the words as you
remember them.

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Word Card - Item C0200

SOCK
BLUE
BED

Category Cue Card – Item C0200

SOCK, something to wear
BLUE, a color
BED, a piece of furniture

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Written Instruction Cards – Item C0300 – Temporal
Orientation Statement Card – C0300A – Year

Section C: Cognitive Patterns

Please tell me what year it is right now.

Question Card – C0300B – Month

What month are we in right now?

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Question Card – Item C0300C – Day

What day of the week is today?

Written Instruction Card – Item C0400 – Recall

Let’s go back to an earlier question
What were those three words that I asked
you to repeat?

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Category Cue Card – Item C0400A – Sock

Something to wear

Category Cue Card – Item C0400B – Blue

A color

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Category Cue Card – Item C0400C- Bed

A piece of furniture

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C0200: Repetition of Three Words

Item Rationale
The inability to repeat three words on first attempt may indicate:
•
•
•
•

a memory impairment
a hearing impairment,
a language barrier, or
inattention that may be a sign of delirium or another health issue.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Basic BIMS interview instructions are shown on pages 65, 66, and 67. In addition, for C0200: Repetition of
Three Words:
•

•
•

Say to the patient: “I am going to say three words for you to remember. Please repeat the words after I
have said all three. The words are: sock, blue, and bed.” Assessing clinicians need to use the words and
related category cues as indicated. If the interview is being conducted with an interpreter present, the
interpreter should use the equivalent words and similar, relevant prompts for category cues.
Immediately after presenting the three words, say to the patient: “Now please tell me the three words.”
After the patient’s first attempt to repeat the items:
o If the patient correctly stated all three words, say, “That’s right, the words are sock, something to
wear; blue, a color; and bed, a piece of furniture” [category cues].

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o Category cues serve as a hint that helps prompt patients’ recall ability. Putting words in context
stimulates learning and fosters memory of the words that patients will be asked to recall in item
C0400, even among patients able to repeat the words immediately.
o If the patient recalled two or fewer words, code C0200, Repetition of Three words according to the
patient’s recall on this first attempt. Next say to the patient: “Let me say the three words again. They
are sock, something to wear; blue, a color; and bed, a piece of furniture. Now tell me the three
words.” If the patient still does not recall all three words correctly, you may repeat the words and
category cues one more time. Do not code the number of repeated words on the second or third
attempt.
o If the patient does not repeat all three words after three attempts, re-assess ability to hear. If the
patient can hear, move on to the next question. If they are unable to hear, attempt to maximize
hearing (alter environment, use hearing amplifier) before proceeding.

Coding Instructions
Record the maximum number of words that the patient correctly repeated on the first attempt. This will be any
number between 0 and 3.
•
•
•
•
•

Code 0, none, if the patient did not repeat any of the 3 words on the first attempt.
Code 1, one, if the patient repeated only 1 of the 3 words on the first attempt.
Code 2, two, if the patient repeated only 2 of the 3 words on the first attempt.
Code 3, three, if the patient repeated all 3 words on the first attempt.
Dash is a valid response for this item.
o A dash indicates “no information”. CMS expects dash use to be a rare occurrence.

Coding Tips
•
•

The words may be recalled in any order and in any context. For example, if the words are repeated back in
a sentence, they would be counted as repeating the words.
Do not score the number of repeated words on the second or third attempt. These attempts help with
learning the item, but only the number correct on the first attempt go into the total score. Do not record the
number of attempts that the patient needed to complete.

Examples
1. The assessing clinician says, “The words are sock, blue, and bed. Now please tell me the three words.” The
patient replies, “Bed, sock, and blue.” The clinician repeats the three words with category cues, by saying,
“That’s right, the words are sock, something to wear; blue, a color; and bed, a piece of furniture.”
Coding: C0200 Repetition of Three Words would be coded 3, three words correct.
Rationale: The patient repeated all three items on the first attempt. The order of repetition does not
affect the score. Per the Response Specific Instructions, the assessing clinician repeats the words with
the category cues after the patient correctly states all three words.
2. The assessing clinician says, “The words are sock, blue, and bed. Now please tell me the three words.” The
patient replies, “Sock, bed, black.” The clinician repeats the three words plus the category cues, saying, “Let
me say the three words again. They are sock, something to wear; blue, a color; and bed, a piece of furniture.
Now tell me the three words.” The patient says, “Oh yes, that’s right, sock, blue, bed.”
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Coding: C0200 Repetition of Three Words would be coded 2, two of three words correct.
Rationale: The patient repeated two of the three items on the first attempt. Patients are scored based on
the first attempt.
3. The assessing clinician says, “The words are sock, blue, and bed. Now please tell me the three words.” The
patient says, “Blue socks belong in the dresser.” The clinician codes according to the patient’s response.
Then the clinician repeats the three words plus the category cues, saying, “Let me say the three words again.
They are sock, something to wear; blue, a color; and bed, a piece of furniture. Now tell me the three words.”
The patient says, “Oh yes, that’s right, sock, blue, bed.”
Coding: C0200 Repetition of Three Words would be coded 2, two of the three words correct.
Rationale: The patient repeated two of the three items—blue and sock on the first attempt. The patient
put the words into a sentence, resulting in the patient repeating two of the three words.
4. The assessing clinician says, “The words are sock, blue, and bed. Now please tell me the three words.” The
patient replies, “What were those three words?” The patient’s response is coded and then the clinician
repeats the three words plus the category cues.
Coding: C0200 Repetition of Three Words would be coded 0, none of the words correct.
Rationale: The patient did not repeat any of the three words on the first attempt.

C0300: Temporal Orientation: Year, Month, Day

Item Rationale
•
•

A lack of temporal orientation may lead to decreased communication or participation in activities.
Not being oriented may be frustrating or frightening.

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Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Basic interview instructions for BIMS (C0200-0500) are shown on pages 65, 66, and 67. In addition, for C0300
(A, B, and C): Temporal Orientation:
• Ask the patient each of the 3 questions in Item C0300 separately.
• Allow the patient up to 30 seconds for each answer and do not provide clues.
• If the patient specifically asks for clues (e.g., “Is this the day my daughter always visits?”) respond by
saying, “I need to know if you can answer this question without any help from me.”

Coding Instructions for C0300A, Able to Report Correct Year
•
•
•
•
•

Code 0, missed by >5 years or no answer, if the patient’s answer is incorrect and is greater than 5
years from the current year or the patient chooses not to answer the item, or the answer is nonsensical.
Code 1, missed by 2-5 years, if the patient’s answer is incorrect and is within 2 to 5 years from the
current year.
Code 2, missed by 1 year, if the patient’s answer is incorrect and is within one year from the current
year.
Code 3, correct, if the patient states the correct year.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Examples
1. The date of interview is May 5, 2020. The patient, responding to the statement, “Please tell me what year it
is right now,” states that it is 2020.
Coding: C0300A would be coded 3, correct.
Rationale: 2020 is the current year at the time of this assessment.
2. The date of interview is June 16, 2020. The patient, responding to the statement, “Please tell me what year it
is right now,” states that it is 2017.
Coding: C0300A would be coded 1, missed by 2-5 years.
Rationale: 2017 is within 2 to 5 years of 2020.
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3. The date of interview is January 10, 2020. The patient, responding to the statement, “Please tell me what
year it is right now,” states that it is 1920.
Coding: C0300A would be coded 0, missed by more than 5 years.
Rationale: Even though the ’20 part of the year would be correct, 1920 is more than 5 years from
2020.
4. The date of interview is April 1, 2020. The patient, responding to the statement, “Please tell me what year it
is right now,” states that it is “’20.” The assessing clinician asks, “Can you tell me the full year?” The
patient still responds “’20,” and the assessing clinician asks again, “Can you tell me the full year, for
example, nineteen-eighty-two.” The patient states, “2020.”
Coding: C0300A would be coded 3, correct.
Rationale: Even though ’20 is partially correct, the only correct answer is the exact year. The patient
must state “2020,” not “20” or “1820” or “1920.”

Coding Instructions for C0300B, Able to Report Correct Month
Count the current day as day 1 when determining whether the response was accurate within 5 days or missed
by 6 days to 1 month.
•
•
•
•

Code 0, missed by >1 month or no answer, if the patient’s answer is incorrect by more than 1
month or if the patient chooses not to answer the item, or the answer is nonsensical.
Code 1, missed by 6 days to 1 month, if the patient’s answer is accurate within 6 days to 1 month.
Code 2, accurate within 5 days, if the patient’s answer is accurate within 5 days, count current date
as day 1.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Examples

1. The date of interview is June 25, 2020. The patient, responding to the question, “What month are we in right
now?” states that it is June.
Coding: C0300B would be coded 2, accurate within 5 days.
Rationale: The patient correctly stated the month.
2. The date of interview is June 28, 2020. The patient, responding to the question, “What month are we in right
now?” states that it is July.
Coding: C0300B would be coded 2, accurate within 5 days.
Rationale: The patient correctly stated the month within 5 days, even though the correct month is June.
June 28th (day 1) + 4 more days is July 2nd, so July is within 5 days of the interview.

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3. The date of interview is June 25, 2020. The patient, responding to the question, “What month are we in right
now?” states that it is July.
Coding: C0300B would be coded 1, missed by 6 days to 1 month.
Rationale: The patient missed the correct month by six days. June 25th (day 1) + 5 more days = June
30th. Therefore, the patient’s answer is incorrect within 6 days to 1 month.
4. The date of interview is June 30, 2020. The patient, responding to the question, “What month are we in right
now?” states that it is August.
Coding: C0300B would be coded 0, missed by more than 1 month.
Rationale: The patient missed the month by more than 1 month.
5. The date of interview is June 2, 2020. The patient, responding to the question, “What month are we in right
now?” states that it is May.
Coding: C0300B would be coded 2, accurate within 5 days.
Rationale: June 2 minus 5 days = May 29th. The patient correctly stated the month within 5 days even
though the current month is June.

Coding Instructions for C0300C, Able to Report Correct Day of the Week
•
•
•

Code 0, incorrect, or no answer, if the answer is incorrect or the patient chooses not to answer the
item, or the answer is nonsensical.
Code 1, correct, if the answer is correct.
Dash is a valid response for this item.
o CMS expects dash use to be a rare occurrence.

Examples
1. The day of interview is Monday, June 27, 2020. The assessing clinician asks: “What day of the week is it
today?” The patient responds, “It’s Monday.”
Coding: C0300C would be coded 1, correct.
Rationale: The patient correctly stated the day of the week.
2. The day of interview is Monday, June 27, 2020. The patient, responding to the question, “What day of the
week is it today?” states, “Tuesday.”
Coding: C0300C would be coded 0, incorrect.
Rationale: The patient incorrectly stated the day of the week.
3. The day of interview is Monday, June 27, 2020. The patient, responding to the question, “What day of the
week is it today?” states, “Today is a good day.”
Coding: C0300C would be coded 0, incorrect.
Rationale: The patient did not answer the question correctly.
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C0400: Recall

Item Rationale
•
•

Many persons with cognitive impairment can be helped to recall if provided cues.
Providing memory cues can help maximize patient cognitive function and decrease frustration for those
patients who respond.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Basic interview instructions for BIMS (C0200-C0500) are shown on pages 65, 66, and 67. In addition, for
C0400 (A, B, and C): Recall:
• Ask the patient the following: “Let’s go back to an earlier question. What were those three words that I
asked you to repeat?”
• Allow up to 5 seconds for spontaneous recall of each word.
• For any word that is not correctly recalled after 5 seconds, provide the category cue used in C0200 (refer
to page 76 for the definition of category cue). Category cues should be used only after the patient is unable
to recall one or more of the three words.
• Allow up to 5 seconds after category cueing for each missed word to be recalled.

Coding Instructions
For each of the three words the patient is asked to remember:
• Code 0, no—could not recall, if the patient cannot recall the word even after being given the category
cue or if the patient responds with a nonsensical answer or chooses not to answer the item.
• Code 1, yes, after cueing, if the patient requires the category cue to remember the word.
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•
•

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Code 2, yes, no cue required, if the patient correctly remembers the word spontaneously without
cueing.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
•

If on the first try (without cueing), the patient names multiple items in a category, one of which is correct,
they should be coded as correct for that item.

•

If, however, the assessing clinician gives the patient the cue and the patient then names multiple items in
that category, the item is coded as could not recall, even if the correct item was in the list.

Examples
1. The patient is asked to recall the three words that were initially presented. The patient chooses not to answer
the question and states, “I’m tired, and I don’t want to do this anymore.”
Coding: C0400A-C0400C would be coded 0, no—could not recall, could not recall for each of the
three words.
Rationale: Choosing not to answer a question often indicates an inability to answer the question, so
refusals are coded 0, no—could not recall. This is the most accurate way to score cognitive function,
even though, on occasion, patients might choose not to answer for other reasons.
2. The patient is asked to recall the three words. The patient replies, “Socks, shoes, and bed.” The examiner
then cues, “One word was a color.” The patient says, “Oh, the shoes were blue.”
Coding: C0400A, sock, would be coded 2, yes, no cue required.
Rationale: The patient’s initial response to the question included “sock.” They are given credit for this
response, even though the patient also listed another item in that category (shoes), because they were
answering the initial question, without cueing.
Coding: C0400B, blue, would be coded 1, yes, after cueing.
Rationale: The patient did not recall spontaneously but did recall after the category cue was given.
Responses that include the word in a sentence are acceptable.
Coding: C0400C, bed, would be coded 2, yes, no cue required.
Rationale: The patient independently recalled the item on the first attempt.
3. The patient is asked to recall the three words. The patient answers, “I don’t remember.” The assessor then
says, “One word was something to wear.” The patient says, “Clothes.” The assessor then says, “OK, one
word was a color.” The patient says, “Blue.” The assessor then says, “OK, the last word was a piece of
furniture.” The patient says, “Couch.”
Coding: C0400A, sock, would be coded 0, no—could not recall.
Rationale: The patient did not recall the item, even with a cue.
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Coding: C0400B, blue, would be coded 1, yes, after cueing.
Rationale: The patient did recall after being given the cue.
Coding: C0400C, bed, would be coded 0, no—could not recall.
Rationale: The patient did not recall the item, even with a cue.

C0500: BIMS Summary Score

Item Rationale
The total score:
• Decreases the chance of incorrect labeling of cognitive ability and improves detection of delirium.
• Provides staff with a more reliable estimate of patient function and allows staff interactions with patients
that are based on more accurate impressions about patient ability.
The BIMS total score is highly correlated with Mini-Mental State Exam (MMSE; Folstein, Folstein, &
McHugh, 1975) scores. Scores from a carefully conducted BIMS assessment where patients can hear all
questions and the patient is not delirious suggest the following distributions:
• 13-15: cognitively intact
• 8-12: moderately impaired
• 0-7: severe impairment

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
•

After completing C0200-C0400:
o Add up the values for all questions from C0200 through C0400.

Coding Instructions
•

Enter the total score as a two-digit number. The total possible BIMS score ranges from 00 to 15.
o If the patient chooses not to answer a specific question(s), that question is coded as incorrect and the
item(s) counts in the total score. If, however, the patient chooses not to answer four or more items,
then the interview is coded as incomplete.
o To be considered a completed interview, the patient had to attempt and provide relevant answers to
at least four of the questions included in C0200-C0400C. To be relevant, a response only has to be

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related to the question (logical); it does not have to be correct. See coding tips that follow below for
patients who choose not to participate at all.
o Code 99, unable to complete interview, if (a) the patient chooses not to participate in the BIMS, (b)
if four or more items were coded 0 because the patient chose not to answer or gave a nonsensical
response, or (c) if any of the BIMS items is coded with a “-” (dash)
 Note: a zero score does not mean the BIMS was incomplete. To be incomplete, a patient had
to choose not to answer or give completely unrelated, nonsensical responses to four or more
items.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
•

Occasionally, a patient can communicate but chooses not to participate in the BIMS and therefore does not
attempt any of the items in the section. This would be considered an incomplete interview; enter code 99
for C0500, BIMS Summary Score.

Examples
1. The patient’s scores on items C0200-C0400 were as follows:
C0200 (repetition)
3
C0300A (year)
2
C0300B (month)
2
C0300C (day)
1
C0400A (recall “sock”)
2
C0400B (recall “blue”)
2
C0400C (recall “bed”)
0
Coding: C0500- BIMS summary score would be coded 12 (Sum of C0200-C0400C).
2. The patient’s scores on items C0200-C0400C were as follows:
C0200 (repetition)
C0300A (year)
C0300B (month)
C0300C (day)
C0400A (recall “sock”)
C0400B (recall “blue”)
C0400C (recall “bed”)

2
2
2
1
0
0
0

Coding: C0500- BIMS summary score would be coded as 07 (Sum of C0200-C0400C).
3. STOP the interview if each of items C0200-C0300C are coded as 0, because a patient chose not to
participate in the BIMS and/or has provided nonsensical answers and/or does not provide verbal or written
responses, then stop the interview after C0300C.

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Example: The patient’s score on items C0200-C0400C were as follows:
C0200 (repetition)
0
C0300A (year)
0
C0300B (month)
0
C0300C (day)
0 (Interview is stopped after C0300C)
C0400A (recall “sock”)
(-)
C0400B (recall “blue”)
(-)
C0400C (recall “bed”)
(-)
Coding: C0200-C0300C, are coded 0 and dashes entered for C0400A-C. C0500 – BIMS Summary
Score, enter code 99, unable to complete interview.
Note: a zero score does not mean the BIMS was incomplete. To be incomplete, a patient had to choose not to
answer or give completely unrelated, nonsensical responses to four or more items. If one or more of the zeros in
C0200 – C0300 are due to incorrect answers, the interview should continue.

C1310: Signs and Symptoms of Delirium

Item Intent
The intent of this item is to identify any signs or symptoms of acute mental status changes as compared to the
patient’s baseline status.

Item Rationale
Delirium is associated with:
• increased mortality,
• functional decline,
• development or worsening of incontinence,
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•
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behavior problems,
withdrawal from activities,
rehospitalizations and increased length of home health stay.

• Delirium can be misdiagnosed as dementia.
• A recent deterioration in cognitive function may indicate delirium, which may be reversible if detected
and treated in a timely fashion.
• Examples of acute mental status changes include:
o A patient who is usually noisy or belligerent becomes quiet, lethargic, or inattentive.
o A patient who is normally quiet and content suddenly becomes restless or noisy.
o A patient who is usually able to find their way around their living environment begins to get lost.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
If SOC/ROC assessment, complete as close to the time of SOC/ROC as possible. If discharge assessment,
complete as close to the time of discharge as possible.
• Observe patient behavior during the assessment for the signs and symptoms of delirium.
• Review medical record documentation and consult with other staff, family members/caregivers and others
in a position to determine the patient’s baseline status compared to status on the day of assessment.
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Consider all relevant information and use clinical judgment to determine if an acute change in mental
status has occurred.

Scoring Guide

Coding Instructions for C1310A, Acute Mental Status Change
•
•
•

Code 0, no, if there is no evidence of acute mental status change from the patient’s baseline.
Code 1, yes, if patient has an alteration in mental status observed or reported or identified that
represents an acute change from baseline.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Examples
1. Patient was admitted to home health. The family reports that the patient was alert and oriented prior to the
day of assessment. During the BIMS interview and assessment, the patient is lethargic and incoherent.
Coding: C1310A would be coded 1, yes.
Rationale: There is an acute change of the patient’s mental status from alert and oriented (family
report prior to admission) to lethargic and incoherent during the start of care assessment.
2. Caregiver reports that a patient with poor short-term memory and disorientation to time has suddenly
become agitated, calling out to their dead spouse, tearing off their clothes, and being completely disoriented
to time, person, and place.
Coding: C1310A would be coded 1, yes.
Rationale: The new behaviors represent an acute change in mental status.

Response-Specific Instructions for C1310B, Inattention
•
•

Assess attention separately from level of consciousness.
An additional step to identify difficulty with attention is to ask the patient to count backwards from 20.

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Coding Instructions for C1310B, Inattention
•
•
•

•

Code 0, behavior not present, if the patient remains focused during the assessment and all other
sources agree that the patient was attentive during other activities.
Code 1, behavior continuously present, does not fluctuate, if the patient had difficulty focusing
attention, was easily distracted, or had difficulty keeping track of what was said AND the inattention did
not vary. All sources must agree that inattention was consistently present to select this code.
Code 2, behavior present, fluctuates, if inattention is noted during the assessment or any source
reports that the patient had difficulty focusing attention, was easily distracted, or had difficulty keeping
track of what was said AND the inattention varied or if information sources disagree in assessing level of
attention.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Examples
1. A patient tries to answer all questions during the BIMS. Although they answer several items incorrectly and
respond “I don’t know” to others, the patient pays attention to the assessing clinician. The family indicates
that this is the patient’s consistent behavior.
Coding: C1310B would be coded 0, behavior not present.
Rationale: The patient remained focused throughout the assessment and this was constant during the
day of assessment.
2. Questions during the BIMS must be frequently repeated because the patient’s attention wanders. This
behavior occurs throughout the assessment. The family agrees that this behavior is consistently present. The
patient has a diagnosis of dementia.
Coding: C1310B would be coded 1, behavior continuously present, does not fluctuate.
Rationale: The patient’s attention consistently wandered throughout the assessment. The patient’s
dementia diagnosis does not affect the coding.
3. During the BIMS interview, the patient was not able to focus on all questions asked and their gaze
wandered. However, the family confirmed that the patient was attentive prior to the nurse arriving for the
home health visit.
Coding: C1310B would be coded 2, behavior present, fluctuates.
Rationale: Evidence of inattention was found during the assessment, but the family indicated the
patient had been attentive earlier in the day. This disagreement shows possible fluctuation in the
behavior. If any information source reports the symptom as present, C1310B cannot be coded as 0,
Behavior not present.
4. Patient is dazedly staring at the television for the first several questions. When you ask a question, the
patient looks at you momentarily but does not answer. Midway through questioning, they pay more
attention and try to answer.
Coding: C1310B would be coded 2, behavior present, fluctuates.
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Rationale: Patient’s attention fluctuated during the assessment. If as few as one source notes
fluctuation, then the behavior should be coded 2.

Coding Instructions for C1310C, Disorganized Thinking
•
•

•
•

Code 0, behavior not present, if all sources agree that the patient’s thinking was organized and
coherent, even if answers were inaccurate or wrong.
Code 1, behavior continuously present, does not fluctuate, if, during the assessment and
according to other sources, the patient’s responses were consistently disorganized or incoherent,
conversation was rambling or irrelevant, ideas were unclear or flowed illogically, or the patient
unpredictably switched from subject to subject.
Code 2, behavior present, fluctuates, if, during the assessment or according to other data sources,
the patient’s responses fluctuated between disorganized/incoherent and organized/clear. Also code as
fluctuating if information sources disagree.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Examples
1. The assessing clinician asks a patient, who is often confused, to give the date, and the patient’s response is:
“Let’s go get the sailor suits!” The patient continues to provide irrelevant or nonsensical responses
throughout the interview, and their family indicates this is constant.
Coding: C1310C would be coded 1, behavior continuously present, does not fluctuate.
Rationale: All sources agree that the disorganized thinking is constant.
2. A patient responds that the year is 1837 when asked to give the date. Their family indicates that the patient
is never oriented to time but has relevant conversations and does not ramble with incoherent speech. For
example, the family reports the patient often discusses their passion for baseball.
Coding: C1310C would be coded 0, behavior not present.
Rationale: The patient’s answer was related to the question, even though it was incorrect. No other
sources report disorganized thinking.
3. The patient was able to tell the assessing clinician their name, the year and where they were. The patient
was able to talk about the activity they just attended in the assisted living facility and the residents and staff
that also attended. Then the patient suddenly asked the clinician, “Who are you? What are you doing in my
daughter’s home?”
Coding: C1310C would be coded 2, behavior present, fluctuates.

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Rationale: The patient’s thinking fluctuated between coherent and incoherent at least once. If as few as
one source notes fluctuation, then the behavior should be coded 2.

Coding Instructions for C1310D, Altered Level of Consciousness
•
•
•

•

Code 0, behavior not present, if all sources agree that the patient was alert and maintained
wakefulness during conversation, interview(s), and activities.
Code 1, behavior continuously present, does not fluctuate, if, during the assessment and
according to other sources, the patient was consistently lethargic, stuporous, vigilant, or comatose.
Code 2, behavior present, fluctuates, if, during the assessment or according to other sources, the
patient’s level of consciousness varied. For example, the patient was at times alert and responsive, while at
other times the patient was lethargic, stuporous, or vigilant. Code as fluctuating if information sources
disagree.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Examples
1. At discharge, a patient is alert and conversational and answers all questions during the BIMS interview,
although not all answers are correct. Medical record documentation and family reports consistently note that
the patient was alert.
Coding: C1310D would be coded 0, behavior not present.
Rationale: All evidence indicates that the patient is alert during conversation, assessment(s) and
activities.
2. The patient is lying in bed. They arouse to soft touch but only converse for a short time before their eyes
close, and they appear to be sleeping. Again, the patient arouses to voice or touch but only for short periods
during the assessment. Information from the caregivers indicates that this has been the patient’s condition.
Coding: C1310D would be coded 1, behavior continuously present, does not fluctuate.
Rationale: The patient’s lethargy was consistent throughout the assessment, and there is consistent
validation from the caregivers..
3. The patient is usually alert, oriented to time, place, and person per family report. Today, at the time of the
BIMS interview, the patient is conversant at the beginning of the interview but becomes lethargic and
difficult to arouse.
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Coding: C1310D would be coded 2, behavior present, fluctuates.
Rationale: The level of consciousness fluctuated during the assessment. If as few as one source notes
fluctuation, then the behavior should be coded 2, fluctuating.

M1700: Cognitive Functioning

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

Response-Specific Instructions
•
•
•
•
•

Interview patient and/or caregiver interview and review referral information.
Consider the signs/symptoms of cognitive dysfunction that have occurred over the past 24 hours.
Consider the amount of supervision and care required due to cognitive deficits.
Links to cognitive assessment resources can be found in Appendix E of this manual.
Dash is not a valid response for this item.

Coding Tips
•
•

Diagnoses such as dementia, delirium, developmental 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.

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

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

Response-Specific Instructions
Interview the patient and/or caregiver and review the referral information.
Assess specifically for confusion in the past 14 days.
Codes 2, 3, and 4 differ from each other based on the time when the confusion occurred and the length of
time the confusion persists.
• Links to cognitive assessment resources can be found in Appendix E of this manual.

•
•
•

Coding Instructions
•
•
•
•
•

Code 0, Never, if the patient had no confusion in the last 14 days.
Code 1, In new or complex situations only, if the patient’s confusion is isolated to a new or a
complex situation.
Code 4, Constantly, if the patient’s confusion was present at all times during the entire 14 days.
Code, NA, Patient nonresponsive, if the patient is nonresponsive at the time of assessment and the
information cannot be elicited from the caregiver or other source.
Dash is not a valid response for this item.

Coding Tips
•

•

The “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 confusion reported or observed on or after August 6 and prior to the HHA admission would be
reported.
“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.

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If the patient is nonresponsive at the time of assessment, elicit from the caregiver or other sources whether
the patient experienced any confusion during the past 14 days.

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

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

Response-Specific Instructions
•
•

Interview the patient and/or caregiver and review referral information.
Links to cognitive assessment resources can be found in Appendix E of this manual.

Coding Instructions
•
•
•

Code 3, All of the time, if the patient felt anxious at all times during the entire look back period of 14
days.
Code NA, Patient nonresponsive, if the patient is nonresponsive at the time of assessment and the
information cannot be elicited from the caregiver or other source.
Dash is not a valid response for this item.

Coding Tips
•
•

•
•

Anxiety includes worry that interferes with learning and normal activities, feelings of being overwhelmed
and having difficulty coping, or symptoms of anxiety disorders.
The “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 anxiety reported or observed on or after August 6 and prior to the HHA admission would be reported.
“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 anxiety.
If the patient is nonresponsive at the time of assessment, elicit from the caregiver or other sources whether
the patient experienced any anxiety during the past 14 days.

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SECTION D: MOOD
Introduction
This section contains items that address mood distress. The presence of indicators does not automatically mean
that the patient has a diagnosis of depression or other mood disorder.

D0150: Patient Mood Interview (PHQ-2 to 9)

Item Intent
This item identifies the presence of signs and symptoms of mood distress, a serious condition that is
underdiagnosed and undertreated in home health and is associated with significant morbidity. It is particularly
important to identify signs and symptoms of mood distress among home health patients because these signs and
symptoms can be treatable.

Item Rationale
Depression can be associated with:
•
•
•
•

psychological and physical distress,
decreased participation in therapy and activities,
decreased functional status, and
poorer outcomes.

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Mood disorders are common in home health and are often underdiagnosed and undertreated.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
If SOC/ROC assessment, complete as close to the time of SOC/ROC as possible. If discharge assessment,
complete as close to the time of discharge as possible.
•
•
•
•

•

•
•

Conduct the interview in a private setting, if possible.
Interact with the patient using their preferred language.
o If the patient appears unable to communicate, offer alternatives such as writing, pointing, sign
language, or cue cards.
If an interpreter is used during patient interviews, the interpreter should not attempt to determine the intent
behind what is being translated, the outcome of the interview, or the meaning or significance of the
patient’s responses.
Explain the reason for the interview before beginning.
Suggested language: “I am going to ask you some questions about your mood and feelings over the past
2 weeks. I will also ask about some common problems that are known to go along with feeling down.
Some of the questions might seem personal, but everyone is asked to answer them. This will help us
provide you with better care.”
Explain and/or show the interview response choices. A cue card with the response choices clearly written
in large print might help the patient comprehend the response choices.
Suggested language: “I am going to ask you how often you have been bothered by a particular problem
over the last 2 weeks. I will give you the choices that you see on this card.” (Say while pointing to cue
card): “0-1 days—never or 1 day, 2-6 days—several days, 7-11 days—half or more of the days, or 12-14
days—nearly every day.”
Ask the first two questions (D0150A D0150B) of the Patient Mood Interview (PHQ-2 to 9).
“Over the last 2 weeks, have you been bothered by any of the following problems?”
For each of the questions:
o Read the item as it is written.
o Do not provide definitions because the meaning must be based on the patient’s interpretation. For
example, the patient defines for themself what “feeling down” means; the item should be scored
based on the patient’s interpretation.

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o Each question must be asked in sequence to assess presence (column 1) and frequency (column 2)
before proceeding to the next question.
o Enter code 9 if the patient was unable or chose not to complete the interview or responded
nonsensically and/or the agency was unable to complete the assessment. A nonsensical response is
one that is unrelated, incomprehensible, or incoherent or if the patient’s response is not informative
with respect to the item being rated (e.g., when asked the question about “poor appetite or
overeating,” the patient answers, “I always win at poker.”).
o For a yes response, ask the patient to tell you how often they were bothered by the symptom over the
last 2 weeks. Use the response choices in D0150 Column 2, Symptom Frequency. Start by asking
the patient the number of days that they were bothered by the symptom and read and show cue card
with frequency categories/descriptions (0-1 days—never or 1 day, 2-6 days—several days, 7-11
days—half or more of the days, or 12-14 days—nearly every day).
• Determine if the patient is rarely/never understood verbally, in writing, or using another method. If
rarely/never understood: Code D0150A1 and D0150B1 as 9 (No response) and leave D0150A2 and
D0150B2 blank, end the PHQ-2 interview and skip D0160.
• Determine whether to complete the PHQ-9 (i.e., ask the remaining seven questions: D0150C to D0150I.
Whether or not further evaluation of a patient’s mood is needed depends on the patient’s responses to the
PHQ-2 (D0150A and D0150B).
o If both D0150A2 and D0150B2 are less than 2 there is no need to continue to the PHQ-9. End the
PHQ-2 and enter the total score from D0150A2 and D0150B2 in D0160 – Total Severity Score.
o If both D0150A2 and D0150B2 are blank, then end the PHQ-2 and skip D0160.
o If either D0150A2 or D0150B2 are 2 or 3, then you must complete the PHQ-9. Proceed to ask the
remaining seven questions (D0150C to D0150I) of the PHQ-9 and complete D0160 – Total Severity
Score.

Coding Instructions for Column 1: Symptom Presence
Record the patient’s responses as they are stated, regardless of whether the patient or the assessor attributes
the symptom to something other than mood.
•
•
•
•

Code 0, no: if patient indicates symptoms listed are not present. Enter 0 in Column 2 as well.
Code 1, yes: if patient indicates symptom listed is present. Enter 0, 1, 2, or 3 in Column 2, Symptom
Frequency.
Code 9, no response, if the patient was unable or chose not to complete the interview, responded
nonsensically and/or the agency was unable to complete the assessment. Leave Column 2, Symptom
Frequency, blank.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Instructions for Column 2: Symptom Frequency
•
•

Code 0, never or 1 day, if the patient indicates that during the past 2 weeks they have never been
bothered by the symptom or have only been bothered by the symptom on 1 day.
Code 1, 2-6 days (several days), if the patient indicates that during the past 2 weeks they have been
bothered by the symptom for 2-6 days.

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Code 2, 7-11 days (half or more of the days), if the patient indicates that during the past 2 weeks
they have been bothered by the symptom for 7-11 days.
Code 3, 12-14 days (nearly every day), if the patient indicates that during the past 2 weeks they have
been bothered by the symptom for 12-14 days.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
Attempt to conduct the interview with ALL patients.
For question D0150I, Thoughts That You Would Be Better Off Dead or of Hurting Yourself in Some
Way:
o Beginning interviewers may feel uncomfortable asking this item because they may fear upsetting the
patient or may feel that the question is too personal. Others may worry that it will give the patient
inappropriate ideas. However,
 Experienced interviewers have found that most patients who are having this feeling
appreciate the opportunity to express it.
 Asking about thoughts of self-harm does not give the person the idea. It does let the provider
better understand what the patient is already feeling.
 The best interviewing approach is to ask the question openly and without hesitation.
• If the patient uses their own words to describe a symptom, this should be briefly explored. If you
determine that the patient is reporting the intended symptom but using their own words, ask them to tell
you how often they were bothered by that symptom.
o Select only one frequency response per item.
 If the patient has difficulty selecting between two frequency responses, code for the higher
frequency.
 If Column 1 equals 0, enter 0 in Column 2.
 If Column 1 equals 9, leave Column 2 blank.
 If the patient describes the presence of a symptom, but cannot quantify a frequency, code the
presence of the symptom as “1: Yes” in Column 1 and enter a dash in Column 2.
 Some items (e.g., item F) contain more than one phrase. If a patient gives different
frequencies for the different parts of a single item, select the highest frequency as the score
for that item.
• Patients may respond to questions:
o verbally,
o by pointing to their answers on the cue card, OR
o by writing out their answers
•
•

Interviewing Tips and Techniques
•
•

Repeat a question if you think that it has been misunderstood or misinterpreted.
Some patients may be eager to talk with you and will stray from the topic at hand. When a person strays,
you should gently guide the conversation back to the topic.
o Example: Say, “That’s interesting, now I need to know…”; “Let’s get back to…”; “I understand,
can you tell me about….”

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Validate your understanding of what the patient is saying by asking for clarification.
o Example: Say, “I think I hear you saying that…”; “Let’s see if I understood you correctly.”; “You
said…. Is that right?”
• If the patient has difficulty selecting a frequency response, start by offering a single frequency response
and follow with a sequence of more specific questions. This is known as unfolding.
o Example: Say, “Would you say [name symptom] bothered you more than half the days in the past 2
weeks?”
 If the patient says “yes,” show the cue card and ask whether it bothered them nearly every
day (12-14 days) or on half or more of the days (7-11 days).
 If the patient says “no,” show the cue card and ask whether it bothered them several days (26 days) or never or 1 day (0-1 day).
• Noncommittal responses such as “not really” should be explored. Patients may be reluctant to report
symptoms and should be gently encouraged to tell you if the symptom bothered them, even if it was only
some of the time. This is known as probing. Probe by asking neutral or nondirective questions such as:
o “What do you mean?”
o “Tell me what you have in mind.”
o “Tell me more about that.”
o “Please be more specific.”
o “Give me an example.”
• Sometimes respondents give a long answer to interview items. To narrow the answer to the response
choices available, it can be useful to summarize their longer answer and then ask them which response
option best applies. This is known as echoing.
o Example: Item D0150E, Poor Appetite or Overeating. The patient responds “the food is always
cold and it just doesn’t taste like it does at home. The doctor won’t let me have any salt.”
 Possible clinician response: “You’re telling me the food isn’t what you eat at home and you
can’t add salt. How often would you say that you were bothered by poor appetite or overeating during the last 2 weeks?”
o Example: Item D0150A, Little Interest or Pleasure in Doing Things. The patient, when asked
how often they have been bothered by little interest or pleasure in doing things, responds, “There’s
nothing to do here, all you do is eat, bathe, and sleep. They don’t do anything I like to do.”
 Possible clinician response: “You’re saying there isn’t much to do here and I want to come
back later to talk about some things you like to do. Thinking about how you’ve been feeling
over the past 2 weeks, how often have you been bothered by little interest or pleasure in
doing things.”
o Example: Item D0150B, Feeling Down, Depressed, or Hopeless. The patient, when asked how
often they have been bothered by feeling down, depressed, or hopeless, responds: “How would you
feel if you were here?”
 Possible clinician response: “You asked how I would feel, but it is important that I
understand your feelings right now. How often would you say that you have been bothered
by feeling down, depressed, or hopeless during the last 2 weeks?”
• If the patient has difficulty with longer items, separate the item into shorter parts, and provide a chance to
respond after each part. This method, known as disentangling, is helpful if a patient has moderate
cognitive impairment but can respond to simple, direct questions.
•

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o Example: Item D0150E, Poor Appetite or Overeating.
 You can simplify this item by asking: “In the last 2 weeks, how often have you been bothered
by poor appetite?” (pause for a response) “Or overeating?”
o Example: Item D0150C, Trouble Falling or Staying Asleep, or Sleeping Too Much.
 You can break the item down as follows: “In the past 2 weeks, how often have you been
bothered by having problems falling asleep?” (pause for response) “How often are you been
bothered by having problems staying asleep?” (pause for response) “How often have you
been bothered by feeling you are sleeping too much?”
o Example: Item D0150H, Moving or Speaking So Slowly That Other People Could Have Noticed.
Or the Opposite—Being So Fidgety or Restless That You Have Been Moving Around a Lot More
than Usual.
 You can simplify this item by asking: “In the past 2 weeks, how often have you been
bothered by having problems with moving or speaking so slowly that other people could
have noticed?” (pause for response) “How often have you been bothered by feeling so
fidgety or restless that you move around a lot more than usual?”

Examples

1. Assessing clinician: “Over the past 2 weeks, have you been bothered by any of the following problems?
Little interest or pleasure in doing things?”
Patient: “I’m not interested in doing much. I just don’t feel like it. I used to enjoy visiting with friends, but I
don’t do that much anymore. I’m just not interested.”
Assessing clinician: “In the past two weeks, how often would you say you have been bothered by this?
Would you say never or 1 day, 2-6 days, 7-11 days, or 12-14 days?
Patient: “7-11 days.”
Coding: D0150A1 (symptom presence) would be coded 1, yes and D0150A2 (Symptom frequency)
would be coded 2, 7-11 days.
Rationale: The patient indicates that they have lost interest in activities that they previously enjoyed.
The patient indicates that the symptom has bothered them 7-11 days in the past two weeks.
2. Assessing clinician: “Over the past 2 weeks, have you had trouble concentrating on things, such as reading
the newspaper or watching television?”
Patient: “Television? I used to like watching the news. I can’t concentrate on that anymore.”
Assessing clinician: “In the past two weeks, how often have you been bothered by having difficulty
concentrating on things like television? Would you say never or 1 day, 2-6 days, 7-11 days, or 12-14 days?
Patient: “I’d say every day. It bothers me every day.”
Coding: D0150G1 (symptom presence) would be coded 1, yes and D0150G2 (Symptom frequency)
would be coded 3, 12-14 days.
Rationale: The patient states that they have trouble concentrating and that this bothers them every day.

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Section D: Mood

D0160: Total Severity Score

Item Intent
This item identifies the severity score calculated from responses to the PHQ-2 to 9, item D0150.

Item Rationale
•
•

The score does not diagnose a mood disorder or depression but provides a standard score which can be
communicated to the patient’s physician, other clinicians and mental health specialists for appropriate
follow up.
The Total Severity Score is a summary of the frequency scores on the PHQ-2 to 9 that indicates the
extent of potential depression symptoms.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Do not add up the score while you are interviewing the patient. Instead, focus your full attention on the
interview.
• Use the scoring guide to complete scoring: Scoring Rules: Patient Mood Interview Total Severity
Score D0160.
• The maximum patient score is 27 (3 x 9).
•

Coding Instructions
•
•
•
•
•

If only the PHQ-2 is completed because D0150A2 and D0150B2 are less than 2 (but not blank) add the
numeric scores from these two frequency items and enter the value in D0160
If the PHQ-9 was completed (D0150C-I were not skipped due to the responses in D0150A and B), and if
the patient answered the frequency responses of at least 7 of the 9 items on the PHQ- 9; add the numeric
scores from D0150A2-D0150I2 and enter in D0160 Total Severity Score.
If symptom frequency is blank for 3 or more items, the interview is deemed NOT complete. Total
Severity Score should be coded as “99”
The Total Severity Score will be between 00 and 27 (or “99” if symptom frequency is blank for 3 or
more items).
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

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Coding Tips
Responses to PHQ-2 to 9 can indicate possible depression if the full PHQ-2 to 9 is completed (i.e.,
interview is not stopped after D0150B due to responses). Responses can be interpreted as follows:
o Major Depressive Syndrome is suggested if—of the 9 items—5 or more items are identified at a
frequency of half or more of the days (7-11 days) during the look-back period.
o Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down, depressed or hopeless,
(2) trouble falling or staying asleep, or sleeping too much, or (3) feeling tired or having little energy
are identified at a frequency of half or more of the days (7-11 days) during the look-back period.
o In addition, PHQ-2 to 9 Total Severity Score can be used to track changes in severity over time.
Total Severity Score can be interpreted as follows:
 0-4:
minimal depression
 5-9:
mild depression
 10-14:
moderate depression
 15-19:
moderately severe depression
 20-27:
severe depression

•

Scoring Rules: Patient Mood Interview Total Severity Score D0160
If only the PHQ-2 is completed because both D0150A2 and D0150B2 are less than 2 (but not blank), add
the numeric scores from these two frequency items and enter the value in D0160.
If items D0150C through D0150I were asked, calculate the Total Severity Score:
•

•

•
•
•
•
•

Item D0160 is used to store the total severity score for the Patient Mood Interview. The score in item
D0160 is based upon the sum of the values that are contained in the following nine items: D0150A2,
D0150B2, D0150C2, D0150D2, D0150E2, D0150F2, D0150G2, D0150H2, and D0150I2. These are
referred to as the "items in Column 2", below.
The following rules explain how to compute the score that is placed in item D0160. These rules consider
the "number of missing items in Column 2" which is the number of items in Column 2 that are either
skipped or are equal to dash. An item in Column 2 is skipped if the corresponding item in Column 1 was
equal to 9 (no response). An item in Column 2 could be equal to dash if the item could not be assessed
for some other reason (e.g., if the Patient was unexpectedly discharged before the interview could be
completed).
If all of the items in Column 2 have a value of 0, 1, 2, or 3 (i.e., they all contain non-missing values),
then item D0160 is equal to the simple sum of those values.
If any of the items in Column 2 are skipped or equal to dash, then omit their values when computing the
sum.
If the number of missing items in Column 2 is equal to one, then compute the simple sum of the eight
items in Column 2 that have non-missing values, multiply the sum by 9/8 (1.125), and place the result
rounded to the nearest integer in item D0160.
If the number of missing items in Column 2 is equal to two, then compute the simple sum of the seven
items in Column 2 that have non-missing values, multiply the sum by 9/7 (1.286), and place the result
rounded to the nearest integer in item D0160.
If the number of missing items in Column 2 is equal to three or more, then item D0160 must equal [99].

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Examples
1. All Items in Column 2 Have Non-missing Values
The following example shows how to score the Patient interview when all of the items in Column 2 have
non-missing values:
Item

Value

D0150A2

1

D0150B2

2

D0150C2

2

D0150D2

0

D0150E2

3

D0150F2

0

D0150G2

1

D0150H2

3

D0150I2

2

D0160

14

Rationale: In this example, all of the items in Column 2 have non-missing values (i.e., none of the
values are skipped or equal to dash). Therefore, the value of D0160 is equal to the simple sum of the
values in Column 2, which is 14.
2. One Missing Value in Column 2
The following example shows how to score the Patient interview when one of the items in Column 2 has a
missing value:
Item

Value

D0150A2

1

D0150B2

2

D0150C2
D0150D2

0

D0150E2

3

D0150F2

0

D0150G2

1

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D0150H2

3

D0150I2

1

D0160

12

Rationale: In this example, one of the items in Column 2 (D0150C2) has a missing value (it is blank or
skipped) and the other 8 items have non-missing values. D0160 is computed as follows:
1. Compute the sum of the 8 items with non-missing values. This sum is 11.
2. Multiply this sum by 1.125. In the example, 11 x 1.125 = 12.375.
3. Round the result to the nearest integer. In the example, 12.375 rounds to 12.
4. Place the rounded result in D0160.
3. Two Missing Values in Column 2
The following example shows how to score the Patient interview when two of the items in Column 2 have
missing values:
Item
Value
D0150A2

1

D0150B2

2

D0150C2
D0150D2

0

D0150E2

3

D0150F2

0

D0150G2

1

D0150H2

1

D0150I2

-

D0160

10

Rationale: In this example, two of the items in Column 2 have missing values: D0150C2 is blank or
skipped, and D0150I2 is equal to dash. The other 7 items have non-missing values. D0160 is computed
as follows:
1. Compute the sum of the 7 items with non-missing values. This sum is 8.
2. Multiply this sum by 1.286. In the example, 8 x 1.286 = 10.288.
3. Round the result to the nearest integer. In the example, 10.288 rounds to 10.
4. Place the rounded result in D0160.
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4. Three or More Missing Values in Column 2
The following example shows how to score the Patient interview when three or more of the items in Column
2 have missing values and at least one of the values is not equal to dash:
Item

Value

D0150A2

1

D0150B2

2

D0150C2
D0150D2

0

D0150E2

3

D0150F2
D0150G2

-

D0150H2

3

D0150I2

2

D0160

99

Rationale: In this example, three of the items in Column 2 have missing values: D0150C2 and
D0150F2 are blank or skipped, and D0150G2 is equal to dash. Because three or more items have
missing values, D0160 is equal to 99.

D0700: Social Isolation

Item Intent
The intent of this item is to identify the patient’s actual or perceived lack of contact with other people, such as
living alone or residing in a remote area.

Item Rationale
•

Social isolation tends to increase with age, is a risk factor for physical and mental illness, and a predictor
of mortality.

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Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
This item is intended to be a patient self-report item. No other source should be used to identify the
response.
• Complete as close to the time of SOC/ROC and DC as possible.
• Data sources/resources: Ask for the patient, “How often do you feel lonely or isolated from those around
you?”

•

Coding Instructions
•
•
•
•
•
•
•
•

Code 0, Never, if the patient indicates never feeling lonely or isolated from others
Code 1, Rarely, if the patient indicates rarely feeling lonely or isolated from others
Code 2, Sometimes, if the patient indicates sometimes feeling lonely or isolated from others
Code 3, Often, if the patient indicates often feeling lonely or isolated from others
Code 4, Always, if the patient indicates always feeling lonely or isolated from others
Code 7, Patient declines to respond, if the patient declines to respond
Code 8, Patient unable to respond, if the patient is unable to respond
Dash is not a valid response for this item

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Section E: Behavior

SECTION E: BEHAVIOR
Introduction

The items in this section help to identify and describe the presence and frequency of behaviors associated with a
variety of disorders.

M1740: Cognitive, behavioral, and psychiatric symptoms

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

Response-Specific Instructions
•

•
•

Interview the patient and/or caregiver, conduct a physical assessment, including observation of the patient.
Review the clinical record, including but not limited to, referral information and physician history and
physical. Links to cognitive assessment resources can be found in Appendix E of this manual.
Behaviors reported could be identified by a formal diagnosis and/or determined by clinical judgment of
the assessing clinician.
Behaviors which are severe enough to make the patient unsafe to self or others, cause considerable stress
to the caregivers and/or require supervision or intervention should be included.

Coding Instructions
•
•

Code 7, None of the above behaviors demonstrated, when none of the other responses are
selected.
Dash is not a valid response for this item.

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M1745: Frequency of Disruptive Behavior Symptoms (Reported or
Observed)

Item Intent
Identifies the 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

Response-Specific Instructions
Interview the patient and/or caregiver and conduct a physical assessment, including observation of the
patient. Behaviors can be reported by the patient, caregiver, family, or others, and/or observed by the
clinician.
• Review the clinical record, including but not limited to the referral information and the physician history
and physical. Links to additional information sources can be found in Appendix E of this manual. Use
professional judgment to determine if the behavior is disruptive or dangerous to the patient or others.
• Consider any and all disruptive/dangerous behaviors to respond to this item, not just the behaviors listed in
M1740. Then consider how frequently these behaviors occur.
• Include behaviors considered symptomatic of neurological, cognitive, behavioral, developmental, or
psychiatric disorders, identified by diagnosis and/or the assessing clinician’s professional judgment.
•

Coding Instructions
•

Dash is not a valid response for this item.

Coding Tips
•

Examples of disruptive/dangerous behaviors include but are not limited to sleeplessness, “sun-downing,”
agitation, wandering, aggression, combativeness, and/or getting lost in familiar places.

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Section F: Preferences for Customary Routine Activities

SECTION F: PREFERENCES FOR CUSTOMARY ROUTINE ACTIVITIES
Introduction
This section identifies the patient’s living situation including types, sources and amounts of assistance needed
for routine activities.

M1100: Patient Living Situation

Item Intent
This item identifies, using the assessing clinician’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
•
•
•

Interview the patient and/or caregiver, and review referral information. Information may also be available
in an assisted living facility agreement or contract.
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) other than home health staff are
in the home and available to provide assistance if needed.
o 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.

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•

•

Section F: Preferences for Customary Routine Activities

Living arrangement
o Lives alone: The patient lives in an independent (non-assisted) setting such as a home, an apartment
or a room in a boarding house. A patient is considered to be living alone when they have:
 Only live-in, paid help.
 A caregiver is temporarily staying in the home to provide assistance, but they normally live
alone.
 A life-line or can obtain emergency help by phone but no other people are living with them.
o Lives with others: The patient lives in an independent (non-assisted) setting with a spouse, family
member or another significant other.
 A patient who lives with others and is occasionally alone when caregiver(s) travel, is still
considered to be living with others.
o Lives in congregate situation: The patient lives in a setting where assistance, supervision and/or
oversight are provided as part of the living arrangement, such as an assisted living facility,
residential care home or personal care home.
 The patient may live alone, or with a spouse or significant other, in an apartment or room in
an assisted living facility, for example, and still be considered living in a congregate
situation.
Availability of Assistance
o Around the clock: Someone is in the home to provide assistance to the patient 24 hours a day.
o Regular daytime: Someone is in the home to provide assistance during daytime hours every day
with infrequent exceptions.
o Regular nighttime: Someone is in the home to provide assistance during nighttime hours every
night with infrequent exceptions.
o Occasional/short-term assistance: Someone is in the home to provide assistance only for a few
hours a day, or on an irregular basis, or only occasionally.
o No assistance available: There is no one available to provide any in-person assistance.

Coding Instructions
Code the response identifying the availability of assistance in the row that matches the patient’s living
arrangement. Only one response should be marked.
• Dash is not a valid response for this item.

•

Coding Tips
•
•
•

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.
Use professional judgment 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.
Assistance refers to any type of in-person assistance provided in the home of the patient, including but not
limited to ADLs and IADLs.

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Use 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 quality episode.
• 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.
•

Examples
1. Patient lives alone in their own apartment. Since the patient’s discharge from the hospital, their two
daughters alternate staying with them 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.
Coding: 01
Rationale: 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
2. Patient lives alone in their home but their son and daughter-in-law live across the street. They bring the
patient dinner every night and are available around the clock by telephone.
Coding: 04
Rationale: 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.
3. Patient lives with their child 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. The patient’s child has back problems that
prevent them from lifting patient, but they assist the patient with dressing every morning and take the patient
to doctor’s appointments.
Coding: 08
Rationale: Patient lives in a home with others who are available every night to offer in-person
assistance. Even if the child can’t meet all of patient’s needs, they are available all night.

4. Patient lives with their spouse 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.
Coding: 09
Rationale: 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.

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5. Patient lives alone in an apartment that is part of an ALF. The apartment does not have a call-bell but their

contract with the ALF includes having a home health aide assist her with ADLs 2 hours every morning. The
patient’s son also comes over occasionally to assist with bills, groceries, and errands.
Coding: 14
Rationale: 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.

M2102: Types and Sources of Assistance

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Section F: Preferences for Customary Routine Activities

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

Response-Specific Instructions
•
•

•

•
•

•

Interview the patient and/or caregiver, and review the clinical record, including but not limited to the
previous health history
At SOC/ROC, report what is known on the day of assessment regarding ability and willingness of nonagency caregivers to provide supervision and safety due to a cognitive impairment 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 in the various categories of
assistance at the time of the discharge.
If patient needs assistance with any aspect of a category of assistance (such as needs assistance with some
ADLs 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.
For each row, enter one description of caregiver assistance.
o a. ADL assistance includes basic self-care activities such as the examples listed.
o 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.
o d. Medical procedures/treatments include procedures/treatments that the physician/allowed
practitioner or physician-designee 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.
o 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. The need for supervision and safety due to cognitive or mental
health issues does not require a specific diagnosis. 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.

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For the purposes of coding d. Medical procedures/treatments, consider devices such as anti-embolism
stockings, prosthetic devices, orthotic devices, or other supports that have a medical and/or therapeutic
impact as medical procedures/treatments. Do not consider these items in a. ADL assistance.

Coding Instructions
•
•

Code 3, Non-agency Caregiver(s) are not likely to provide assistance, if they are unwilling, reluctant,
or unable to provide care.
Dash is not a valid response for this item.

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SECTION G: FUNCTIONAL STATUS
Introduction

The items in this section address the patient’s ability to safely perform personal care activities. The items
identify the patient’s ABILITY, not necessarily actual performance. “Willingness” and “adherence” are not the
focus of these items. 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.

M1800: Grooming

Item Intent
Identifies the patient’s ability to tend to personal hygiene needs, excluding bathing, shampooing hair, and
toileting hygiene.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response-Specific Instructions
•
•
•

•

Observation/demonstration is the preferred method for coding this item.
The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.
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.
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

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frequently performed activities (for example, washing hands and face) but unable to do less frequently
performed activities (trimming fingernails) should be considered to have more ability in grooming.
In cases where a patient’s ability is different for various grooming tasks, enter the response that best
describes the patient’s level of ability to perform the majority of grooming tasks.

Coding Instructions
Code 2, Someone must assist the patient, if the patient can participate in grooming tasks but needs
some assistance. The word “assistance” in this item refers to assistance from another person by verbal
cueing/reminders, supervision, and/or stand-by or hands-on assistance.
• Dash is not a valid response for this item.

•

M1810: Current Ability to Dress 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.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response-Specific Instructions
•
•
•
•

Observation/demonstration is the preferred method for coding this item.
The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.
For the purposes of coding this item, 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.

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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 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.
•

Coding Instructions
Code 2, Someone must help the patient, if the patient can participate in upper body dressing tasks
but needs some assistance. The word “assistance” in this item refers to assistance from another person by
verbal cueing/reminders, supervision, and/or stand-by or hands-on assistance.
• Code 3, Patient depends entirely upon another person to dress the upper body, is selected
only when the patient is dependent, relying entirely on another person to complete the majority of the
upper body dressing tasks.
• Dash is not a valid response for this item.
•

M1820: Current Ability 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.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response-Specific Instructions
•
•

Observation/demonstration is the preferred method for coding this item.
The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.

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For the purposes of coding this item, 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.
• 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 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.
•

Coding Instructions
Code 2, Someone must assist the patient, if the patient can participate in lower body dressing
tasks but needs some assistance. The word “assistance” in this item refers to assistance from another
person by verbal cueing/reminders, supervision, and/or stand-by or hands-on assistance.
• Code 3, Patient depends entirely upon another person to dress lower body, is selected only
when the patient is dependent, relying entirely on another person to complete the majority of lower body
dressing tasks.
• Dash is not a valid response for this item.
•

M1830: Bathing

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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.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response-Specific Instructions
Observation/demonstration is the preferred method for coding this item.
The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.
• 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 patient’s status should not be coded based on a patient’s ability to perform a task with equipment they
have not been assessed using.
•
•

Coding Instructions
Code 4, 5 or 6, depending on the patient’s ability to participate in bathing activities:
o If a patient is medically restricted from stair climbing, and the tub/shower requires climbing stairs
o If the patient does not have a tub or shower in the home
o If the tub/shower is nonfunctioning or not safe for patient use
• Dash is not a valid response for this item.

•

Coding Tips
•
•
•

For Response 4, the patient must be able to bathe outside the tub/shower safely and independently,
including independently accessing water at the sink, or setting up a basin at the bedside, etc.
For Response 5, the patient is unable to bathe in the tub/shower and needs intermittent or continuous
assistance.
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.

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M1840: Toilet Transferring

Item Intent
Identifies the patient’s ability to safely get to and from and transfer on and off the toilet or bedside commode.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response-Specific Instructions
Observation/demonstration is the preferred method for coding this item.
The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.
• 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.
•
•

Coding Instructions
Code 1, if the patient:
o Requires standby assistance to get to and from the toilet safely or requires verbal cueing/reminders.
o if the patient needs assistance getting to/from the toilet or with toileting transfer or both.
o if the patient can independently get to the toilet but requires assistance to get on and off the toilet.
• Code 3, if the patient who is unable to get to/from the toilet or bedside commode is able to place and
remove a bedpan (and urinal if applicable) independently, whether or not a patient requires assistance to
empty the bedpan/urinal.
• Code 4, if the patient, who is unable to get to/from the toilet, 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.
• Dash is not a valid response for this item.
•

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Coding Tips
•

If the patient can get to and from the toilet during the day independently but uses the commode at night for
convenience code 0.

M1845: Toileting Hygiene

Item Intent
Identifies the patient’s ability to manage personal hygiene and clothing when toileting.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions

Observation/demonstration is the preferred method for coding this item.
The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.
• 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.
• This item refers to the patient’s ability to manage personal hygiene and clothing with or without assistive
devices.
•
•

Coding Instructions
•
•

Code 0, if the patient is independent in managing toileting hygiene and managing clothing.
Code 1, if the patient is able to manage toileting hygiene and manage clothing IF supplies are laid out for
the patient.

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Code 2, if the patient can participate in hygiene and/or clothing management but needs some assistance
with either or both activities The word “assistance” in this item refers to assistance from another person by
verbal cueing/reminders, supervision, and/or stand-by or hands-on assistance.
Dash is not a valid response for this item.

M1850: Transferring

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.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response-Specific Instructions
•
•
•
•

•

Observation/demonstration is the preferred method for coding this item.
The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.
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.
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.

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Able to bear weight refers to the patient’s ability to support the majority of their 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 their entire weight through the other lower extremity and upper
extremities).
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.

Coding Instructions
Code 1, if the patient:
o Transfers either with minimal human assistance (but not a device), or with the use of a device (but
no human assistance).
• Code 2, if the patient:
o Requires both minimal human assistance AND an assistive device to transfer safely
o Can both bear weight and pivot, but requires more than minimal human assistance
• Code 3, if the patient is unable to bear weight or pivot and is not bedfast.
• Dash is not a valid response for this item.
•

Coding Tips
•
•

“Minimal human assistance” applies when the helper is contributing less than 25% of the total effort
required to complete the task.
Assistance may include any combination of verbal cueing, environmental set-up, and/or actual hands-on
assistance.

M1860: Ambulation/Locomotion

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.

Time Points Item(s) Completed
Start of Care
Resumption of Care
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Follow-up
Discharge from agency

Response-Specific Instructions
•

Observation/demonstration is the preferred method for coding this item.

•

The assessing clinician may also interview the patient and/or caregiver, conduct environmental assessment
and may consider available input from other agency staff who have had direct patient contact.

•

Variety of surfaces refers to typical surfaces that the patient would routinely encounter in their
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. 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.

Coding Instructions
•
•

•
•

•

Code 2 or 3, if the patient requires human assistance (hands on, supervision and/or verbal cueing) to
safely ambulate, regardless of the need for an assistive device. Code 2 if the assistance required is
intermittent. Code 3 if the assistance required is continuous.
Code 2, if the patient is:
o Able to safely ambulate without a device on a level surface, but requires minimal assistance on
stairs, steps, and uneven surfaces.
o Able to safely ambulate with a walker in the hallway or living room, even if there are some
situations in the home where a cane provides adequate support as long as the patient does not require
continuous human assistance.
Code 3, if a patient does not have a walking device but is clearly not safe walking alone, unless the
patient is chairfast.
Code 4 or 5, if a patient:
o Is unable to ambulate even with the use of assistive devices and/or continuous assistance.
o Demonstrates or reports ability to take one or two steps to complete a transfer, but is otherwise
unable to ambulate.
Dash is not a valid response for this item.

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SECTION GG: FUNCTIONAL ABILITIES AND GOALS
GG0100: Prior Functioning: Everyday Activities

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
•

Ask the patient and/or family/caregiver or review the clinical record for details describing the patient’s
prior functioning with everyday activities.

Coding Instructions
•
•
•
•
•
•

Code 3, Independent, if the patient completed ALL the activities by themself, 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
ANY of the activities.
Code 1, Dependent, if the helper completed ALL the activities for the patient, or the assistance of two
or more helpers was required for the patient to complete the activities.
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 activities were not applicable to the patient prior to the current illness,
exacerbation, or injury.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

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Coding Tips
For GG0100 – Prior Functioning; Everyday Activities report the patient’s functional ability prior to the
onset of the current illness, exacerbation of a chronic condition, or injury, whichever is most recent, that
initiated this episode of care.
• If no information about the patient’s ability is available after attempts to interview the patient or their
family and after reviewing the patient’s clinical record, code as 8, Unknown.
• Completing the stair activity for GG0100C Stairs indicates that a patient went up and down the stairs, by
any safe means, with or without handrails or assistive devices or equipment (such as a cane, crutch, walker
or stair lift), and/or with or without some level of assistance. “By any safe means” may include a patient
scooting up/down stairs on buttocks. Stairs include internal or external without a defined number.
• Going up and down a ramp is not considered going up and down stairs for coding GG0100C Stairs
•

Examples
1. Prior to their recent illness, the patient ambulated with a walker around their home without assistance. They
required the use of a stair lift to negotiate the stairs to the second floor, where their bedroom is located. They
were safe using the stair lift without any assistance or supervision.
Coding: GG0100C, Stairs, would be coded 3, Independent.
Rationale: Using the stair lift, the patient’s prior status was that they were able to go up and down the
stairs safely and independently.

GG0110. Prior Device Use

Item Intent
This item identifies the patient’s use of devices and aids immediately prior to the most recent illness,
exacerbation, or injury.

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

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Response-Specific Instructions
Ask the patient and/or family/caregiver, or review the clinical record, for details describing the patient’s
use of prior devices and aids.
• For GG0110C, Prior Device Use report the devices used by the patient prior to the onset of the current
illness, exacerbation of a chronic condition, or injury, whichever is more recent, that initiated this episode
of care.
• Check all devices that apply.
• For the response categories in GG0110 (e.g., Mechanical lift, Orthotics/Prosthetics), CMS does not
provide an exhaustive list of assistive devices that may be used when coding prior device use.
• Devices may have been used indoors and/or outdoors.
•

Coding Instructions
GG0110C, Prior Devices: Mechanical lift includes any mechanical device or equipment a patient or
caregiver requires for lifting or supporting the patient’s bodyweight. Examples include, but are not limited
to: Stair lift, Hoyer lift, bathtub lift, sit-to-stand lift, stand assist, electric recliner and full-body style lifts,
if required.
o Clinical judgment may be used to determine whether other devices, meet the mechanical lift
definition provided.
• GG0110D, Walker refers to all types of walkers. Examples include but are not limited to: pick-up
walkers, hemi-walkers, rolling walkers, and platform walkers.
• Code 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.
• Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.
•

Examples
1. The patient is a bilateral lower extremity amputee and has multiple diagnoses, including diabetes, obesity,
and peripheral vascular disease. They are unable to walk and did not walk prior to the current episode of
care, which started because of a pressure ulcer and respiratory infection. They used a motorized wheelchair
to mobilize.
Coding: GG0110B, Motorized wheelchair and/or scooter would be checked.
Rationale: The patient used a motorized wheelchair prior to the current illness/injury.
2. The patient has bilateral lower extremity neuropathy secondary to diabetes. Prior to this current home health
admission, they used a cane. Today, they are using a walker.
Coding: GG0110Z, None of the above, would be checked.
Rationale: A cane is not a device included in the list of devices in GG0110. Not all devices and aids
are included in this item.

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Introduction

This section presents guidance that is applicable for both GG0130 Self-Care and GG0170 Mobility. Itemspecific guidance follows this section, first for GG0130 Self-Care, then for GG0170 Mobility.

GG0130 Self-Care

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GG0170 Mobility

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Item Intent
These items identify the patient’s ability to perform the listed self-care and mobility activities, and the discharge
goals established.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response Specific Instructions – General
•

Licensed clinicians may assess the patient’s self-care and mobility performance based on direct
observation (preferred), patient/caregiver report, assessment of similar activities and/or collaboration with

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other agency staff who have had direct contact with the patient or some other means of gathering
information.
• 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.
• Communicating the activity request (e.g., “Can you stand up from the toilet?”) would not be considered
verbal cueing. If additional prompts are required in order for the patient to safely complete the activity
(e.g., “Push down on the grab bar”, etc.), the assessing clinician may need to use clinical judgment to
determine the most appropriate code.
• If the patient only completes a portion of the activity (e.g., performs a partial bath or transfers into but not
out of a vehicle) and does not complete the entire activity during the assessment timeframe, use clinical
judgment to determine if the situation allows the clinician to adequately assess the patient’s ability to
complete the activity. If the clinician determines that this observation is adequate, code based on the type
and amount of assistance the patient requires to complete the ENTIRE activity. If the clinician determines
the partial activity does not provide adequate information to support determination of a performance code,
select an appropriate “activity not attempted” code.
• When a GG function activity is not completed entirely during one clinical observation (i.e., a patient
transfers bed-to-chair in the morning, and transfers chair-to-bed at night), code based on the type and
amount of assistance required to complete the ENTIRE activity.
• Patients with cognitive impairments/limitations may need physical and/or verbal assistance when
completing an activity (for example, due to choking risk due to rate of eating, amount of food placed into
mouth, risk of falling). Code based on the type and amount of assistance required to perform the activity
safely.
• When using patient or caregiver reports, it is expected that the patient and caregivers are reporting on the
patient’s status within the time period under consideration (e.g., reporting on the patient’s ability to
complete an activity within the past 24 hours).
• For GG0130 and GG0170 the assessing clinician would code each activity based on the type and amount
of assistance needed to complete the activity safely, not based on the availability of such assistance.
• Assessment of the GG self-care and mobility items is based on the patient’s ability to complete the activity
with or without assistance and/or a device. This is true regardless of whether or not the activity is
being/will be routinely performed (e.g., walking may be assessed for a patient who did/does/will use a
wheelchair as their primary mode of mobility, stair activities may be assessed for a patient not routinely
accessing stairs).
• Refer to agency, Federal, and State policies and procedures to determine which agency staff members may
complete an assessment. Patient assessments are to be done in compliance with agency, Federal, and State
requirements.

Response Specific Instructions – Assistive Devices
Activities may be completed with or without an assistive device. This includes the use of any new or
previously utilized assistive device(s) or equipment. Use of a device or equipment may result in the patient
needing less assistance from a helper.
• The patient may be assessed based on the first use of an assistive device or equipment that has not been
previously used. The clinician would provide assistance, as needed, in order for the patient to complete the

•

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activity safely, and code based on the type and amount of assistance required, prior to the benefit of
services provided by your agency staff.
• “Prior to the benefit of services” means prior to provision of any care by your agency staff that would
result in more independent coding.
• Introducing a new device should not automatically be considered as “providing a service”. Whether a
device used during the clinical assessment is new to the patient or not, use clinical judgment to code based
on the type and amount of assistance that is required for the patient to complete the activity prior to the
benefit of services provided by your agency staff.
• CMS does not provide an exhaustive list of assistive devices that may be used when coding self-care and
mobility performance. Clinical assessments may include any device or equipment (including a stair lift)
that the patient can use to allow them to safely complete the activity as independently as possible.
• If the only help a patient needs to complete an activity is for a helper to retrieve an assistive device or
adaptive equipment that is required for safe completion of the activity, such as a cane for walking, or a tub
bench for bathing, before or after the activity, then enter code 05, Setup or clean-up assistance.

Response-Specific Instructions for SOC/ROC Performance

•
•

At SOC/ROC, the self-care or mobility performance code is to be based on a functional assessment that
occurs at or soon after the patient’s SOC/ROC.
At SOC/ROC, the self-care or mobility performance code is to reflect the patient’s baseline ability to
complete the activity, prior to the benefit of services provided by agency staff.
o This may be achieved by having the patient attempt the activity prior to providing any instruction
that could result in a more independent code, and then coding based on the type and amount of
assistance that was required prior to the benefit of services provided by your agency staff.

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

A discharge goal is coded with each SOC/ROC assessment.
Agencies are required to complete a discharge goal for a minimum of one of the following self-care or
mobility activities:
o GG0130A2 - Eating
o GG0130B2 – Oral Hygiene
o GG0130C2 – Toileting Hygiene

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GG0170B2 – Sit to lying
GG0170C2 – Lying to sitting on side of bed
GG0170D2 – Sit to stand
GG0170E2 – Chair/bed-to-chair transfer
GG0170F2 – Toilet transfer
GG0170J2 – Walk 50 feet with two turns
GG0170K2 – Walk 150 feet
GG0170R2 – Wheel 50 feet with two turns
GG0170S2 – Wheel 150 feet

Agencies may choose to complete more than one self-care or mobility discharge goal and should dash any
remaining self-care or mobility goals where a discharge goal is not established.
• Agencies may report a discharge goal for all GG0130 and GG0170 activities.
• Licensed clinicians can establish a patient’s discharge goal(s) at the 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, and standards of practice, expected treatments, patient motivation to
improve, anticipated length of stay, and the patient’s discharge plan. Goals should be established as part of
the patient’s care plan.
• Use agency policies, practices and clinical judgment to determine when and how discharge goals will be
established and how goals and interventions will be documented on the Plan of Care. Questions related to
documentation requirements may be directed to [email protected]
• Once a discharge goal is established, there is no need to update it if circumstances change or additional
information becomes available either within or after the SOC/ROC assessment timeframe.
• Discharge goals should be coded using the 6-point scale or using one of the four “activity not attempted”
codes (07, 09, 10, or 88).
• Discharge goal(s) may be coded the same as SOC/ROC performance, higher than SOC/ROC performance,
or lower than SOC/ROC performance.
• If an activity was not completed prior to the current illness, exacerbation, or injury, and is not expected to
occur for the patient, even with assistance and/or an assistive device, the discharge goal would be code 09
– Not applicable.
• If the SOC/ROC performance of an activity was coded with any activity not attempted code, a discharge
goal may be coded using the 6-point scale if the activity is expected to be completed at discharge.
• If the activity was completed prior to the current illness, exacerbation, or injury; was not completed at
SOC/ROC due to medical conditions or safety concerns; and is not expected to be completed at discharge,
the discharge goal would be code 88 – Not attempted due to medical condition or safety concerns.
•

Response-Specific Instructions for Follow-up and Discharge Performance

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Follow-up Performance: Clinicians should code the patient’s functional status based on a functional
assessment that occurs within the Recertification or Other Follow-up assessment timeframe.
Discharge Performance: Code the patient’s discharge functional status based on a functional assessment that
occurs at or close to the time of discharge.

Coding Instructions
When coding the patient’s performance and discharge goal(s), use the six-point scale or use one of the 4
“activity not attempted” codes (07, 09, 10, and 88) to specify the reason why an activity was not completed.
Performance Codes:
•
•

•

•
•
•

Code 06, Independent, if the patient completes the activity by themself 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 set-up 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 the activity; or patient may require only contact
guard or steadying assistance during the activity.
o Code 04, Supervision or touching assistance, if a single helper is required to manage the oxygen tank
and/or oxygen tubing and/or provide steadying assistance/contact guard, to allow the patient to
complete an activity safely.
o Code 04, Supervision or touching assistance, if a single helper only manages the oxygen tank or the
IV pole and otherwise the patient needs no assistance to safely complete the activity.
o Code 04, Supervision or touching assistance, if the patient requires only verbal cueing to complete
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 minimal assistance from a helper to support partial weight-bearing during sit-to-stand.
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. For example, the patient is only
able to wash their left arm and chest and requires a helper to complete all the remaining bath.
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.
o Code 01, Dependent, if a patient requires the assistance of two helpers to complete an activity (one
to provide support to the patient and a second to manage the necessary equipment to allow the
activity to be completed).
o Code 01, Dependent, if two helpers are required to complete an activity, even if the second helper
was there for supervision/stand-by assist and did not end up needing to provide hands on assistance.

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Activity Not Attempted Codes:
Use of an “activity not attempted” code should occur only after determining that the activity is not completed,
and the performance code cannot be determined based on patient/caregiver report, collaboration with other
agency staff, or assessment of similar activities.
•
•
•
•
•

Code 07, Patient refused, if the patient refused to complete the activity and no other Performance or
“activity not attempted” code is applicable.
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, and 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, and the activity was completed prior to the current
illness, exacerbation, or injury.
A Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

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Decision Tree
•

This decision tree may be used to assist with coding the patient’s self-care and mobility performance. If
helper assistance is required because the patient’s performance is unsafe or of poor quality, code
according to the type and amount of assistance required. Use of an “activity not attempted” code should
occur only after determining that the activity is not completed, and the performance code cannot be
determined based on patient/caregiver report, collaboration with other agency staff, or assessment of
similar activities.

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GG0130: Description, Coding Tips, and Examples for GG0130 Self-Care
Activities
The following are descriptions, coding tips and coding examples for each GG0130 Self-Care activity.

GG0130A Eating

Coding Tips
If the patient requires assistance (e.g., supervision or cueing) to swallow safely, code based on the type
and amount of assistance required for feeding AND safe swallowing.
• If a patient swallows safely, exclude swallowing from consideration when coding GG0130A, Eating.
• If the patient eats finger foods using their hands, then code GG0130A, Eating based upon the type and
amount of assistance required. If the patient eats finger foods with their hands independently, for example,
the patient would be coded as 06, Independent.
• If the patient eats and drinks by mouth and relies partially on obtaining nutrition and liquids via tube
feedings or parenteral nutrition, code eating based on the amount of assistance the patient requires to eat
and drink by mouth.
• Assistance with tube feedings and parenteral nutrition is not considered when coding this activity.
• Code 88, Not attempted due to medical condition or safety concern, if the patient does not eat
or drink by mouth and relies solely on nutrition and liquids through tube feedings or total parenteral
nutrition (TPN) due to a new (recent-onset) medical condition.
• Code 09, Not applicable, 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.
•

Examples
1. The patient does not have any food consistency restrictions, but often needs to swallow two or three times so
that the food clears their throat due to difficulty with pharyngeal peristalsis. They require 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: The patient 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. The patient is unable to eat or drink by mouth since they had a stroke 1 week ago. They receive nutrition
and fluids through a G-tube, which is administered by a helper

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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 (their recent-onset stroke). This item includes eating and drinking by mouth only. If eating and
drinking do not occur due to a recent-onset medical condition, then the activity is coded as 88, Not
attempted due to medical condition or safety concerns. Assistance with G-tube feedings is not
considered when coding this item.
3. The patient has no difficulty swallowing and is fed all meals by a helper, because the patient has severe arm
weakness and is unable to assist.
Coding: GG0130A would be coded 01, Dependent.
Rationale: GG0130A Eating would be coded 01, Dependent, because the patient does not have a
swallowing problem, and the helper does all of the effort related to bringing food/liquids to the mouth.

GG0130B Oral hygiene

Coding Tips
If the patient does not perform oral hygiene during the home visit, determine the patient’s ability based on
the patient’s performance of similar activities during the assessment, or on patient/caregiver report or
collaboration with agency staff.
• For a patient who is edentulous, code oral hygiene based on the type and amount of assistance needed
from a helper to clean the patient’s gums.

•

Examples
1. During the SOC/ROC assessment, the patient states they prefer to participate in oral hygiene twice daily. On
assessment, the clinician identifies that the patient’s caregiver completes more than half of this activity. The
patient 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 the patient is not expected to progress to a higher level of functioning during the
episode of care. However, the clinician anticipates that they will be able to maintain their SOC/ROC
performance level. The clinician discusses functional goals with the patient and they agree maintaining
current function is a reasonable goal.
Coding: GG0130B Oral Hygiene
SOC/ROC Performance would be coded 02, Substantial/maximal assistance.
Discharge Goal would be coded 02, Substantial/maximal assistance.
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Rationale: Performance assessment revealed the patient’s caregiver completes more than half the Oral
Hygiene activity, which would be coded Code 02, substantial/maximal assistance.
The patient’s condition makes it unlikely that their performance of this activity will improve, but that
maintenance of their current level of function is possible, so the discharge goal is coded the same as
admission performance.

GG0130C Toileting hygiene

Coding Tips
•
•
•
•
•

•

•
•

Toileting hygiene includes performing perineal hygiene and managing clothing (e.g., undergarments,
incontinence briefs, pants) before and after voiding or having a bowel movement.
Includes toileting hygiene and adjusting any clothing relevant to the individual patient.
The toileting hygiene activity can be assessed and coded regardless of the patient’s need to void or have a
bowel movement at the time of the assessment.
When the patient requires different levels of assistance to perform toileting hygiene after voiding vs after a
bowel movement, code based on the type and amount of assistance required to complete the ENTIRE
activity.
Toileting hygiene (managing clothing and perineal cleansing) takes place before and after use of the toilet,
commode, bedpan, or urinal. For some patients this may include assessing the type and amount of
assistance needed to complete clothing management and hygiene tasks after episodes of incontinence. If
the patient completes a bowel toileting program in bed, code the item Toileting hygiene based on the
patient’s need for assistance for managing clothing and perineal cleansing.
If the patient has an indwelling urinary catheter and has bowel movements, code the Toileting hygiene
item based on the type and amount of assistance needed by the patient when moving their bowels. This
may necessarily include the need to perform perineal hygiene to the indwelling urinary catheter site after
the bowel movement.
If a patient has an indwelling catheter, toileting hygiene includes perineal hygiene to the indwelling
catheter site, but not management of the equipment.
If a patient manages an ostomy, toileting hygiene includes wiping the opening of the ostomy or colostomy
bag, but not management of the equipment.

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Examples
1. The patient has a progressive neurological illness that affects their strength, coordination, and endurance.
The patient prefers to use the bedside commode for as long as possible rather than using incontinence
undergarments. The helper currently provides steadying assistance while the patient is standing so that the
patient can pull down their underwear before sitting onto the bedside commode. After voiding, the patient
wipes their perineal area, then requires the helper to support their trunk while the patient pulls up their
underwear. The assessing clinician, using professional judgment, all available information and collaboration
as allowed anticipates that the patient will weaken further by discharge, and while they will still be able to
use the bedside commode, they will need the helper to provide most of the effort needed to complete
toileting hygiene.
Coding: GG0130C, Toileting hygiene
SOC/ROC Performance would be coded 03, Partial/moderate assistance.
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 the patient’s toileting hygiene. The assessing clinician expects that
by discharge, the patient will need the helper to assist with more than half the effort of toileting hygiene.

GG0130E Shower/bathe self

Coding Tips
•
•
•
•
•
•
•

Shower/bathe self includes the ability to wash, rinse and dry the face, upper and lower body, perineal area
and feet, regardless of where the bathing takes place. Do not include washing, rinsing and drying the
patient’s back or hair.
Shower/bathe self does not include transferring in/out of a tub/shower, or onto or off of the tub bench.
Assessment of GG0130E, Shower/bathe self can take place in any location including a shower or bathtub,
at a sink, or in bed (i.e., full-body sponge bath). Bathing can be assessed with the patient sitting on a tub
bench.
If the patient can complete bathing tasks only after a helper retrieves or sets up supplies necessary to
perform the included tasks before or after the activity, code 05, Setup or clean-up assistance.
If the only help a patient requires is assistance before or after the activity to cover wounds or devices for
water-protection during bathing, code 05, Setup or clean-up assistance.
If the patient cannot bathe their entire body, then code GG0130E Shower/bathe self based on the type and
amount of assistance needed to complete the activity.
Use clinical judgment to determine if completing a partial bath or simulating the shower/bath allows the
clinician to adequately assess the patient’s ability to complete the activity of shower/bathe self
(GG0130E). If the clinician determines that this observation is adequate, code based on the type and
amount of assistance required to complete the shower/bathing activity.

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If the patient cannot bathe their entire body because of a medical condition (e.g. cast or a non-removable
dressing), then code Shower/bathe self, based on the type and amount of assistance needed to complete the
activity.

Examples
1. During SOC/ROC functional assessment, the patient states they prefers to bathe themself rather than
depending on helpers or their spouse to perform this activity. The clinician assesses the patient’s SOC/ROC
performance for Shower/bathe self, and determines the helper performs more than half the effort. The
assessing clinician, using professional judgment, available information and collaboration as allowed
anticipates that by discharge the patient will require a helper for less than half of the activity Shower/bathe
self.
Coding: GG0130E, Shower/bathe self,
SOC Performance, would be coded 02, Substantial/maximal assistance.
Shower/bathe self, Discharge Goal would be coded 03, Partial/moderate assistance.
Rationale: At SOC/ROC assessment, the patient participates in the activity Shower/bathe self, but a
helper performs more than half the activity. The assessing clinician expects the patient 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.

GG0130F, GG0130G, and GG0130H
This section presents Coding Tips that are applicable for GG0130F – Upper body dressing, GG0130G – Lower
body dressing, and GG0130H – Putting on/taking off footwear. Item-specific guidance and examples follow.
• Upper body and lower body dressing and footwear include dressing and undressing in clothing and
footwear routinely worn by the patient.
o 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.
• 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.
• For upper body dressing, lower body dressing, and putting on/taking off footwear, if the patient dresses and
undresses themself and the only help the patient requires is for a helper to retrieve or put away the patient’s
clothing before or after the activity, then code 05, Setup or clean-up assistance.
• If a patient requires assistance with dressing including assistance with buttons, fasteners and/or fastening a
bra, code based on the type and amount of assistance required to complete the entire dressing activity.
• When donning and doffing a supportive elastic bandage, compression stockings, or an orthosis or
prosthesis, count the elastic bandage/compression stocking/orthosis/prosthesis as a piece of clothing when
determining the amount of assistance the patient needs to complete the dressing activity.
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• Coding of the dressing activities should consider all dressing items relative to the patient, regardless of the
timing of when each item is put on/taken off.
o For example, if a patient dresses in the morning, puts on a prosthetic device later in the day, and
then undresses in the evening, code based on the type and amount of assistance required to complete
the entire dressing activity, even if portions occur in the morning, evening or throughout the day.

GG0130F Upper body dressing

Coding Tips
•
•
•

Upper body dressing items to consider when coding GG0130F include but are not limited to: bra,
undershirt, T-shirt, button-down shirt, pullover shirt, dresses, sweatshirt, sweater, and pajama top.
If a patient requires assistance with upper body dressing including assistance with buttons and/or fastening
a bra, code based on the type and amount of assistance required to complete the entire upper body dressing
activity.
The following items are considered a piece of clothing as related to tasks associated with upper body
dressing or undressing:
o thoracic-lumbar-sacrum-orthosis (TLSO), abdominal binder, back brace, stump sock/shrinker, upper
body support device, neck support, hand or arm prosthetic/orthotic.

Examples
1. The patient has right-side upper extremity weakness as a result of a stroke and has received therapy to relearn how to dress their upper body. During the day, they require a helper to place clothing next to the
bedside. The patient can then use compensatory strategies to put on their bra and top without any assistance.
At night they remove their top and bra independently and put the clothes on the nightstand and the helper
puts them away.
Coding: GG0130F would be coded 05, Setup or clean-up assistance.
Rationale: The patient dresses and undresses their upper body and requires a helper only to retrieve
and put away their clothing; that is, setting-up the clothing for patient use. The description refers to the
patient as “independent” (when removing clothes), but they need setup assistance, so they are not
independent with regard to the entire activity of upper body dressing.

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GG0130G Lower body dressing

Coding Tips
•
•

Lower body dressing items to consider when coding GG0130G include but are not limited to: underwear,
incontinence brief, slacks, shorts, capri pants, pajama bottoms, and skirts.
The following items are considered a piece of clothing as related to tasks associated with lower body
dressing or undressing:
o knee brace, elastic bandage, stump sock/shrinker, above knee or below knee lower-limb prosthesis.

Examples
1. The patient has severe rheumatoid arthritis and multiple fractures and sprains due to a fall. They have been
issued a knee brace to be worn during the day. The patient threads their legs into their garments and pulls up
and down their clothing to and from just below the hips. Only a little assistance from a helper is needed to
pull up their garments over the hips. The patient requires the helper to fasten the knee brace because of
grasp and fine motor weakness.
Coding: GG0130G would be coded 03, Partial/moderate assistance.
Rationale: A helper provides only a little assistance when the patient is putting on their lower
extremity garments and fastening the knee brace. The helper provides less than half of the effort.
Assistance putting on and removing the knee brace is considered when determining the type and amount
of assistance required when coding lower body dressing.

GG0130H Putting on/taking off footwear

Coding Tips
•
•

•

Footwear dressing items to consider when coding GG0130H include but are not limited to: socks, shoes,
boots, and running shoes.
The following items are considered a piece of clothing as related to tasks associated with putting on/taking
off footwear:
o Footwear examples - ankle foot orthosis (AFO), elastic bandages, foot orthotic, orthopedic walking
boots, compression stockings (considered footwear because of dressing don/doff over foot).
If the patient wears just shoes or just socks (e.g., grip socks) that are safe for mobility, then GG0130H,
Putting on/taking off footwear, may be coded.

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Note that while some types of clothing, wraps or supportive devices may cover both the lower leg/lower
body and the foot, the patient’s ability to put them on/take them off should not be considered for both
GG0130G, Lower Body Dressing and GG0130H, Footwear. In order to assist in determining which
activity the piece of clothing/wrap/orthotic/prosthetic should apply to, consider items that cover all or
part of the foot (even if it extends up the leg, like a sock or ankle foot orthosis) as footwear.
For patients with bilateral lower extremity amputations with or without use of prostheses, the activity of
putting on/taking off footwear may not occur. For example, the socks and shoes may be attached to the
prosthesis associated with the upper or lower leg.
o If the patient performed the activity of putting on/taking off footwear immediately prior to the
current illness, exacerbation, or injury but the activity is not completed at SOC/ROC, code as 88,
Not attempted due to medical condition or safety concerns.
o If the patient did not perform the activity of putting on/taking off footwear immediately prior to the
current illness, exacerbation, or injury because the patient had bilateral lower-extremity amputations
and the activity of putting on/taking off footwear was not completed at SOC/ROC, code as 09, Not
applicable - Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation, or injury.
For patients with a single lower extremity amputation with or without use of a prosthesis, the activity of
putting on/taking off footwear could apply to the intact limb or both the limb with the prosthesis and the
intact limb.
o If the activity of putting on/taking off footwear occurs for the intact limb only, then code based upon
the type and amount of assistance needed to complete the activity for one limb.
o If the activity of putting on/taking off footwear occurs for both the intact limb and the prosthetic
limb then code based upon the type and amount of assistance needed to complete the activity for
both limbs.

Examples
1. The patient has been receiving physical and occupational therapy for right-side upper and lower body
weakness following a stroke. They have made significant progress toward independence and are being
discharged from home health today. The patient wears an ankle-foot orthosis that they put on their foot and
ankle after they put on their socks but before they put on their shoes. They always place their AFO, socks,
and shoes within easy reach of the bed. While sitting on the bed, they need to bend over to put on and take
off the AFO, socks, and shoes, and they occasionally lose their sitting balance, requiring a helper to place
their hands on them to maintain their balance while performing this task.
Coding: GG0130H would be coded 04, Supervision or touching assistance.
Rationale: The patient puts on and takes off their AFO, socks, and shoes by themself; however,
because of occasional loss of balance, they need a helper to provide touching assistance when they are
bending over.

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GG0170: Description, Coding Tips, and Examples for GG0170 Mobility
Activities
The following are descriptions, coding tips and coding examples for each GG0170 Mobility activity.

GG0170A, GG0170B, and GG0170C
This section presents Coding Tips that are applicable for GG0170A - Roll left and right, GG0170B – Sit to
lying, and GG0170C - Lying to sitting on side of bed. Item-specific guidance and examples follow.
• If the patient does not sleep in a bed, assess bed mobility activities using the preferred or necessary
sleeping surface used by the patient.
• For GG0170A, Roll left and right, GG0170B, Sit to lying, and 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.
• Code 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, but could perform this activity prior to
the current illness, exacerbation or injury. 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.
• Code 09, Not applicable, 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.

GG0170A Roll left and right

Coding Tips
•
•
•

The activity includes the patient rolling to both the left and to the right while in a lying position on their
preferred or necessary sleeping surface.
If the clinician determines that bed mobility cannot be assessed because of the degree to which the head of
the bed must be elevated due to the patient’s medical condition, code GG0170A, Roll left and right, using
the appropriate “activity not attempted” code.
If the patient does not sleep in a bed, assess the patient rolling to both the left and to the right while in a
lying position, and returning to lying on the back on their preferred or necessary sleeping surface.

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Examples
1. At SOC, the physical therapist observes the patient turn onto their right side while their spouse prompts
them to bend their left leg and roll to the right side. The spouse then prompts the patient to position their
limbs to return to lying on their back and then to repeat a similar process for rolling onto their left side and
then return to lying on their back. The patient completes the activity without physical assistance from a
helper. The patient was moving about in bed without difficulty prior to hospitalization. The therapist expects
the patient will roll left and right by themself without any assistance from a helper 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 spouse provides verbal cues to the patient as they roll from their back to their
right side and returns to lying on their back. No physical assistance is provided. After assessment and
considering the patient’s current condition, the therapist expects they will be independently rolling left
and right at discharge.

GG0170B Sit to lying

Coding Tips
The activity includes the ability to move from sitting on side of bed to lying flat on the bed or on their
preferred or necessary sleeping surface.
• If the patient does not sleep in a bed, assess the patient’s ability to move from sitting on side of the
patient’s preferred or necessary sleeping surface to lying flat on the patient’s preferred or necessary
sleeping surface.
• If the clinician determines that bed mobility cannot be assessed because of the degree to which the head of
the bed must be elevated due to the patient’s medical condition, code GG0170A, Roll left and right, using
the appropriate “activity not attempted” code.
•

Examples
1. At SOC, the patient 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 their right side, obesity, and cognitive limitations. One of the helpers
explains to the patient each step of the sitting to lying activity. The patient is then fully assisted by the 2
helpers to get from sitting to a lying position on the bed. The patient makes no attempt to assist when asked
to perform the incremental steps of the activity.
Coding: GG0170B, Sit to lying would be coded 01, Dependent.
Rationale: 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.
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2. The patient suffered multiple vertebral fractures due to a fall off a ladder. At SOC, they require assistance
from a therapist to get from a sitting position to lying flat on the bed because of significant pain in their
lower back. The therapist supports the patient’s trunk and lifts both legs to assist them from sitting at the
side of the bed to lying flat on the bed. The patient assists themself a small amount by bending both knees
while transitioning into a lying position.
Coding: GG0170B, Sit to lying would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided more than half the effort for the patient to complete the activity of sit to
lying.

GG0170C Lying to sitting on side of bed

Coding Tips
The activity includes patient transitions from lying on their back to sitting on the side of the bed and
sitting upright on the bed, or alternative sleeping surface, without back support.
• It is not required that the patient’s feet be flat on the floor to consider the activity as being completed.
Note that the reference to the patient having their feet flat on the floor has been removed from GG0170C
in the OASIS-E instrument.
• Back support refers to an object or person providing support for the patient’s back.
• If the clinician determines that bed mobility cannot be assessed because of the degree to which the head of
the bed must be elevated due to the patient’s medical condition, code GG0170A, Roll left and right, using
the appropriate “activity not attempted” code.
•

Examples
1. The patient is recovering from a spinal fusion. At Discharge, they roll to their right side and push themself
up from the bed to get from a lying to a seated position. The family provides needed verbal cues as the
patient safely uses their hands and arms to avoid twisting as they raise themself from the bed. The patient
then maneuvers to the edge of the bed, to complete the activity without hands-on assistance.
Coding: GG0170C, Lying to sitting on side of bed would be coded 04, Supervision or touching
assistance.
Rationale: The helper provides verbal cues only as the patient moves from a lying to sitting position on
the side of the bed.

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GG0170D Sit to stand

Coding Tips
The activity includes the patient coming to a standing position from any sitting surface.
Code 05, Setup or clean-up assistance, if the only help a patient requires 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.
• If a mechanical lift is used to assist in transferring a patient for a chair/bed-to-chair transfer, and even with
assistance the patient is not able to complete the sit to stand activity, code GG0170D, Sit to stand with the
appropriate “activity not attempted” code.
• If a sit to stand lift is used and the patient requires the assistance of two helpers to get from a sitting to
standing position, code as 01, Dependent.
•
•

Examples
1. The patient is being admitted to home health for pressure ulcer care. They have complete tetraplegia from an
injury one year ago and have been unable to bear weight in standing since the injury. At SOC, even when
fully supported, they are unable to stand, and are via Hoyer transferred from their bed into a wheelchair with
assistance.
Coding: GG0170D, Sit to stand, SOC Performance would be coded 09, Not applicable.
Rationale: The activity was not attempted at SOC 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.

GG0170E Chair/bed-to-chair transfer

Coding Tips
•
•
•
•

The activity reflects a transfer between (to and from) any two sitting surfaces. This could be a chair-tochair transfer that does not include the bed.
Depending on the patient’s abilities, the transfer may be a stand-pivot, squat-pivot, or a slide board
transfer.
When possible, the transfer should be assessed in an environmental situation where taking more than a
few steps would not be necessary to complete the transfer.
If a mechanical lift is used to assist in transferring a patient for a chair/bed-to-chair transfer and the patient
requires the assistance of two helpers code as 01, Dependent, even if the patient assists with any part of the
chair/bed-to-chair transfer.

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When a GG function activity is not completed entirely during one clinical observation (i.e., a patient
transfers bed-to-chair in the morning, and transfers chair-to-bed at night), code based on the type and
amount of assistance required to complete the ENTIRE activity. In addition to direct observation, coding
can be determined based on patient/caregiver report, collaboration with other agency staff, or assessment
of similar activities.
The activities of GG0170B - Sit to lying and GG0170C - Lying to sitting on side of bed are two separate
activities that are not assessed as part of GG0170E – Chair/Bed to Chair Transfer.

Examples
1. The patient had a stroke and uses a wheelchair for mobility. When they get out of bed at SOC, their
daughter moves the wheelchair into the correct position and locks the brakes so that the patient can transfer
into the wheelchair safely. The patient transfers into the wheelchair by themself without the need for
supervision or assistance during the transfer. The family reports that the patient does transfer safely from
bed to wheelchair and back without the need for supervision, once the wheelchair is placed and locked. The
therapist does not expect the patient’s mobility status to change by discharge.
Coding: GG0170E, Chair/bed-to-chair transfer, SOC Performance would be coded 05, Setup or cleanup 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, the patient transfers
to and from the wheelchair safely and does not need supervision or physical assistance during the
transfer activity. The therapist expects the patient will continue to need wheelchair setup assistance for
this transfer at discharge.

GG0170F Toilet transfer
Coding Tips
Toilet transfer includes the patient’s ability to get on and off a toilet (with or without a raised toilet seat),
or bedside commode.
• Toileting hygiene, clothing management, getting to and from the toilet, and transferring on and off a
bedpan are not considered part of the toilet transfer activity.
• The Toilet transfer activity can be assessed and coded regardless of the patient’s need to use a toilet or
commode to void or have a bowel movement in conjunction with the toilet transfer assessment.
• Communicating the activity request (i.e., “Can you stand up from the toilet?”) would not be considered
verbal cueing. If additional prompts are required in order for the patient to safely complete the activity
(“Push down on the grab bar”, etc.), the assessing clinician may need to use clinical judgment to
determine the most appropriate code, utilizing the Coding Section GG Activities Decision Tree.
• Code 05, Setup or clean-up assistance, if the patient requires a helper to position/set-up the
bedside commode before and/or after the patient’s bed to commode transfers (place at an accessible
angle/location next to the bed) and the patient does not require helper assistance during toilet transfers.
•

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Code 05, Setup or clean-up assistance, 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.
Code 01, Dependent, if the patient requires assistance from two or more helpers to get on and off the
toilet or commode.

Examples
1. 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 the patient with a light contact when the patient lowers their
underwear and also as they transfer onto the toilet. After voiding, the patient cleanses themself. They then
stand up supporting their own weight as the aide steadies them with contact guard assistance. The patient
pulls up their underwear as the aide steadies them to ensure they does not lose their balance.
Coding: GG0170F, Toilet transfer, SOC Performance would be coded 04, Supervision or touching
assistance.
Rationale: The aide needs to provide only steadying assistance as the patient transfers on and off the
toilet. Assistance with managing clothing and cleansing when toileting is coded under item GG0130C,
Toileting hygiene, and is not considered when coding the toilet transfer item.
2. At SOC, the patient is on bedrest due to a new medical complication. They use 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.

GG0170G Car transfer

Coding Tips
• The activity includes the patient’s ability to transfer in and out of a car or van seat on the passenger side.
• Any vehicle model available may be used for the assessment of GG0170G, Car transfer.
• The car transfer could still be completed while accommodating medical restrictions such as long sitting,
• The Car transfer does not include getting to or from the vehicle, opening/closing the car door, or
fastening/unfastening the seat belt.
• If the patient remains in a wheelchair and does not transfer in and out of a car or van seat, the activity is
not considered completed and the appropriate “activity not attempted” code would be used.
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The setup and/or clean-up of an assistive device that is used for walking to and from the car, but not used
for the transfer in and out of the car seat, would not be considered when coding the car transfer activity.
• Clinicians may use clinical judgment to determine if observing a patient performing a portion of the car
transfer activity (e.g., getting into the car) allows the clinician to adequately assess the patient’s ability to
complete the entire GG0170G, Car transfer activity (transferring in and out of a car). If the clinician
determines that this observation is adequate, code based on the type and amount of assistance required to
complete the activity.
• Use of an “activity not attempted” code should occur only after determining that the car transfer activity is
not completed, and the performance code cannot be determined based on patient/caregiver report,
collaboration with other agency staff, or assessment of similar activities.
•

Example
1. The patient uses a wheelchair and ambulates for only short distances. At SOC, the patient requires the
physical therapist to lift most of their weight to get from a seated position in the wheelchair to a standing
position. The therapist provides trunk support when the patient takes several steps during the transfer turn.
The patient lowers themself into the car seat with steadying assistance from the therapist. The patient moves
their legs into the car as the therapist lifts the weight of their 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 the patient 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.
2. The day after being admitted to home health, the patient is evaluated by 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, the patient required verbal reminders for safety and
contact guarding assistance from the OT. 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 verbal cues and touching assistance only as the patient transfers in
and out of 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.

GG0170I, GG0170J, GG0170K, and GG0170L
This section presents Coding Tips that are applicable for GG0170I – Walk 10 feet, GG0170J – Walk 50 feet
with two turns, GG0170K – Walk 150 feet, and GG0170L – Walking 10 feet on uneven surfaces. Item-specific
guidance and examples follow.
•
•

Assessment of the walking activities starts with the patient in a standing position.
Code based on the type and amount of assistance required to complete the walking activity, with or
without the use of assistive devices or adaptive equipment.

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Use of assistive device(s) and adaptive equipment (for instance a cane or leg brace) required to complete
the walking activity should not automatically result in the reporting of a more dependent code.
The walking activities cannot be completed without some level of patient participation that allows patient
ambulation to occur for the entire stated distance. A helper cannot complete a walking activity for a
patient.
During a walking activity, a patient may take a brief standing rest break. If the patient needs to sit to rest
during a GG walking activity, consider the patient unable to complete the walking activity.
Report an appropriate “activity not attempted” code when the patient requires a sitting rest break, and/or
cannot complete the walking activity with the assistance of one or more helpers.
Clinicians can use clinical judgment to determine how the actual patient assessment of walking is
conducted.
If a clinician chooses to combine the assessment of multiple walking activities, use clinical judgment to
determine the type and amount of assistance needed for each individual activity.
Use clinical judgment when assessing activities that overlap or occur sequentially to determine the type
and amount of assistance needed for each individual activity
If the patient who participates in walking requires the assistance of 2 helpers to complete the activity, code
01, Dependent.
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.

GG0170I Walk 10 feet

Coding Tips
•

Starting from standing, the activity includes the patient’s ability to walk 10 feet.

Examples
1. The patient had bilateral below the knee amputations 3 years ago, and prior to this home health admission
for pressure ulcer care and initiation of prostheses use, they used a wheelchair and did not walk. At SOC,
the patient does not use prosthetic devices and only uses a wheelchair for mobility. The patient’s care plan
will include assisting with fitting and use of bilateral lower extremity prostheses. The therapist’s care plan
goal is for the patient to walk distances of 30 feet with contact guard assistance within their 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.
Rationale: When assessing the patient for GG0170I, Walk 10 feet, consider the patient’s status prior to
the current illness, exacerbation or injury. Use code 09, Not applicable, because the patient could not
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perform the activity of walking at SOC and did not perform the activity of walking prior to the most
recent illness, exacerbation or injury (the pressure ulcer). The therapist expects the patient will be
walking more than 10 feet with contact guard assistance by discharge.

GG0170J Walk 50 feet with two turns

Coding Tips
• Starting from standing, the activity includes the patient’s ability to walk 50 feet, making two turns.
• The turns included in the items GG0170J (Walk 50 feet with two turns) are 90 degree turns. The turns
may occur at any time during the 50-foot walk. The turns 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 left and one 90 degree turn to the right). The 90-degree turn should occur at the person’s ability level
and can include use of an assistive device (for example, cane).

Examples
1. At SOC, the patient is recovering from a recent stroke and now has difficulty walking. Even with assistance,
they walk only 30 feet. The patient’s care plan includes muscle strengthening and gait training. The therapist
expects the patient will walk 50 feet with two turns safely with the assistance of a caregiver for verbal cues
and contact guard for steadying while turning at discharge.
Coding: GG0170J, Walk 50 feet with two turns,
SOC Performance would be coded 88, Not attempted due to medical condition or safety concerns.
Discharge Goal would be 04 Supervision or touching assistance.
Rationale: The patient is ambulatory but was not able to walk the entire distance because of their 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 the patient 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.

GG0170K Walk 150 feet

Coding Tips
•

Starting from standing, the activity includes the patient’s ability to walk 150 feet.

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When coding GG0170K, 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.

Examples
1. The patient has recent endurance limitations due to an exacerbation of heart failure and is only
walking about 30 feet before they tire, lose strength and must sit and rest. They report they were
walking 150 feet or more with their cane prior to this exacerbation of their heart failure.
Coding: GG0170K, Walk 150 feet would be coded 88, Not attempted due to medical conditions
or safety concerns.
Rationale: The activity was not completed due to the patient’s recent endurance limitations and current
medical condition, and a helper cannot complete the walking activity for a patient. The patient was able
to complete the activity prior to the recent exacerbation of their condition.

GG0170L Walking 10 feet on uneven surfaces

Coding Tips
• Starting from standing, the activity includes the patient’s ability to walk 10 feet on uneven surfaces.
• GG0170L Walking 10 feet on uneven surfaces can be assessed inside or outside. Examples of surfaces
include: uneven or sloping surfaces, turf or gravel. Use clinical judgment to determine if a surface meets
this intent.

Examples
1. The patient has severe joint degenerative disease and is recovering from sepsis. When walking on the
uneven (gravel) driveway was attempted yesterday when they came home from the hospital, they
were able to mostly walk by themself, but reports that their neighbor held their belt and helped
support their weight during a few steps.
Coding: GG0170L, Walking 10 feet on uneven surfaces would be coded 03, Partial/moderate
assistance.
Rationale: Per patient report, the patient required some weight-bearing support from a neighbor, as
they walked 10 feet on uneven surfaces. The patient provided more than half the effort for walking 10
feet on uneven surfaces

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GG0170M, GG0170N, and GG0170O
This section presents Coding Tips that are applicable for GG0170M – 1 step (curb), GG0170N – 4 steps, and
GG0170O – 12 steps. Item-specific guidance and examples follow.
Completing the stair activities indicates that a patient goes up and down the stairs, by any safe means, with
or without any assistive devices (for example, railing or stair lift) and with or without some level of
assistance.
• Getting to/from stairs is not included when coding the curb/step activities.
• Going up and down stairs by any safe means includes the patient walking up and down stairs on their feet
or bumping/scooting up and down stairs on their buttocks.
• Ascending and descending stairs does not have to occur sequentially or during one session. If the
assessment of going up and down stairs occurs sequentially, the patient may take a standing or seated rest
break between ascending and descending the 4 steps or 12 steps.
• A patient who is a wheelchair user may be assessed going up and down stairs (including 1 step/curb) in a
wheelchair. Code based on the type and amount of assistance the patient required from the helper.
• If the patient goes up and down steps (1, 4, or 12) by any safe means (for example, walking on their feet,
in a wheelchair, or bumping/scooting on their buttocks), with or without an assistive device, and with no
set-up assistance, verbal or physical assistance, code 06, Independent.
• If the patient requires a helper to provide total assist, code 01, Dependent (for example, a patient requires
total assist from a helper to move up and down a curb in their wheelchair).
• 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 concerns.
•

GG0170M 1 step (curb)

Coding Tips
•
•

Assess the patient going up and down 1 step or up and down a curb.
If both are assessed, and the patient’s performance going up and down a curb is different than their
performance going up and down one step (e.g., because the step has a railing), code GG0170M 1 step
(curb) based on the activity with which the patient requires the most assistance.

Examples
1. The patient had a stroke and needs to step up and down one step to enter and exit their home. At SOC, the
patient’s daughter is observed providing needed verbal cueing as the patient uses their quad cane to aid
their balance in stepping up and back down one step. No physical assistance was required.
Coding: GG0170M, 1 step would be coded 04, Supervision or touching assistance.
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Rationale: The patient needs only verbal cueing to complete the activity of stepping up and down one
step.

GG0170N 4 steps

Coding Tips
•

Assess the patient going up and down 4 steps.

Examples
1. At SOC, the patient has lower body weakness and the physical therapist provides light touching assistance
when they ascend 4 steps. While descending 4 steps, the physical therapist faces the patient and descends
the stairs providing trunk support, with one hand on the patient’s hip and the other holding the gait belt, as
the patient holds the stair railing.
Coding: GG0170N, 4 steps would be coded 03, Partial/moderate assistance.
Rationale: The therapist provides touching assistance as the patient ascends 4 steps. The therapist
provides trunk support when they descend the 4 steps, providing less than half the effort to complete the
activity. The patient requires partial/moderate assistance to go up and down 4 steps.

GG0170O 12 steps

Coding Tips
• Assess the patient going up and down 12 steps.
• If a patient’s environment does not have 12 steps, clinical judgment may be used to determine if the
combination of going up and down 4 stairs 3 times consecutively in a safe manner is an acceptable
alternative to meet the intention of this activity.

Examples
1. At SOC, the patient is recovering from a stroke resulting in motor issues and poor endurance. The patient’s
home has 12 stairs, with a railing, and they need to use these stairs to enter and exit their home. The
patient’s physical therapist uses a gait belt around the patient’s trunk and provides less than half of the effort
as they ascend and then descend 12 stairs.
Coding: GG0170O, 12 steps would be coded 03, Partial/moderate assistance.

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Rationale: The helper provides less than half the required effort in providing the necessary support for
the patient as they ascend and descend 12 stairs.
2. The patient is returning home after a hip replacement. They are restricted from stair climbing until they are
seen for their follow-up MD appointment in one week. Just prior to their surgery, they climbed a flight of 12
stairs with stand-by assist of a helper.
Coding: GG0170O, 12 steps would be coded 88, Not attempted due to medical conditions 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, the patient was able
to complete that activity with assistance so code 88 is appropriate.

GG0170P Picking up object

Coding Tips
The activity includes the patient bending/stooping from a standing position to pick up a small object, such
a spoon, from the floor.
• Assistive device(s) and adaptive equipment may be used, for example a cane to support standing balance
and/or a reacher to pick up the object.
• Picking up object must be assessed while the patient is in a standing position. If the patient is not able to
stand, the activity did not occur and the appropriate “activity not attempted” code would be used.
• If a standing patient is unable to pick up a small object from the floor, therefore requiring the helper to
pick up the object, code 01, 02, or 03, depending on whether the helper is providing all the effort, more
than half of the effort, or less than half of the effort. Clinicians should use clinical judgment to apply
guidance regarding a patient’s degree of participation in picking up an object.
•

Examples
1. The patient has a neurologic condition that has resulted in coordination and balance problems. At SOC, the
patient reports they and their spouse worked with the OT in the SNF on picking things up from the floor.
The patient demonstrates how they stoop to pick up a pencil from the floor as their spouse provides the right
amount of verbal cues for safety and stands by, ready to help in case the patient loses their balance.
Coding: GG0170P, Picking up object would be coded 04, Supervision or touching assistance.
Rationale: A helper is needed to provide verbal cues and stand-by assistance when the patient picks up
an object due to their coordination and balance limitations.
2. The patient has recently undergone a hip replacement. At SOC, they walk with a walker without assistance.
When they drop a hairbrush from their walker basket, they ask a helper to locate their long-handled reacher

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and bring it to them. Using the reacher, the patient bends slightly, and safely picks up the hairbrush 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 helper provides set-up assistance only by retrieving the reacher and then the patient is
able use the device to pick up the hairbrush safely.

GG0170Q, GG0170R, GG0170RR, GG0170S, and GG0170SS
This section presents guidance that is applicable for GG0170Q – Does patient use wheelchair and/or scooter?,
GG0170R – Wheel 50 feet with two turns, GG0170RR – Indicate the type of wheelchair or scooter used,
GG0170S – Wheel 150 feet, and GG0170SS – Indicate the type of wheelchair or scooter used. Item-specific
guidance and examples follow.
•

The intent of the wheelchair mobility items is to assess the ability of patients who use a wheelchair and/or
scooter under any condition.

GG0170Q Does patient use wheelchair and/or scooter?

Coding Tips
The intent of the wheelchair mobility items is to assess the ability of patients who use a wheelchair and/or
scooter under any condition. This includes patients who are learning how to self-mobilize using a
wheelchair or scooter, those who require assistance from a helper to mobilize using a wheelchair/scooter,
and those who require a helper to push them in a wheelchair.
• Only Code 0, No, if at the time of the assessment the patient does not use a wheelchair or scooter under
any condition.
o Skip all remaining wheelchair questions (including related Discharge Goals for skipped wheelchair
activities).
• Code 1, yes, if the patient uses a wheelchair and/or scooter.
• The responses for the gateway wheelchair item (GG0170Q1 and GG0170Q3) might not be the same on
admission and discharge assessments.
o For example, at SOC a patient may never have used a wheelchair before and is currently not using
one under any condition. GG0170Q at SOC is coded 0-No. During the episode, the patient does
begin instruction in wheelchair use, and at Discharge the patient is able to mobilize the manual chair
for short distances. GG0170Q at Discharge is coded 1-Yes.
•

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Examples
1. Patient does not own a wheelchair but uses the assisted living facility’s wheelchair in order to access
activities and locations in the facility which are too far for the patient to walk.
Coding: GG0170Q - Does patient use wheelchair and/or scooter would be coded 1- Yes.
Rationale: Although it is in specific and possibly infrequent situations, the patient does use a
wheelchair for mobility.

GG0170R, GG0170RR, GG0170S, GG0170SS
Coding Tips
•
•

Clinicians can use clinical judgment to determine how the actual patient assessment of wheelchair
mobility is conducted. If a clinician chooses to combine the assessment of multiple wheelchair activities
use clinical judgment to determine the type and amount of assistance needed for each individual activity.
A helper can assist a patient to complete the wheelchair distance or make turns if required. When a patient
is unable to wheel the entire distance themselves the activity can still be completed, and a performance
code can be determined based on the type and amount of assistance required from the helper to complete
the entire activity.

GG0170R Wheel 50 feet with two turns, and
GG0170RR Indicate the type of wheelchair or scooter used

Coding Tips
Assess the patient’s ability to wheel 50 feet with two turns.
The turns included in the item GG0170R (wheeling 50 feet with 2 turns) are 90-degree turns. The turns
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 left and one 90-degree turn to the right). The 90degree turn should occur at the person’s ability level.
• If at the time of assessment, the patient uses both a manual and a motorized wheelchair or scooter to
complete the Wheel 50 feet with two turns activity, code the activity based on the type of
wheelchair/scooter with which the patient requires the most assistance.

•
•

Examples
1. At SOC, the patient is unable to bear any weight on their right leg due to a recent fracture. The nurse
observes as the certified nursing assistant in the assisted living facility provides steadying assistance when
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transferring the patient from the bed into the manual wheelchair. Once in the wheelchair, the patient propels
themselves safely about 60 feet down the hall using their left leg and both arms and safely makes two turns
without any necessary physical assistance or supervision.
Coding: GG0170R, Wheel 50 feet with two turns would be coded 06, Independent.
GG0170RR, Indicate the type of wheelchair/scooter used would be coded 1, Manual.
Rationale: Using a manual wheelchair, the patient wheels themself 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.
2. Once seated in the manual wheelchair, the patient wheels about 10 feet, including around one corner to the
hallway. Due to shoulder pain, the patient asks a helper to push the wheelchair the additional 40 feet around
another corner and into the bathroom.
Coding: GG0170R, Wheel 50 feet with two turns would be coded 02, Substantial/maximal
assistance.
GG0170RR, Indicate the type of wheelchair/scooter used would be coded 1, Manual.
Rationale: Using a manual wheelchair, the patient assists in propelling themself in a wheelchair and
also needs assistance from a helper, who provides more than half of the effort to complete distance and
the activity.

GG0170S Wheel 150 feet, and
GG0170SS Indicate the type of wheelchair or scooter used

Coding Tips
•

If at the time of assessment, the patient uses both a manual and a motorized wheelchair or scooter to
complete the Wheel 150 feet activity, code the activity based on the type of wheelchair/scooter with which
the patient requires the most assistance.

•

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.

Examples
1. The patient uses a below-the-knee prosthetic limb. The patient has peripheral neuropathy and limited vision
due to complications of diabetes. Via observation and patient report, the assessing clinician determines that
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the patient’s usual performance is that a helper is needed to provide verbal cues for safety due to vision
deficits, and the patient mobilizes their manual wheelchair a distance of 150 feet within their home.
Coding: GG0170S, Wheel 150 feet would be coded 04, Supervision or touching assistance.
GG0170SS, Indicate the type of wheelchair/scooter used would be coded 1, Manual.
Rationale: Using a manual wheelchair, the patient requires the helper to provide verbal cues for their
safety as they propel themself in their wheelchair for 150 feet.

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Section H: Bladder and Bowel

SECTION H: BLADDER AND BOWEL
Introduction
The items in this section assess bowel and bladder function to identify situations that could impact patient
health status or their plan of care.

M1600: Has this patient been treated for a Urinary Tract Infection in the past
14 days?

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

Response-Specific Instructions
•
•

Interview the patient and/or caregiver and review referral information.
The “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 14day 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.

Coding Instructions
•
•

•
•

Code 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.
Code 1, Yes, when:
o The patient has been prescribed an antibiotic within the past 14 days specifically for a confirmed or
suspected UTI
o The patient is on prophylactic treatment and develops a UTI.
Code NA, if the patient is on prophylactic treatment for the prevention of UTI.
Dash is not a valid response for this item.

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M1610: Urinary Incontinence or Urinary Catheter Presence

Item Intent
Identifies presence of urinary incontinence or urinary catheterization of any type, including intermittent or
indwelling.

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

Response-Specific Instructions
• Interview patient and/or caregiver and review referral information.
• The etiology (cause) of incontinence is not addressed in this item.

Coding Instructions
•

•

•

•

Code 0, No incontinence or catheter, if the patient has:
o Anuria
o An ostomy for urinary drainage (for example: an ileal conduit)
o A urinary diversion that is pouched (ileal conduit, urostomy, ureterostomy, nephrostomy), with or
without a stoma
Code 1, patient is incontinent, if the patient is:
o Incontinent at any time, including occasionally, “only when I sneeze,” “sometimes I leak a little bit”
etc.
o Dependent on a timed-voiding program

Code, 2, patient requires a urinary catheter, when the patient:
o Uses a catheter or tube for drainage, even if catheterizations are intermittent
o Requires the use of a catheter for urinary drainage for any reason (for example: retention, postsurgery, incontinence)
o Has a catheter inserted during the comprehensive assessment
o Is both incontinent, and requires a urinary catheter
Dash is not a valid response for this item.

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Coding Tips
•
•
•

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, Code 0 or 1 would be appropriate, depending on
whether or not the patient is continent.

M1620: Bowel Incontinence Frequency

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.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
•

Interview patient and/or caregiver and review referral information.

Coding Instructions
•

Dash is not a valid response for this item.

Coding Tips
•
•

“On a daily basis” means the patient experiences bowel incontinence once per day
This item does not address treatment of incontinence or constipation (for example, a bowel program)

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M1630: Ostomy for Bowel Elimination

Item Intent
Identifies whether the patient has an ostomy for bowel elimination and, if so, whether the ostomy was related to
a recent inpatient stay or caused a change in medical treatment plan.

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

Response-Specific Instructions
•
•
•
•
•

Interview patient and/or caregiver and review referral information including current supply list.
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 the patient has 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 “last 14 days” is the two-week period immediately preceding the Start/Resumption of Care. 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.

Coding Instructions
•

Dash is not a valid response for this item.

Coding Tips
•

If an ostomy has been reversed, then the patient does not have an ostomy at the time of assessment.

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Section I: Active Diagnoses

SECTION I: ACTIVE DIAGNOSES
Introduction

This section includes three items that identify active diagnoses and co-morbidities.

M1021/M1023: Primary Diagnosis/Other Diagnoses

Item Intent
The intent of these items is to accurately report and enter ICD-10 CM codes for the patient’s primary (M1021)
and other (M1023) home health diagnoses and document the degree of symptom control for each diagnosis.

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

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Response-Specific Instructions
Identifying Primary (M1021) and Other (M1023) Diagnoses
• The assessing clinician must determine the primary and other home health diagnoses based on the
assessment findings, information in the medical record including but not limited to physician/allowed
practitioner orders, medication list and referral information, and input from the physician/allowed
practitioner.
• The assessing clinician is expected to complete the patient’s comprehensive assessment and understand
the patient’s overall medical condition and care needs before assigning diagnoses.
• The assessing clinician 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 primary diagnosis (M1021) and other diagnoses (M1023) may or may not relate to the patient’s most
recent hospital stay, but must meet the definitions of primary and other diagnoses presented in this
guidance.
• 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 assessing
clinician must assess the patient’s clinical status and determine the primary and other diagnoses based on
patient status and treatment plan at the time of the assessment.
• Only current diagnoses should be reported as primary and 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
Reporting ICD-10-CM codes for Primary (M1021) and Other (M1023) Diagnoses
• Adherence to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10CM) 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 OASIS meet these guidelines.
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CMS and the National Center for Health Statistics (NCHS) provide the “Official Guidelines for Coding
and Reporting.” “These guidelines should be used as a companion document to the official version of the
ICD-10-CM as published on the NCHS website.”
The assessing clinician can enter the ICD-10-CM codes. 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 other diagnoses in Column 1.

Reporting the Symptom Control Rating in Column 2
• Assessing degree of symptom control includes but is not limited to review of presenting signs and
symptoms, type and number of medications, frequency of treatment readjustments, and frequency of
contact with health care providers.
o Inquire about the degree to which each condition limits daily activities.
o Assess the patient to determine if symptoms are controlled by current treatments.
• Clarify which diagnoses/symptoms have been poorly controlled in the recent past.

Coding Instructions
Column 1, Diagnoses:
o Enter the description of each diagnosis
o List each diagnosis for which the patient is receiving home care
o Diagnoses are listed in the order that best reflects the seriousness of each condition and supports the
disciplines and services provided
o Complete Column 1 from top to bottom, leaving any blank entries at the bottom.
o Order other diagnoses (M1023) according to the degree 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 being treated, even if the fungal infection is “poorly controlled.”
• Column 2, ICD-10 CM codes:
o For each diagnosis in Column 1, enter its ICD-10 CM code at the highest level of specificity
o No surgical or procedure codes allowed in Column 2
o ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any
diagnoses.
o 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 (Other Diagnoses).
o 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.
 See the ICD-10-CM “Official Guidelines for Coding and Reporting” for complete
instructions on code assignment and sequencing related to the use of Z-codes, and use of
multiple coding for a single condition (such as manifestation/etiology pairs).

•

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M1028: Active Diagnoses – Comorbidities and Co-existing Conditions

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 ulcers/injuries.

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 be present at the time of assessment.
o Clinical record sources for these diagnoses include, but are not limited to transfer documents,
physician/allowed practitioner: progress notes, recent history and physical, discharge summary,
orders, and consults.
o Do not include diseases or conditions that have been resolved or do not affect the patient’s current
functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of
death at the time of assessment.
o 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 physician (or others as
listed above) to ensure validity, follow-up, and coordination of care.
o Only diagnoses confirmed and documented by the physician (or others, as listed above) should be
considered when coding this item.
2. Determine whether diagnoses are active: Once a diagnosis is identified, determine whether the
diagnosis is active.
o If information regarding active diagnoses is learned after the end of the assessment timeframe, the
OASIS item should not be revised to reflect this new information. The OASIS should reflect what
was documented at the time of the assessment.
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

If, however, it comes to light after the OASIS assessment is submitted an error occurred,
where a documented active diagnosis was initially present but not indicated on the OASIS,
the Home Health Agency should correct the OASIS following the agency’s correction policy
and M0090 would not necessarily be changed.

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).
• Code 2, Diabetes Mellitus (DM), if the patient has an active diagnosis of Diabetes Mellitus (DM).
• Code 3, None of the Above, if the patient does not have any of the active diagnoses listed above.
• Dash is a valid response for this item.
o Dash indicates “no information.” 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.
• If a diabetic patient has either PAD or PVD both Response 1 and Response 2 should be checked.
• 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
A patient is prescribed insulin for diabetes mellitus. They require 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.

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2. None of the Above
During the SOC/ROC assessment, a patient told Nurse J, RN that they have 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.

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Section J: Health Conditions

SECTION J: HEALTH CONDITIONS
Introduction

This section includes seven items to assess risk for hospitalization, pain interfering with activities, frequency of
falls and shortness of breath.

M1033: Risk of Hospitalization

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
Follow-up

Response-Specific Instructions
•
•
•
•
•

Interview the patient/caregiver, conduct physical assessment, consult with the physician, and/or review the
clinical record, including but not limited to health history, and referral information.
History of falls (Response 1) includes witnessed and reported (unwitnessed) falls.
Multiple hospitalizations (Response 3) includes only acute care hospitalizations. Inpatient psychiatric and
long-term care hospitals (LTCHs) are excluded.
Multiple hospitalizations (Response 3) defines hospitalization as the patient being admitted for 24 hours
or longer to an inpatient acute bed for reasons other than diagnostic testing.
Multiple emergency department visits (Response 4) includes only hospital emergency room departments
(e.g., not urgent care centers or walk-in clinics).

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•

•

•
•

Section J: Health Conditions

Decline in mental, emotional, or behavioral status (Response 5) 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. A decline is considered a change in which the patient, family, caregiver
or physician has noted a decline regardless of cause. A decline can be temporary or permanent. Physician
consultation may or may not have occurred.
Medications (Response 7) include prescribed and over-the-counter (OTC) medications, nutritional
supplements, vitamins, and homeopathic and herbal products administered by any route and as noted on
the reconciled medication profile. Medications may also include total parenteral nutrition (TPN) and
oxygen
Other risk(s), (Response 9) 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).
If None of the above (Response 10) is selected, no other responses should be selected.

Coding Instructions
•

Dash is not a valid response for this item.

J0510-J0530: Pain Interview

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Item Intent
The intent of the items in this section is to assess the effect of pain on sleep, pain interference with therapy
activities, and pain interference with day-to-day activities.

Item Rationale
The assessment of pain is not associated with any particular approach to pain management. Since the use of
opioids is associated with serious complications, an array of successful non-pharmacologic and non-opioid
approaches to pain management may be considered. There are a range of pain management strategies that can
be utilized, including but not limited to non-narcotic analgesic drugs, transcutaneous electrical nerve stimulation
(TENS) therapy, supportive devices, acupuncture, biofeedback, application of heat/cold, massage, physical
therapy, nerve block, stretching and strengthening exercises, chiropractic, electric stimulation, radiotherapy, and
ultrasound.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Give an introduction before starting the interview. Suggested language: “I’d like to ask you some
questions about pain. The reason I am asking these questions is to understand how pain affects your sleep
and activities. This will help us to develop the best plan of care to help manage your pain.”
• Directly ask the patient each item in J0510 through J0530 in the order provided.
o Use other terms for pain or follow-up discussion if the patient seems unsure or hesitant. Some
patients avoid use of the term “pain” but may report that they “hurt.” Patients may use other terms
such as “aching” or “burning” to describe pain.
• If the patient is unsure about whether the pain effect or interference occurred in the 5-day time interval,
prompt the patient to think about the most recent episode of pain and try to determine whether it occurred
within the look-back period.
•

Coding Instructions
•
•

Code 8, Unable to answer, if the patient is unable to answer the question, does not respond (refuses)
or gives a nonsensical response.
Dash is not a valid response for this item.

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Section J: Health Conditions

J0510: Pain Effect on Sleep

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
•
•
•

Read the question and response choices as written.
No pre-determined definitions are offered to the patient. The response should be based on the patient’s
interpretation of frequency response options.
If the patient’s response does not lead to a clear answer, repeat the patient’s response and then try to
narrow the focus of the response. For example, if the patient responded to the question, “Over the past 5
days, how much of the time has pain made it hard for you to sleep at night?” by saying, “I always have
trouble sleeping,” then the assessing clinician might reply, “You always have trouble sleeping. Is it your
pain that makes it hard for you to sleep?” The clinician can then narrow down responses with additional
follow-up questions about the frequency.

Coding Instructions
If SOC/ROC assessment, complete as close to the time of SOC/ROC as possible. If discharge assessment,
complete as close to the time of discharge as possible.
•
•
•
•
•
•

Code 0, Does not apply, if the patient responds that they did not have any pain or hurting in the past 5
days.
Code 1, Rarely or not at all, if the patient responds that pain has been present and the pain rarely or
not at all made it hard to sleep in the past 5 days.
Code 2, Occasionally, if the patient responds that pain has occasionally made it hard to sleep in the
past 5 days.
Code 3, Frequently, if the patient responds that pain has frequently made it hard to sleep in the past 5
days.
Code 4, Almost constantly, if the patient responds that pain has almost constantly made it hard to
sleep in the past 5 days.
Code 8, Unable to answer, if the patient is unable to answer the question, does not respond or gives a
nonsensical response.

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Dash is not a valid response for this item.

Coding Tips
•
•
•

This item should be coded based on the patient’s interpretation of the provided response options for
frequency. If the patient is unable to decide between 2 options, then the assessing clinician should code for
the option with the higher frequency.
The key difference between code 0, Does not apply and code 1, Rarely or not at all is that for code 0,
the patient reports no pain/hurting in the past 5 days, and code 1, the patient reports pain/hurting HAS
been present in the past 5 days, but has rarely or not at all impacted sleep.
If the patient reports they had pain in the past 5 days and the pain does not interfere with the patient’s
sleep (e.g., because the patient is using pain management strategies successfully), code 1, Rarely or not
at all.

Examples
1. Assessing clinician: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at
night?”
Patient: “I’ve had a little back pain from being in the wheelchair all day, but it’s felt so much better when I
go to bed. The pain hasn’t kept me from sleeping at all.”
Coding: J0510 would be coded 1, Rarely or not at all.
Rationale: The patient reports pain has been present, but no sleep problems related to pain.
2. Assessing clinician: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at
night?”
Patient: “All the time. It’s been hard for me to sleep all the time. I have to ask for extra pain medicine, and I
still wake up several times during the night because my back hurts so much.”
Coding: J0510 would be coded 4, Almost constantly.
Rationale: The patient reports pain-related sleep problems “all the time,” so the most applicable
response is “Almost constantly.”

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J0520: Pain Interference with Therapy Activities

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Read the question and response choices as written.
No pre-determined definitions are offered to the patient. The response should be based on the patient’s
interpretation of frequency response options.
• Confirm that the patient has been offered rehabilitation therapies during the reference timeframe.

•
•

Coding Instructions
If SOC/ROC assessment, complete as close to the time of SOC/ROC as possible. If discharge assessment,
complete as close to the time of discharge as possible.
Code 0, Does not apply, if the patient responds that they did not participate in rehabilitation therapy
for reasons unrelated to pain (e.g., therapy not needed, unable to schedule) in the past 5 days.
• Code 1, Rarely or not at all, if the patient responds that pain has rarely or not at all limited
participation in rehabilitation therapy sessions in the past 5 days.
• Code 2, Occasionally, if the patient responds that pain has occasionally limited participation in
rehabilitation therapy sessions in the past 5 days.
• Code 3, Frequently, if the patient responds that pain has frequently limited participation in
rehabilitation therapy sessions in the past 5 days.
•

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Code 4, Almost constantly, if the patient responds that pain has almost constantly limited
participation in rehabilitation therapy sessions in the past 5 days.
• Code 8, Unable to answer, if the patient is unable to answer the question, does not respond or gives a
nonsensical response.
• Dash is not a valid response for this item.
•

Coding Tips
This item should be coded based on the patient’s interpretation of the provided response options for
frequency. If the patient is unable to decide between 2 options, then the assessing clinician should code for
the option with the higher frequency.
• Rehabilitation therapies may include treatment supervised in person by a therapist or nurse or other staff,
or the patient/family/caregivers carrying out a prescribed therapy program without agency staff present.

•

Examples
1. Assessing clinician: “Over the past 5 days, how often have you limited your participation in rehabilitation
therapy sessions due to pain?”
Patient: “Since the surgery a week ago, the pain has made it hard to even get out of bed. I try to push
myself, but the pain frequently limits how much I can do with my therapist.”
Coding: J0520 would be coded 3, Frequently
Rationale: The patient reports that pain frequently limits participation in therapies.

J0530: Pain Interference with Day-to-Day Activities

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
•
•

Read the question and response choices as written.
No pre-determined definitions are offered to the patient. The response should be based on the patient’s
interpretation of frequency response options.

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Coding Instructions
If SOC/ROC assessment, complete as close to the time of SOC/ROC as possible. If discharge assessment,
complete as close to the time of discharge as possible.
Code 1, Rarely or not at all, if the patient responds that pain has rarely or not at all limited day-to-day
activities (excluding rehabilitation therapy sessions) in the past 5 days.
• Code 2, Occasionally, if the patient responds that pain has occasionally limited day-to-day activities
(excluding rehabilitation therapy sessions) in the past 5 days.
• Code 3, Frequently, if the patient responds that pain has frequently limited day-to-day activities
(excluding rehabilitation therapy sessions) in the past 5 days.
• Code 4, Almost constantly, if the patient responds that pain has almost constantly limited day-to-day
activities (excluding rehabilitation therapy sessions) in the past 5 days.
• Code 8, Unable to answer, if the patient is unable to answer the question, does not respond or gives a
nonsensical response.
• Dash is not a valid response for this item.
•

Coding Tips
•

This item should be coded based on the patient’s interpretation of the provided response options for
frequency. If the patient is unable to decide between 2 options, then the assessing clinician should code for
the option with the higher frequency.

Examples
1. Assessing clinician: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
Patient: “Although I have some pain in my back, I’m still able to read, eat my meals, and take walks like I
usually do.”
Coding: J0530 would be coded 1, Rarely or not at all.
Rationale: The patient reports that pain has not limited participation in day-to-day activities.
2. Assessing clinician: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
Patient: “The pain has made it hard to do pretty much anything. Even getting out of bed to brush my teeth
has been hard. I haven’t been able to talk to my family because the pain is so bad. It’s just constant. I’d say
it constantly limits what I do.”
Coding: J0530 would be coded 4, Almost constantly.
Rationale: The patient reports that pain has constantly limited participation in other activities.

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J1800: Any Falls Since SOC/ROC

Item Intent
This item is intended to code any witnessed or unwitnessed falls since the most recent SOC/ROC.

Item Rationale
•
•

Falls are a leading cause of morbidity and mortality.
Fear of falling can limit an individual’s activity and negatively impact quality of life.

Time Points Item(s) Completed
Transfer
Death at home
Discharge from agency

Response-Specific Instructions
Interview the patient and/or caregiver, review the home health clinical record and any other relevant
clinical documentation, such as incident reports or fall logs.
• Include all falls since the most recent SOC/ROC, regardless of where the fall occurred.

•

Coding Instructions
•
•

Code 0, No, if the patient has not had any falls since the most recent SOC/ROC.
Code 1, Yes, if the patient has fallen since the most recent SOC/ROC and continue to J1900. Number of
Falls since SOC/ROC.

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Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
•

Report falls that occurred at any time during the quality episode, regardless of where the fall occurred. For
example,
o a fall that occurred at the doctor’s office during the HH quality episode would be reported
o a fall that occurred during a qualifying inpatient facility transfer (e.g., hospital or SNF) would not be
reported as it did not occur within a HH quality episode

Examples
1. The discharging RN reviews the clinical record and interviews 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 the caregiver reported the patient slipped from their 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. An incident report describes an event in which a patient was walking down the hall and appeared to slip on a
wet spot on the floor. The patient lost their balance and bumped into the wall, but was able to grab onto the
handrail and steady themself.
Coding: J1800 would be coded 1, Yes.
Rationale: An intercepted fall is considered a fall. An intercepted fall occurs when the patient would
have fallen if they had not caught themself or had not been intercepted by another person.
3. A patient is participating in balance training during a therapy session. The therapist is intentionally
challenging the 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 steadying/contact guard assistance to allow the patient
to maintain standing.
Coding: J1800 would be coded 0, No.
Rationale: The patient’s balance was intentionally being challenged, so a loss of balance is anticipated
by the physical therapist. When assistance is provided to a patient to allow them to maintain standing
during an anticipated loss of balance, this is not considered a fall or “intercepted fall.”
4. A patient is ambulating with a walker and with the help of a physical therapist. The patient unexpectedly
stumbles, and the therapist has to bear some of the patient’s weight in order to prevent the fall.
Coding: J1800 would be coded 1, Yes.
Rationale: The patient unexpectedly stumbled, which was not anticipated by the therapist, and the
therapist intervened to prevent a fall. An intercepted fall is considered a fall if it is not an anticipated loss

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of balance resulting from a supervised therapeutic intervention where the patient’s balance is being
intentionally challenged during balance training.

J1900: Number of Falls since SOC/ROC

Item Intent
This item is intended to code the number of falls a patient had since the most recent SOC/ROC and fall-related
injury.

Item Rationale
•
•

Falls are a leading cause of morbidity and mortality.
Fear of falling can limit an individual’s activity and negatively impact quality of life.

Time Points Item(s) Completed
Transfer
Death at Home
Discharge from agency
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Response-Specific Instructions
Interview the patient and/or caregiver and review the home health clinical record, incident reports, and any
other relevant clinical documentation such as fall logs.
• Include all falls since the most recent SOC/ROC, regardless of where the fall occurred.

•

Coding Instructions
•
•

Determine the number of falls that occurred since the most recent SOC/ROC and code the level of fallrelated injury for each.
Code each fall only once. If the patient has multiple injuries in a single fall, code the fall for the highest
level of injury.

Coding Instructions for J1900A, No injury
•
•
•
•

Code 0, None, if the patient had no injurious fall 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.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Instructions for J1900B, Injury (except major)
•
•
•
•

Code 0, None, if the patient had no injurious fall (except major) since the most recent SOC/ROC.
Code 1, One, if the patient had one injurious fall (except major) since the most recent SOC/ROC.
Code 2, Two or more, if the patient had two or more injurious falls (except major) since the most
recent SOC/ROC.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Instructions for J1900C, Major injury
•
•
•
•

Code 0, None, if the patient had no major injurious fall since the most recent SOC/ROC.
Code 1, One, if the patient had one major injurious fall since the most recent SOC/ROC.
Code 2, Two or more, if the patient had two or more major injurious falls since the most recent
SOC/ROC.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
•

Report falls that occurred at any time during the quality episode, regardless of where the fall occurred. For
example,
o a fall that occurred at the doctor’s office during the HH quality episode would be reported
o a fall that occurred during a qualifying inpatient facility transfer (e.g., hospital or SNF) would not be
reported as it did not occur within a HH quality episode

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Agencies are encouraged to correct errors as accurate information regarding fall-related injuries becomes
known. For example,
o Injuries can present themselves later than the time of the fall.
o The agency may not learn of the level of injury until after the OASIS assessment is completed (e.g.,
because the patient was transported to ER and admitted to an inpatient facility post-fall).
o Errors should be corrected following the agency’s correction policy. The M0090 date would not
necessarily be changed.

Examples
1. A nursing note states that a patient slipped out of their wheelchair onto the floor during a transfer from the
bed to the wheelchair. Before being assisted back into bed, an assessment was completed that indicated no
injury.
Coding: J1900A, No injury, would be coded 1, One, if no other falls without injury occurred.
Rationale: Slipping onto the floor is a fall. No injury was noted.
2. A nurse’s note describes a patient who climbed over their bedrail and fell to the floor. On examination, they
had a cut over their left eye and some swelling on their arm. The patient was sent to the emergency room,
where x-rays revealed no injury and neurological checks revealed no changes in mental status. The patient
returned home within 24 hours.
Coding: J1900B, Injury (except major), would be coded 1, One.
Rationale: Lacerations and swelling without fracture are classified as injury (except major).
3. A patient fell, lacerated their head, and was sent to the emergency room, where a head computerized
tomography (CT) scan revealed a subdural hematoma. The patient received treatment and returned home
after 2 days.
Coding: J1900C, Major injury, would be coded 1, One.
Rationale: Subdural hematoma is a major injury, and it occurred as a result of the fall.
4. 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 the patient tripped on the bathroom rug and almost fell, but caught themself against the
sink. The RN assessment identified no injury. The second describes an event during which the patient, while
coming up the basement stairs with the laundry, fell against the stair and sustained a bruise and laceration on
their 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.
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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. 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 the patient fell while walking from the bedroom to the bathroom and was transported to
the emergency room via ambulance. Examination and testing revealed a skin tear on the patient’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.
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.

M1400: When is the patient dyspneic or noticeably Short of Breath?

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
Discharge

Response-Specific Instructions
•
•

Conduct physical assessment, including observation. Interview the patient/caregiver and/or review the
health history.
If the patient uses oxygen continuously, code the response based on assessment of the patient’s shortness
of breath while using oxygen.

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If the patient uses oxygen intermittently, code the response based on the patient’s shortness of breath
without the use of oxygen.
o Responses are based on the patient’s actual use of oxygen in the home, not on the physician’s
oxygen order.
• 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.
•

Coding Instructions
Code 0, Patient is not short of breath, if the patient has not been short of breath on the day of
assessment.
• Code 1, When walking more than 20 feet, climbing stairs, and/or if demanding bed-mobility
activities produce dyspnea in the bedbound patient (or physically demanding transfer activities produce
dyspnea in the chairfast patient).
• Dash is not a valid response for this item.
•

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SECTION K: SWALLOWING/NUTRITIONAL STATUS
Introduction

This section includes three items. Height and weight to calculate body mass, nutritional approaches and
assessment of the ability to eat, chew and swallow food.

M1060: Height and Weight

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
Whenever possible, a current height and weight should be obtained by the agency as part of the SOC/ROC
assessment.
•

•

M1060.A Height
o Measure height in accordance with the agency’s policies and procedures.
o Measure and record the patient’s height to the nearest whole inch.
o 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.
o 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
o Weight should be measured in accordance with the agency’s policies and procedures.
o Measure and record the patient’s weight in pounds.
o 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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o If agency staff weighs the patient multiple times during the assessment period, use the first weight.
o 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.

Coding Instructions
•

Dash is a valid response to this item if:
o the patient falls outside the following height and/or weight parameters
 Height parameters <50 inches or >80 inches
 Weight parameters <65 lbs. or > 440lbs
o If a patient’s height/weight cannot be measured during the assessment timeframe, and no agencyobtained height/weight from a documented visit conducted within the previous 30-day window is
available
o Dash indicates “no information.” 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.
When there is an unsuccessful attempt to measure a patient’s height or weight, at SOC/ROC, an agencyobtained height or weight from a documented home health visit conducted within the previous 30-day
window may be used to complete this item.

K0520: Nutritional Approaches

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Item Intent
The intent of this item is to identify if any nutritional approaches listed are used by the patient.

Item Rationale
•
•

Nutritional approaches such as mechanically altered food or those that rely on alternative methods (e.g.,
parenteral/IV or feeding tubes) can diminish an individual’s sense of dignity and self-worth as well as
diminish pleasure from eating.
The patient’s clinical condition may potentially benefit from the various nutritional approaches included
here.

5

Academy of Nutrition and Dietetics. (2019). Academy of Nutrition and Dietetics definition of terms list. Retrieved from
https://www.eatrightpro.org/-/media/eatrightpro-files/practice/scope-standards-of-practice/20190910-academy-definition-of-termslist.pdf?la=en&hash=1DB6495E0B94CB5FA3E7443B1E8436A32E50B8B8

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Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions for SOC/ROC
•

Consult the patient, family, or caregiver and/or review the clinical record or other available documentation
to determine if any of the listed nutritional approaches apply during the time period under consideration
for the SOC/ROC assessment.

Coding Instructions for SOC/ROC
•
•

Check all that apply during the time period under consideration for the SOC/ROC assessment. If none
apply, check K0520Z, None of the above.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Response Specific Instructions for Discharge
•

Consult the patient, family, or caretaker and/or review the clinical record or other available documentation
to determine if any of the listed nutritional approaches were received in the last 7 days (Column 1) and
during the time period under consideration for the discharge assessment (Column 2).

Coding Instructions for Discharge
•
•

Check all nutritional approaches that were received in the last 7 days (Column 1) and during the time
period under consideration for the discharge assessment (Column 2). If none apply, check K0520Z, None
of the above.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

General Coding Tip
•

If a patient will receive one of the listed nutritional approaches as a result of this SOC/ROC assessment
(for example, IV hydration will be started at this visit or a specified subsequent visit; the physician is
contacted for an enteral order, etc.), mark the applicable nutritional approach.

Coding Tips for K0520A, Parenteral/IV feeding
•

Parenteral/IV feeding includes parenteral or IV fluids provided for nutrition or hydration. Includes
additional fluid intake specifically addressing a documented nutrition or hydration need. Excludes fluids
provided solely to maintain access and patency.
o The following items may be included:
 IV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered
continuously or intermittently.
 Hypodermoclysis and subcutaneous ports in hydration therapy.
 IV fluids can be coded in K0520A if needed to prevent dehydration if the additional fluid

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intake is specifically needed for nutrition and hydration.
o The following items are NOT to be coded in K0520A:
 IV medications—Code these when appropriate in O0110H, IV Medications.
 IV fluids used to reconstitute and/or dilute medications for IV administration.
 IV fluids administered as a routine part of an operative or diagnostic procedure or recovery
room stay.
 IV fluids administered to flush the IV line.
 Parenteral/IV fluids administered in conjunction with chemotherapy or dialysis.

Coding Tips for K0520B, Feeding tube
•

Code only feeding tubes used to deliver nutritive substances and/or hydration during the time period under
consideration.

Coding Tips for K0520D, Therapeutic Diet
Enteral feeding formulas:
o Should not be coded as a mechanically altered diet.
o Should only be coded as K0520D, Therapeutic Diet when the enteral formula is altered to manage
problematic health conditions, e.g. enteral formulas specific to diabetes.
• A nutritional supplement given as part of the treatment for a disease or clinical condition manifesting an
altered nutrition status, does not constitute a therapeutic diet, but may be part of a therapeutic diet.
Therefore, supplements (whether taken with, in-between, or instead of meals) are only coded in K0520D,
Therapeutic Diet when they are being taken as part of a therapeutic diet to manage problematic health
conditions (e.g. supplement for protein-calorie malnutrition).
o Food elimination diets related to food allergies (e.g. peanut allergy) can be coded as a therapeutic
diet.

•

Examples for SOC/ROC: K0520A, Parenteral/IV feeding
1. A patient is admitted with orders for an antibiotic in 100 cc of normal saline via IV for symptoms of a
urinary tract infection (UTI), fever, abnormal lab results (e.g., new pyuria, microscopic hematuria, urine
culture with growth >105 colony forming units of a urinary pathogen), and documented inadequate fluid
intake (i.e., output of fluids far exceeds fluid intake) with signs and symptoms of dehydration. The plan of
care is updated to include a hydration intervention to ensure adequate hydration. Documentation shows IV
fluids are being administered as part of the already identified need for additional hydration.
Coding: K0520A would be checked. The IV medication would be coded at IV Medications item
(O0110H).
Rationale: The patient received 100 cc of IV fluid and there is supporting documentation that reflected
an identified need for additional fluid intake for hydration.
2. A patient is admitted and receiving an antibiotic in 100 cc of normal saline via IV. They have a UTI, no
fever, and documented adequate fluid intake. The patient is placed on an oral hydration plan to maintain
adequate hydration.
Coding: K0520A would NOT be checked. The IV medication would be coded at IV Medications item
(O0110H).

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Rationale: The patient received IV fluids but it is not reported in K0520A because documentation
indicated that fluid intake was adequate. Oral hydration is not included in K0520.

Examples for Discharge

1. The patient will be discharged today. They were receiving rehabilitation services for a stroke. The patient
has longstanding Celiac disease and therefore was placed on a gluten free diet. Because of their recent
stroke, they also have documented dysphagia requiring a mechanical soft diet and honey-thick liquids to
prevent aspiration and will be discharged on this same diet.
Coding: K0520C4 and K0520C5 as well as K0520D4 and K0520D5 would be checked.
Rationale: The patient requires both a mechanically altered diet (i.e., mechanical soft diet and honeythick liquids) and a therapeutic diet (i.e., gluten free) for Celiac disease and they were administered in
the last seven days as well as during the time period under consideration for the discharge assessment
and are expected to continue after discharge.
2. Prior to their SOC/ROC with home health, the patient had been on a chopped diet due to facial trauma. They
will be discharged today after rehabilitation services for multiple fractures after a car accident. The patient
has been on a regular diet during their entire home health stay and has not required any parenteral or enteral
nutrition.
Coding: K0520Z4 and K0520Z5 would be checked.
Rationale: The patient had a regular diet their entire home health stay and did not require any
nutritional modifications.

M1870: Feeding or Eating

Item Intent
Identifies the patient’s ability to feed themself, 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 this item.

Time Points Item(s) Completed
Start of Care
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Resumption of Care
Discharge from agency

Response-Specific Instructions
Observation/demonstration is the preferred method to complete this item. Other sources of information
include but are not limited to patient/caregiver interview, physical assessment, nutritional assessment,
physician orders, plan of care, referral information, and review of past history. When coding this item, the
assessing clinician may consider available input from other agency staff who have had direct patient
contact.
• Code this item based on the assistance needed by the patient to feed themself once the food is placed in
front of them. Assistance means human assistance by verbal cueing/reminders, supervision, and/or standby or hands-on assistance.
• 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.
• Do not consider preparation of food, or transport of food to the table when coding this item.
• “Meal set up”, (Response 1, option a), refers to 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 adaptions of the meal for
the patient.
•

Coding Instructions
Code 5, Unable to take in nutrients orally or by tube feeding, if all nutrition is received
intravenously (such as TPN) or for patients who are receiving only intravenous hydration.
• Dash is not a valid response for this item.

•

Coding Tips
•

If a patient is being weaned from tube feeding, code 3 or 4 will continue to apply until the patient no
longer uses the tube for nutrition, at which time, code 0, 1, or 2. This is true, even if the tube remains in
place, unused for a period of time.

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SECTION M: SKIN CONDITIONS
Introduction

This section includes items that assess the presence of pressure ulcers, stasis ulcers and surgical wounds.

M1306: Unhealed Pressure Ulcer/Injury at Stage 2 or Higher

Item Intent
Identifies the presence or absence of Unhealed Stage 2 or higher or Unstageable pressure ulcers/injuries only.

Item Rationale
•

An existing pressure ulcer/injury identifies patients at risk for further complications or skin injury.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Follow-up
Discharge from agency

Response-Specific Instructions
•

•

The presence of pressure ulcers/injuries and unstageable ulcers/injuries should be determined by physical
assessment and observation. Medical records, patient/caregiver report and physician input may be used for
historical purposes only to identify the presence of an existing ulcer/injury or the stage of a previously
healed pressure ulcer.
Review the history of each pressure ulcer/injury in the clinical record. If the pressure ulcer/injury was
previously classified at a higher numerical stage than what is observed now, as long as it remains
stageable, it should continue to be classified at the higher numerical stage until healed.

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Home health agencies may adopt the National Pressure Injury Advisory Panel (NPIAP) guidelines in their
clinical practice and documentation. However, since CMS has adapted the NPIAP guidelines for OASIS
purposes, the definitions do not perfectly align with each stage as described by NPIAP. When
discrepancies exist between the NPIAP definitions and the OASIS scoring instructions provided in the
OASIS Guidance Manual and CMS Q&As, providers should rely on the CMS OASIS instructions.

Coding Instructions
Code 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.
• Code 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.
• Dash is not a valid response for this item.
•

Coding Tips
If pressure is not the primary cause of the lesion, do not report the wound as a pressure ulcer/injury.
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.
• 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 reepithelialization (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
•
•

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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.

M1307: The Oldest Stage 2 Pressure Ulcer that is 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.

Item Rationale
•
•

Stage 2 pressure ulcers may worsen without proper interventions.
These patients are at risk for further complications or skin injury.

Time Points Item(s) Completed
Discharge from agency

Response-Specific Instructions
Staging of a pressure ulcer/injury should be determined by physical assessment and observation. Medical
records, patient/caregiver report and physician input may be used for historical purposes only to identify
the presence of an existing ulcer/injury or the stage of a previously healed pressure ulcer.
• Review the history of each pressure ulcer/injury in the clinical record. If the pressure ulcer/injury was
previously classified at a higher numerical stage than what is observed now, as long as it remains
stageable, it should continue to be classified at the higher numerical stage until healed.
• 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
•

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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 or becomes unstageable.
• Stage 2 (partial thickness) pressure ulcers heal through the process of regeneration of the epidermis
across a wound surface called, “re-epithelialization.”
• 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).

Coding Instructions
•
•

•
•
•

Code 1, Was present at the most recent SOC/ROC assessment, 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 most recent SOC/ROC.
Code 2, Developed since the most recent SOC/ROC assessment, 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 most recent SOC/ROC.
o If Code 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, 2021 would be 05/04/2021).
Code 2, Developed since the most recent SOC/ROC assessment, if no pressure ulcer
existed at the SOC, then a Stage 1 pressure injury developed, which progressed to a Stage 2 by
discharge. Specify the date that the pressure ulcer was first identified as a Stage 2 ulcer.
Code NA, No Stage 2 pressure ulcers are present at discharge, if there are no Stage 2
pressure ulcers at the time of discharge, or all previous Stage 2 pressure ulcers have healed.
Dash is not a valid response for this item.

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

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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.

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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.

Item Rationale
•

It is important to recognize and evaluate each patient’s risk factors for developing skin ulcers, wounds or
lesions, and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is
essential to an effective pressure ulcer/injury prevention and skin treatment program.

•

It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the
proper treatment and management of the wound.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
The presence of pressure ulcer/injuries and unstageable ulcers/injuries should be determined by physical
assessment and observation. Medical records, patient/caregiver report and physician input may be used for
historical purposes only to identify the presence of an existing ulcer/injury or the stage of a previously
healed pressure ulcer.
• Review the history of each pressure ulcer/injury in the clinical record. If the pressure ulcer/injury was
previously classified at a higher numerical stage than what is observed now, as long as it remains
stageable, it should continue to be classified at the higher numerical stage until healed.
• 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
•

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•

•

•

•

•

Section M: Skin Conditions

clinician should make every effort to contact previous providers (including patient’s physician) to
determine the highest numerical stage of the pressure ulcer.
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.
o When the assessing clinician is unable to complete a full skin assessment at the first visit, the
assessing clinician may collaborate with a second clinician who completes the first clinical skin
assessment, within the assessment timeframe.
Stage 2 Pressure Ulcers
o Report in M1311A1 the number of Stage 2 pressure ulcers that are observed on the current day of
assessment.
o 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.
o Granulation tissue, slough, and eschar are not present in Stage 2 pressure ulcers.
Stage 3 Pressure Ulcers
o Report in M1311B1 the number of Stage 3 pressure ulcers that are observed on the current day of
assessment.
o A previously closed Stage 3 pressure ulcer that is currently open again should be reported as a Stage
3 pressure ulcer, unless currently presenting at a higher stage or unstageable.
Stage 4 Pressure Ulcers
o Report in M1311C1 the number of Stage 4 pressure ulcers that are observed on the current day of
assessment
o 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.
o A previously closed Stage 4 pressure ulcer that is currently open again should be reported as a Stage
4 pressure ulcer, unless currently unstageable.
Unstageable Ulcers/Injury: Non-removable dressing/device
o Report in M1311D1 the number of pressure ulcers/injuries that on the current day of assessment are
known but not stageable due to non-removable dressing/device.
o Pressure ulcers/injuries that are known to be present but that are Unstageable due to a nonremovable dressing/device, such as a cast that cannot be removed to assess the skin underneath,
should be reported in M1311D1, Unstageable.
o “Known” refers to when documentation is available that states a pressure ulcer/injury exists under
the non-removable dressing/device. Unstageable pressure ulcers/injuries covered with a nonremovable dressing would not be considered healed.

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Unstageable Ulcers: Slough/Eschar
o Report in M1311E1 the number of pressure ulcers that on the current day of assessment are
unstageable due to coverage of wound bed by slough and/or eschar.
 Pressure ulcers that have eschar or slough 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 when 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.
o Unstageable pressure ulcers due to eschar or slough would not be considered healed.

Unstageable: Deep Tissue Injury (DTI)
o Report in M1311F1 the number of unstageable pressure injuries presenting as deep tissue injury.
 Deep tissue injury may be difficult to detect in individuals with dark skin tones.
 Deep Tissue Injury (DTI), although closed (intact skin), would not be considered healed.
 A pressure ulcer/injury presenting with characteristics of a DTI is reported as a DTI unless
full thickness tissue loss is present. For example, a DTI presenting as purple localized
discoloration with tenderness caused by pressure, but without full thickness tissue loss would
be coded as a DTI, even though the wound is not completely intact.

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Determining “Present at the most recent SOC/ROC” to answer M1311X2
For each pressure ulcer/injury observed and reported 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 patient has a pressure ulcer that was documented at SOC/ROC and at discharge is documented at the
same stage, it would be considered as “present at the most recent SOC/ROC”, even if during the episode
the original pressure ulcer healed and reopened.
• 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.
• 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 M1311E2.
• If an unknown pressure ulcer/injury is discovered upon removal of a non-removable dressing/device, that
pressure ulcer/injury should be considered new, and not be coded as “present at the most recent
SOC/ROC” for M1311X2.
• If a pressure ulcer/injury that is stageable at SOC is unstageable due to a non-removable dressing/device at
discharge, it would be considered “present at the most recent SOC/ROC” if it had not 1) increased in
numerical stage, or 2) become unstageable due to slough/eschar when the non-removable dressing/device
was applied. This is because even though the stage of the pressure ulcer/injury is unknown at discharge,
there is no documentation or indication that it increased in numerical stage or worsened during the stay.
• 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.
• If a DTI that was observed at SOC/ROC does not evolve to be numerically stageable, but is subsequently
classified as another type of unstageable pressure ulcer/injury, it would be considered and coded as
“present at the most recent SOC/ROC” on the discharge assessment in that unstageable pressure
ulcer/injury category (M1311X1=1 and M1311X2=1).
•

Coding Instructions
•

•
•

•

At SOC/ROC, enter a response for the following rows of this item: A1, B1, C1, D1, E1, and F1.
o 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.
Dash is not a valid response for this item at the SOC/ROC time points.
At Discharge, enter a response for each row of this item: A1, A2, B1, B2, C1, C2, D1, D2, E1, E2, F1, and
F2, unless directed to skip.
o Example: At Discharge, in A1 enter the number of Stage 2 pressure ulcers that are observed at the
discharge assessment. If no Stage 2 pressure ulcers are observed, enter “0” in A1, and skip A2. 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.
Dash is a valid response for this item at the discharge time point.

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o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
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.
•

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 a patient’s skin at the SOC and identifies a DTI with intact skin on the patient’s 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
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 discharge).
Coding: On the discharge 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 discharge assessment, the patient had one Stage 3 pressure ulcer, and zero
unstageable pressure injuries presenting as DTI. The Stage 3 pressure ulcer observed on the discharge
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
The RN completes a skin assessment during the SOC visit for a patient 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 discharge.
Coding: On the DC discharge 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).
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 discharge assessment, the Stage 4 pressure ulcer at discharge is considered new, and not coded as
present at the most recent SOC/ROC.

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3. Deep Tissue Injury (DTI) with intact skin at SOC, becomes numerically stageable, then is
unstageable due to slough and/or eschar at discharge
The RN assesses a patient’s skin during the assessment timeframe for the SOC and identifies a DTI with intact
skin on the patient’s right heel. This DTI first becomes numerically stageable at the third home visit, as a Stage
3 pressure ulcer. At the discharge skin assessment, this pressure ulcer is unstageable due to slough and eschar.
Coding: On the discharge 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 discharge skin assessment
the ulcer was unstageable due to slough and eschar. Any pressure ulcer/injury that is unstageable due to
slough and/or eschar at discharge, but was previously numerically stageable, is considered new, and not
coded as present at the most recent SOC/ROC.

M1322: Current Number of Stage 1 Pressure Injuries

Item Intent
Identifies the presence and number of Stage 1 pressure injuries.

Item Rationale
•
•

Stage 1 pressure injuries may deteriorate to more severe pressure ulcers/injuries without adequate
intervention; as such, they are an important risk factor for further tissue damage.
Development of a Stage 1 pressure injury is one of multiple factors that should lead providers to initiate
pressure ulcer/injury prevention interventions.

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

Response-Specific Instructions
Staging of a pressure ulcer/injury should be determined by physical assessment and observation. Medical
records, patient/caregiver report and physician/allowed practitioner input may be used for historical
purposes only to identify the presence of an existing ulcer/injury or the stage of a previously healed
pressure ulcer.
• Review the history of each pressure ulcer/injury in the clinical record. If the pressure ulcer/injury was
previously classified at a higher numerical stage than what is observed now, as long as it remains
stageable, it should continue to be classified at the higher numerical stage until healed.
• Recognize that although Stage 1 pressure injuries are closed (intact skin), they would not be considered
healed.

•

Coding Instructions
•
•

Enter the number of Stage 1 pressure injuries present at the first skin assessment completed at the
SOC/ROC.
Dash is not a valid response for this item.

M1324: Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is
Stageable

Item Intent
Identifies the stage of the most problematic unhealed stageable pressure ulcer/injury.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

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Response-Specific Instructions
Staging of a pressure ulcer/injury should be determined by physical assessment and observation. Medical
records, patient/caregiver report and physician input may be used for historical purposes only to identify
the presence of an existing ulcer/injury or the stage of a previously healed pressure ulcer.
• Review the history of each pressure ulcer/injury in the clinical record. If the pressure ulcer/injury was
previously classified at a higher numerical stage than what is observed now, as long as it remains
stageable, it should continue to be classified at the higher numerical stage until healed.

•

Coding Instructions
Enter the response that most accurately describes the stage of the most problematic unhealed stageable
pressure ulcer/injury.
o Step 1: Determine which pressure ulcer(s)/injur(ies) are stageable or unstageable. Definitions of
pressure ulcer/injury stages are in guidance for M1311, Current Number of Unhealed Pressure
Ulcers/Injuries. 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.
 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.
 It presents as a deep tissue injury
o Step 2: Determine which stageable pressure ulcer/injury is the most problematic.
 “Most problematic” may be the largest, the most advanced stage, the most difficult to access
for treatment, the most difficult to relieve pressure, etc., depending on the specific situation.
 If the patient has only one stageable pressure ulcer, then that ulcer is the most problematic.
• Enter “NA” if the patient has NO pressure ulcers or only has pressure ulcers that are unstageable at the
time of the assessment.
• Stage 1 pressure injuries, although closed (intact skin), would not be considered healed.
• Dash is not a valid response for this item.
•

Coding Tips
•
•

Pressure ulcers/injuries that have healed are not considered for this item.
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.
o If a pressure ulcer is Stage 4 at SOC and is granulating at the next assessment, the ulcer remains
a Stage 4 ulcer.

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M1330: Does this patient have a Stasis Ulcer?

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.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Physical assessment and observation are the preferred approach to determine the presence of stasis ulcers.
Patient/caregiver report, medical records including physician/allowed practitioner orders and input may be
used.
• It is important to differentiate stasis ulcers from other types of skin lesions, and only report stasis ulcers in
this item.
• Stasis ulcers DO NOT include arterial lesions or arterial ulcers.
• Once a stasis ulcer has completely epithelialized, it is considered healed and should not be reported as a
current stasis ulcer.
• Unobservable stasis ulcers are reported stasis ulcer(s) 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.
•

Coding Instructions
•
•
•
•

Code 1, Yes, if patient has BOTH observable and unobservable stasis ulcers.
Code 2, Yes, if the patient has observable stasis ulcers ONLY.
Code 3, Yes, if the patient has unobservable stasis ulcers ONLY.
Dash is not a valid response for this item.

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

Item Intent
Identifies the number of visible (observable) stasis ulcers.

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

Response-Specific Instructions
Physical assessment and observation are the preferred approach to determine the presence of stasis ulcers.
Patient/caregiver report, medical records including physician/allowed practitioner orders and input may be
used.
• All stasis ulcers except those that are covered by a non-removable dressing/device, such as a cast or Unna
boot, are considered observable.
• Dash is not a valid response for this item.
•

M1334: Status of Most Problematic Stasis Ulcer that is Observable

Item Intent
Identifies the degree of healing present in the most problematic, observable stasis ulcer.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

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Response-Specific Instructions
Physical assessment and observation are the preferred approach to determine the presence of stasis ulcers.
Patient/caregiver report, medical records, including physician/allowed practitioner orders and input may
be used.
• Determine which stasis ulcers are observable. Include all stasis ulcers that are not covered with a nonremovable dressing/device, such as a cast or Unna boot.
• If the patient has only one observable stasis ulcer, that ulcer is the most problematic.
• “Most problematic” is determined by the clinician’s professional evaluation of the individual’s overall
wound status, and may be based on factors including, but not limited to:
o Healing status, such as an ulcer that is infected or resistant to treatment
o Size (may be the largest ulcer)
o Location (may be difficult to access for treatment)
• 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.
•

Coding Instructions
Code 1, Fully Granulating, when the stasis ulcer wound bed:
o is filled with granulation tissue to the level of the surrounding skin or new epithelium;
o has no dead space;
o has no avascular tissue;
o has no signs or symptoms of infection; and,
o has open wound edges.
• Code 2, Early/Partial Granulation, when:
o ≥ 25% of the wound bed is covered with granulation tissue;
o there is minimal avascular tissue (that is, <25% of the wound bed is covered with avascular tissue);
o may have dead space;
o has no signs or symptoms of infection; and,
o has open wound edges.
• Code 3, Not Healing, when:
o ≥25% of the wound bed is avascular tissue – AND/OR
o signs/symptoms of infection are present – AND/OR
o the wound bed is clean but non-granulating – AND/OR
o the wound edges are closed/hyperkeratotic – AND/OR
o there is persistent failure to improve despite appropriate comprehensive wound management.
• Dash is not a valid response for this item.
•

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M1340: Does this patient have a Surgical Wound?

Item Intent
Identifies the presence of a wound resulting from a surgical procedure.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Physical assessment and observation are the preferred approach to determine the presence of surgical
wounds. Patient/caregiver report, medical records, including physician/allowed practitioner orders and
input may be used.
• The agency may use any skin assessment conducted during the assessment timeframe to code M1340.
• 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.
• 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.
• An incision line is considered a surgical wound. The staple or suture sites are not considered surgical
wounds.
•

Coding Instructions
•

•
•

Code 1, Yes, patient has at least one observable surgical wound, if the patient has at least one
observable surgical wound
o If the patient has both an observable surgical wound, and a known but not observable surgical
wound, Code 1, Yes.
Code 2, Surgical wound known but not observable if the only surgical wound is not observable.
A surgical wound is considered not observable when it is covered by a dressing/device, such as a cast,
which is not to be removed per physician order.
Dash is not a valid response for this item.

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Coding Tips
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.
o 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.
• Other examples of surgical wounds include, but are not limited to:
o Orthopedic pin sites,
o Central line sites (centrally inserted venous catheters),
o Wounds with drains,
o Medi-port sites and other implanted infusion devices, or
o Venous access devices
• 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 do NOT create a surgical wound for the purpose of this item.
•

M1342: Status of Most Problematic Surgical Wound that is Observable

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
Discharge from agency

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Response-Specific Instructions
•
•
•
•
•

Physical assessment and observation are the preferred approach to determine the presence of surgical
wounds. Patient/caregiver report, medical records, including physician/allowed practitioner orders and
input may be used.
Determine which surgical wounds (as defined in M1340 guidance) are observable.
Identify the most problematic observable surgical wound.
If the patient has only one observable surgical wound, that wound is the most problematic.
“Most problematic” is determined by the clinician’s professional evaluation of the individual’s overall
wound status, and may be based on factors including, but not limited to:
o Healing status, such as a surgical wound that is infected or resistant to treatment
o Size (may be the largest surgical wound)
o Location (may be difficult to access for treatment)

Surgical Wound Assessment
•

•

•

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). For surgical wounds healing by primary
intention, observe if the incision line has re-epithelialized.
Surgical wounds healing by primary intention (approximated incisions) do not granulate; therefore, the
only appropriate responses are Response 0 – “Newly epithelialized” or Response 3 – “Not healing”
o A surgical incision is not automatically coded Response 3 – “Not healing” solely due to the presence
of staples.
For a surgical wound healing by primary intention, if there is not full re-epithelialization, such as in the
case of a scab adhering to underlying tissue, the correct response is Response 3 – “Not healing”

Surgical wounds with incisional separation heal by secondary intention.
Surgical incisions healing by secondary intention do granulate; therefore, in addition to meeting the
definition for 0 – Newly epithelialized or 3 – Not healing, these secondary intention wounds may also fit
the definitions for Response 1 – “Fully granulating” or Response 2 – “Early, partial granulation” if
appropriate.
• If complete epidermal resurfacing of a surgical wound has occurred, the correct response is Response 0 "Newly epithelialized" until approximately 30 days have passed without complication, at which time it is
no longer a reportable surgical wound.

•
•

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Coding Instructions
•

•

•

•

•

Code 0, Newly epithelialized, when:
o the wound bed is completely covered with new epithelium; no exudate; no avascular tissue (eschar
and/or slough); no signs or symptoms of infection.
o the incision site of an implanted venous access device or infusion device is healed and without signs
and symptoms of infection.
Code 1, Fully granulating, when:
o the wound bed is filled with granulation tissue to the level of the surrounding skin and
o has no dead space,
o has no avascular tissue;
o has no signs or symptoms of infection;
o has open wound edges.
Code 2, Early/partial granulation, when:
o ≥25% of the wound bed is covered with granulation tissue;
o < 25% of the wound bed is covered with avascular tissue,
o may have dead space; and
o wound bed has no signs or symptoms of infection;
o wound has open edges.
Code 3, Not healing, when:
o The wound bed has ≥25% avascular tissue – AND/OR
o signs/symptoms of infection – AND/OR
o the wound bed is clean but non-granulating – AND/OR
o wound edges are closed/hyperkeratotic – AND/OR
o persistent failure to improve despite appropriate comprehensive wound management.
Dash is not a valid response for this item.

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SECTION N: MEDICATIONS
Introduction

The intent of the items in this section is to record whether:
•
•
•

the patient is taking any medications in high-risk drug classes, there is an indication noted and the
patient/caregiver have been educated about the high-risk medications
a drug regimen review was conducted
the patient can manage oral and injectable medications

N0415: High -Risk Drug Classes: Use and Indication

Item Intent
This item identifies if the patient is taking any prescribed medications in the specified drug classes and whether
the indication was noted for all medications in the drug class.

Item Rationale
•

Patients who take medications in these high-risk drug classes are at risk for side effects that can adversely
affect health, safety, and quality of life.

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Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Data sources/resources include medical records received from facilities where the patient received health
care, the patient’s most recent history and physical, transfer documents, discharge summaries, medication
lists/records, clinical progress notes, and other resources as available.
o Discussions (including with the acute care hospital, other staff and clinicians, the patient, and the
patient’s family/significant other) may supplement and/or clarify the information gleaned from the
patient’s medical records.
• Determine whether the patient is taking any prescribed medications in any of the drug classes (Column 1).

•

Coding Instructions
If Column 1 is checked (patient is taking medication in the drug class), review patient documentation to
determine if there is a documented indication noted for all medications in the drug class (Column 2).
• Code medications according to the medication’s therapeutic category and/or pharmacological
classification, regardless of why the patient is taking it.
• Code a medication that is part of a patient’s current drug regimen, even if it was not taken on the day of
assessment.
• Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as
N0415E, Anticoagulant.
• Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require
laboratory monitoring, should be coded in N0415E, Anticoagulant.
• Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.
•

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Coding Tips
Include any of these medications used by any route (e.g., PO, IM, transdermal, or IV) in any setting (e.g.,
at home, in a hospital emergency room, at physician office or clinic) while a patient of the home health
agency.
• Medications that have more than one therapeutic category and/or pharmacological classification should be
coded in all categories/classifications assigned to the medication, regardless of how it is being used. For
example, prochlorperazine is dually classified as an antipsychotic and an antiemetic. Therefore, in this
section, it would be coded as an antipsychotic, regardless of how it is used.
• Count long-acting medications, such as fluphenazine decanoate or haloperidol decanoate, that are given
every few weeks or monthly only if they are part of the current drug regimen at the time of assessment.
• Include newly prescribed medications that are part of the current drug regimen, even if the medication is
not yet in the home and/or the first dose has not been taken.
• A transdermal patch is designed to release medication over a period of time (typically 3–5 days);
therefore, transdermal patches would be considered long-acting medications for the purpose of coding the
OASIS and are included as long as it is part of the patient’s current drug regimen.
• Combination medications should be coded in all categories/pharmacologic classes that constitute the
combination.
• Herbal and alternative medicine products are considered to be dietary supplements by the Food and Drug
Administration (FDA). Therefore, they should not be counted as medications (e.g., melatonin, chamomile,
valerian root) for N0415.
•

Examples
1. The documentation for a patient reflects that (at SOC) they are taking edoxaban and glipizide. The
documentation indicates the patient has type 2 diabetes and is taking the glipizide to control high blood
sugar. There is no indication documented for the edoxaban.
Coding: Medications in N0415, would be coded as follows: Column 1 (is taking) would be checked for
E. Anticoagulant and J. Hypoglycemic. Column 2 (Indication noted) would be checked only for J.
Hypoglycemic.
Rationale: Column 2 would not be checked for E. Anticoagulant because there was no indication
documented for the edoxaban.
2. At discharge, a patient’s documentation indicates they are taking oxycodone for pain. Tramadol is also
listed but there is no indication documented for the Tramadol.
Coding: Medications in N0415, would be coded as follows: Column 1 (is taking) would be checked for
H. Opioid. Column 2 (Indication noted) would not be checked for H. Opioid.
Rationale: Column 1, H. Opioid is checked because the patient is taking oxycodone and tramadol, both
medications within that class. However, all medications in the class need the indication to be
documented to check Column 2.

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M2001: Drug Regimen Review

Item Intent
Identifies if a drug regimen review was conducted, and whether any potential or actual clinically significant
medication issues were found.

Item Rationale
•
•

Potential and actual patient medication adverse consequences and errors are prevalent among post-acute
care (PAC) settings and often occur during transitions in care.
Medication errors can lead to medication-related adverse reactions (adverse consequences related to
medications may result in serious harm or death), emergency department visits, and re-hospitalizations,
and affect the patient’s health, safety and quality of life.

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

Response-Specific Instructions
•
•

•

Complete a drug regimen review as close to the actual time of SOC/ROC as possible.
The drug regimen review includes all medications, prescribed and over the counter (OTC) including
nutritional supplements, vitamins and homeopathic and herbal products, 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:
o adverse reactions to medications (such as a rash)
o ineffective drug therapy (such as analgesic that does not reduce pain)
o side effects (such as potential bleeding from an anticoagulant)
o drug interactions (such as serious drug-drug, drug-food and drug-disease interactions)

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•
•

Section N: Medications

o duplicate therapy (such as generic name and brand name equivalent drugs are both prescribed)
o omissions (such as missing drugs from a prescribed regimen)
o dosage errors (either too high or too low)
o nonadherence (purposeful or accidental)
Any of the circumstances listed above must reach a level of clinical significance that in the clinician’s
professional judgment warrants notification of the physician/allowed practitioner (or 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.

Coding Instructions

•

Code 0, No – No issues found during review, if a complete drug regimen review was conducted
upon SOC/ROC and based on the assessing clinician’s professional judgement, no potential or actual
clinically significant issues were identified.
o Examples may include, but 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 complete drug regimen review is conducted upon
SOC/ROC and based on the assessing clinician’s professional judgment, potential or actual clinically
significant medication issues are identified.
o 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 they 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.

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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 was conducted at the
time of the patient’s SOC/ROC and, per data sources/resources reviewed, there were no medications
prescribed for the patient and the patient was not taking any medications, by any route, at the time of the
assessment.
Dash is a valid response for this item; however,
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.
o 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.


•

•

Coding Tips
•

•

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.
o 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.
o The M0090 Date Assessment Completed, is the last date that information used to complete the
comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and
documentation of the specific information/responses was completed.

Examples
1. No issues identified
During the comprehensive assessment visit, the PT reviews all the patient’s medications and identifies no
problems except that the patient’s newly prescribed pain medication is not in the home. The patient’s child
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 patient and their child; they both agree the medication
should be on hand, and to follow physician’s instructions for administration. Prior to the PT leaving the home,
the child went to the drugstore and returned with the medication.
Coding: M2001 would be coded 0, No – No issues found during review.

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Rationale: Because the issue, in the PT’s professional judgment, did not require physician (or
physician- designee) 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, the nurse 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.

M2003: Medication Follow-up

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

Item Rationale
•
•

Integral to the process of safe medication administration practice is timely communication with physician/
allowed practitioner (or physician-designee) when a potential or actual clinically significant medication
issue has been identified.
Completion of physician/allowed practitioner (or physician-designee) prescribed/recommended actions in
response to identified potential or actual clinically significant medication issues by midnight of the next
calendar day at the latest reduces patient harm.

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

Response-Specific Instructions
•

Review the clinical record, communication notes, plan of care and medication list.

•

Determine whether the following criteria were met for all potential and actual clinically significant
medication issues that were identified during the SOC/ROC drug regimen review;
o Two-way communication between the agency and the physician/allowed practitioner (or physiciandesignee) was completed by midnight of the next calendar day; AND
o All physician/allowed practitioner (or physician-designee) prescribed/recommended actions were
completed to the extent possible by midnight of the next calendar day.
For each potential or actual clinically significant medication issue identified during the SOC/ROC
comprehensive assessment, identify if the physician/allowed practitioner (or physician-designee) was
contacted, and prescribed/recommended actions were completed, to the extent possible, by midnight of the
next calendar day (at the latest).
o Examples of by midnight of the next calendar day:
 A clinically significant medication issue is identified at 10:00 AM on February 12th and
physician (or physician-designee) prescribed/recommended action is completed on or before
11:59 PM on February 13th.
 A clinically significant medication issue is identified at 10:00 PM on February 12th physician
(or physician-designee) prescribed/recommended action is completed on or before 11:59 PM
on February 13th.

•

Coding Instructions
•

Code 0, No, if all identified potential or actual clinically significant medication issues were not
communicated to the physician/allowed practitioner (or physician designee), with
prescribed/recommended actions completed to the extent possible by midnight of the next calendar day.
o Examples:
 Clinician did not communicate all identified clinically significant medication issues to the
physician/allowed practitioner (or physician-designee) until after midnight of the next
calendar day.
 Clinician communicated all identified clinically significant medication issues to the
physician/allowed practitioner (or physician-designee) by midnight of the next calendar day,
but the clinician did not receive a response from the physician/allowed practitioner (or
physician-designee) to communicate prescribed/ recommended actions until after midnight of
the next calendar day.
 Clinician did not complete all physician/allowed practitioner (or physician-designee)
prescribed/recommended actions for all identified clinically significant medication issues
until after midnight of the next calendar day (even if all but one medication issue was
addressed before midnight of the next calendar day).

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•

•

Section N: Medications

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.
o Examples:
 Clinician communicated all identified clinically significant medication issues to the
physician/allowed practitioner (or physician-designee), and all physician/allowed practitioner
(or physician-designee) prescribed/recommended actions for all identified medication issues
were completed by midnight of the next calendar day.
 Clinician contacted the physician/allowed practitioner (or physician-designee) regarding all
identified medication issues; and the physician/allowed practitioner (or physician-designee)
communicated to the clinician that no actions were necessary regarding the reported issues.
All communications took place before midnight of the next calendar day.
Dash is a valid response for this item; however,
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips
•

If the physician/allowed practitioner (or physician-designee) recommends an action that will take longer
than the allowed time to complete, then Code 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.
o Example of a physician/allowed practitioner (or physician-designee) recommended action that
would take longer than midnight of the next calendar day to complete:
 Physician/allowed practitioner (or physician-designee) writes an order instructing the
clinician to monitor the medication issue over the next three days and call if the problem
persists.
o Examples of by midnight of the next calendar day:
 A clinically significant medication issue is identified at 10:00am on Sept 12. The
physician/allowed practitioner (or physician-designee)-prescribed/-recommended action is
completed on or before 11:59pm on Sept 13.
 A clinically significant medication issue is identified at 11:00pm on Sept 12. The
physician/allowed practitioner (or physician-designee)-prescribed/-recommended action is
completed on or before 11:59pm on Sept 13.

Examples

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 their recent hospital stay,
and another that they were taking prior to 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.
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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.

M2005: Medication Intervention

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/allowed practitioner (or physiciandesignee) and to the extent possible, prescribed/recommended actions were completed by midnight of the next
calendar day following their identification.

Item Rationale
•

Potential or actual clinically significant medication issues can occur throughout the patient’s home health
stay.

Time Points Item(s) Completed
Transfer
Death at Home
Discharge from agency

Response-Specific Instructions
•

•

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/allowed practitioner (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:
o adverse reactions to medications (such as a rash)
o ineffective drug therapy (such as analgesic that does not reduce pain)
o side effects (such as potential bleeding from an anticoagulant)
o drug interactions (such as serious drug-drug, drug-food and drug-disease interactions)

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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)

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/allowed practitioner (or physiciandesignee) and/or all prescribed/recommended actions were not completed, to the extent possible, by
midnight of the next calendar day.
o 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/allowed practitioner (or physician-designee) all identified potential or actual
clinically significant medication issues, but the physician/allowed practitioner (or physiciandesignee) 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/allowed practitioner (or physician-designee) prescribed/recommended
actions to the extent possible for all identified potential or actual clinically significant
medication issues by midnight of the next calendar day.
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/allowed practitioner (or physiciandesignee) 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.
o 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/allowed
practitioner (or physician-designee), and all physician/allowed practitioner (or physiciandesignee) 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/allowed practitioner (or physician-designee) regarding all identified potential
or actual clinically significant medication issues, and the physician/allowed practitioner (or
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.
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.
Dash is a valid response for this item; however,
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

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Coding Tips
•

If the physician/allowed practitioner (or physician-designee) prescribed/recommended action will take
longer than midnight of the next calendar day to complete, then code 1, Yes, should still be entered, if by
midnight of the next calendar day, the clinician has taken the appropriate steps to comply with the
recommended action.
o Example of a physician/allowed practitioner (or physician-designee) recommended action that
would take longer than midnight of the next calendar day to complete:
 The Physician/allowed practitioner (or physician-designee) writes an order instructing the
clinician to monitor the medication issue over the next three days and call if the problem
persists.
o Examples of by midnight of the next calendar day:
 A clinically significant medication issue is identified at 10:00 AM on February 12th.
Communication occurs and the physician/allowed practitioner (or physician-designee)
prescribed/recommended action is completed on or before 11:59 PM on February 13th.
 A clinically significant medication issue is identified at 10:00 PM on February 12th.
Communication occurs and the physician/allowed practitioner (or physician-designee)
prescribed/recommended action is completed on or before 11:59 PM on February 13th.

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 their 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.

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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.

M2010: Patient/Caregiver High-Risk Drug Education

Item Intent
Identifies if clinicians instructed the patient and/or caregiver about all high-risk medications the patient takes.

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

Response-Specific Instructions
•

•
•

Review the clinical record, communication notes, medication list, plan of care, documentation of other
agency staff responsible for educating patient/care givers on medications. High-risk medications should
be identified based on one or more authoritative sources (e.g., the Institute for Safe Medication Practices,
the American Geriatrics Society, and The Joint Commission) and would be identified from medications
included on the patient’s reconciled medication profile.
High-risk medications are those identified by an authoritative source as having considerable potential for
causing significant patient harm when they are used erroneously.
If agency staff other than the clinician responsible for completing the SOC/ROC provided high-risk
medication education to the patient/caregiver, this information may be communicated to the assessing
clinician for consideration in completing the SOC/ROC OASIS assessment. This collaboration does not

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violate the requirement that the comprehensive patient assessment is the responsibility of and ultimately
must be completed by one clinician.
• Links to resources for identifying high-risk medications can be found in Appendix E of this manual.

Coding Instructions
•
•
•
•

Code 0, No, if the interventions are not completed as outlined in this item.
Code 1, Yes, if high-risk medications are prescribed and education was provided.
Code NA, if patient/caregiver is fully knowledgeable about special precautions associated with all highrisk medications in their medication profile, or if there are no high-risk drugs in their medication profile.
Dash is not a valid response for this item.

M2020: Management of Oral Medications

Item Intent
This item is intended to identify the patient’s ability to prepare and take all oral (p.o.) medications reliably and
safely on the day of the assessment.

Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
•
•

Observation/demonstration is the preferred method, followed by patient/caregiver interview, and review of
the referral information.
The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance.
“Willingness” and “adherence” are not the focus of these items. These items address the patient’s ability
to safely take oral medications, given the current physical and mental/emotional/cognitive status, activities
permitted, and environment. The patient must be viewed from a holistic perspective in assessing ability to
perform medication management. Ability can be temporarily or permanently limited by:
o physical impairments (for example, limited manual dexterity);

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o emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment,
fear);
o sensory impairments (for example, impaired vision, pain);
o environmental barriers (for example, access to kitchen or medication storage area, stairs, narrow
doorways).
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.
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.
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.
If an oral 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, Code 2, Able
to take medication(s) at the correct times if given reminders by another person at the appropriate times. If
the patient did not need any PRN oral medications on the day of assessment and therefore no reminders
were necessary, assess the patient’s ability based on all of the medications scheduled to be taken on the
day of assessment.

Coding Instructions
•
•

•

•

Code 0, Able to independently, if the patient is able to manage all oral medications without
assistance. This includes if the patient sets up a their 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.
Code 1, Able to take medication(s) correctly, if the patient is able to take their oral medication(s)
but:
o another person must prepare individual doses in advance (for example, place medications in a mediplanner or other device)
o and/or 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),
o and/or someone in the home must develop a drug diary or chart which the patient relies on to take
medications appropriately.
Code 2, Able to take medication(s) at correct times if given reminders, 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.”).
Code 3, Unable to take medication unless administered by another person, if the patient
does not have the physical or cognitive ability on the day of assessment to take all medications correctly

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(right medication, right dose, right time) as ordered and every time ordered, and it has not been established
that set up, diary, or reminders have already been or will be 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.
• Dash is not a valid response for this item.

Coding Tips
•

For a patient who resides in a facility, such as an assisted living facility (ALF), where the facility holds or
locks up the patient’s medications:
o Report the patient’s ability to take the correct oral medication(s) including proper dosage(s) reliably
and safely at the correct times.
o Determine ability based on observation and assessment of the complexity of the patient’s drug
regimen, as well as patient characteristics, including cognitive status, vision, strength, manual
dexterity and general mobility.
o Assessment includes consideration of whether a patient:
 can get to the location where the medications are routinely stored at the correct times,
 can recognize the correct medication dose(s) and take their oral medications, recognizing that
someone would need to make the medication available to the patient once they are at the
location (e.g., nursing office or medication cart)
o Select response 0, 1, 2 or 3 depending on the level and timing of assistance required on the day of
assessment to allow the patient to take the correct dose(s) of all oral medications reliably and safely
at the correct times.

M2030: Management of Injectable Medications

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

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

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Response-Specific Instructions
•
•

•
•
•

•
•

•

Observation/demonstration is the preferred method, followed by patient/caregiver interview and review of
the referral information.
The intent of the item is to identify the patient’s ABILITY, not necessarily actual performance.
“Willingness” and “adherence” are not the focus of these items. These items address the patient’s ability
to safely manage injectable medications, given the current physical and mental/emotional/cognitive status,
activities permitted, and environment. The patient must be viewed from a holistic perspective in assessing
ability to perform medication management. Ability can be temporarily or permanently limited by:
o physical impairments (for example, limited manual dexterity);
o emotional/cognitive/behavioral impairments (for example, memory deficits, impaired judgment,
fear);
o sensory impairments (for example, impaired vision, pain);
o environmental barriers (for example, access to kitchen or medication storage area, stairs, narrow
doorway.
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, 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), draw
up the correct dose accurately using aseptic technique, inject in an appropriate site using correct technique,
and dispose of the syringe properly.
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.

Coding Instructions
•

•

Code 0, Able to independently take the correct medication(s) and proper dosage(s) at the
correct times, if the patient is able to manage all injectable medications without assistance. This
includes if the patient sets up their own individual doses and is able to take the correct medication(s) in the
correct dosage(s) at the correct time as a result of this.
Code 1, Able to take injectable medication(s) at the correct times if, the patient is able to
administer their injectable medication(s) but:
o another person must prepare syringes/individual doses in advance

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o and/or another person in the home must modify the original medication container in advance to
enable patient access (for example marking labels for the visually impaired or those who cannot
read),
o and/or if another person must develop a drug diary or chart which the patient relies on to take
medications appropriately
Code 2, Able to take medication(s) at the correct time if given reminders by another
person, if reminders to take medications are necessary, regardless of 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.”)
Code 3, Unable to take injectable medication unless administered by another person, if:
o The patient does not have the physical or cognitive ability on the day of assessment to take all
injectable medications correctly (right medication, right does, right time) as ordered, or
o even with reminder the patient requires assistance administering their injectable medication(s), or
o the physician ordered the RN to administer an injection in the home.
Dash is not a valid response for this item.

Coding Tips
•

For a patient residing in a facility, such as an assisted living facility (ALF), where the facility holds or
locks up the patient’s medications
o Report the patient’s ability to administer all injectable medication(s) and proper dosage(s) reliably
and safely at the correct times.
o Determine ability based on observation, an assessment of the complexity of the patient’s drug
regimen, as well as patient characteristics, including cognitive status, vision, strength, manual
dexterity and general mobility.
o Assessment includes consideration of whether a patient:
 Can get to the location where the medications are routinely stored at the correct times, .
 Can recognize the correct medications dose(s) and administer their injectable medications,
recognizing that someone would need to make the medications available to the patient once
they are at the location (e.g., nursing office or medication cart).
o Select response 0, 1, 2, or 3 depending on the level and timing of assistance required on the day of
assessment to allow the patient to take the correct dose(s) of all injectable medications reliably and
safely at the correct times.

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Section O: Special Treatments, Procedures, and Programs

SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND
PROGRAMS
O0110: Special Treatments, Procedures, and Programs

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Discharge
O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.

c. At Discharge
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2 IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the Above

Item Intent
The intent of the item is to identify any special treatments, procedures, and programs that apply to the patient.

Item Rationale
•

The treatments, procedures, and programs listed can have a profound effect on an individual’s health
status, self-image, dignity, and quality of life.

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Time Points Item(s) Completed
Start of Care
Resumption of Care
Discharge from agency

Response-Specific Instructions
Review the patient’s clinical record and consult with the patient, family, caregiver(s) and/or staff to
determine whether or not any of the treatments, procedures, or programs apply during the time period
under consideration for the SOC/ROC assessment (for the SOC/ROC) or during the time period under
consideration for the DC assessment (for the DC).
• Check all treatments, programs and procedures that are part of the patient’s current care/treatment plan.
• Include treatments, programs and procedures performed by others and those the patient performed
themselves independently or after set-up by agency staff or family/caregivers.
• Check treatments, procedures and programs that are performed in the patient’s home, or in other settings
(e.g., dialysis performed in a dialysis center).
• Do not check services that were provided solely in conjunction with a surgical procedure or diagnostic
procedure, such as IV medications. Surgical procedures include routine pre- and post-operative
procedures.
• For O0110A1 (Chemotherapy), O0110B1 (Radiation), and O0110J1 (Dialysis), check if the patient is
undergoing treatment at the time of assessment.
•

Coding Instructions
•
•

•
•

Check each type of treatment, procedure, or program that applies.
Code O0110A1, Chemotherapy, if any type of chemotherapy medication administered as an
antineoplastic for cancer treatment given by any route in this item.
o Code O0110A2, Chemotherapy, IV, if chemotherapy administered intravenously.
o Code O0110A3, Chemotherapy, Oral, if chemotherapy administered orally (e.g., pills,
capsules, or liquids the patient swallows). This sub-element also applies if the chemotherapy is
administered enterally (e.g., feeding tube/PEG).
o Code O0110A10, Chemotherapy, Other, if chemotherapy administered in a way other than
intravenously, enterally, or orally (e.g., intramuscular, intraventricular/intrathecal, intraperitoneal, or
topical routes).
Code O0110B1, Radiation, if radiation is administered intermittently or via radiation implant in this
item.
Code O0110C1, Oxygen Therapy, if continuous or intermittent oxygen is used via mask, cannula,
etc., including in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP).
Do not include hyperbaric oxygen for wound therapy in this item.
o Code O0110C2, Oxygen Therapy, Continuous, if oxygen therapy is continuously delivered
for ≥ 14 hours per day.
o Code O0110C3, Oxygen Therapy, Intermittent, if oxygen therapy is delivered intermittently
(< 14 hours continuously).

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Code O0110C4, Oxygen Therapy, High concentration, if oxygen is delivered via a highconcentration delivery system at a concentration that exceeds FiO2 of 40% (i.e., exceeding that of
simple low-flow nasal cannula at a flow-rate of 4 liters per minute).
o A high-concentration delivery system can include either high or low-flow systems (e.g., simple face
masks, partial and non-rebreather masks, face tents, venturi masks, aerosol masks, high-flow cannula
or masks).
o These devices may also include invasive mechanical ventilators, non-invasive mechanical
ventilators, or trach masks, if the delivered FiO2 of these systems exceeds 40%.
o Oxygen-conserving nasal cannula systems with reservoirs (e.g., mustache, pendant) should be
included only if they are used to deliver an FiO2 greater than 40%.
Code O0110D1, Suctioning, only if tracheal and/or nasopharyngeal suctioning is performed. Do not
include oral suctioning here. This item may also be checked if the patient performs their own tracheal
and/or pharyngeal suctioning.
o Code O0110D2, Suctioning, Scheduled, if suctioning is scheduled. Scheduled suctioning is
performed when the patient is assessed to clinically benefit from regular interventions, such as every
hour. Scheduled suctioning applies to medical orders for performing suctioning at specific intervals
and/or implementation of agency-based clinical standards, protocols, and guidelines.
o Code O0110D3, Suctioning, As needed, if suctioning is performed on an as needed basis, as
opposed to regular scheduled intervals, such as when secretions become so prominent that gurgling
or choking is noted, or a sudden desaturation occurs from a mucus plug.
Code O0110E1, Tracheostomy care, if cleansing of the tracheostomy and/or cannula is performed.
This item may also be checked if the patient performs their own tracheostomy care or receives assistance.
Code O0110F1, Invasive Mechanical Ventilator (ventilator or respirator), if any type of
electrically or pneumatically powered closed-system mechanical ventilator support device is used that
ensures adequate ventilation in the patient who is or who may become (such as during weaning attempts)
unable to support their own respiration.
Code O0110G1, Non-Invasive Mechanical Ventilator, if any type of respiratory support device is
used that prevents airways from closing by delivering slightly pressurized air through a mask or other
device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP
mask/device enables the individual to support their own spontaneous respiration. This item may be
checked if the patient places or removes their own BiPAP/CPAP mask/device or if the family/caregiver
applies it for the patient
o Code O0110G2, BiPAP, if the non-invasive mechanical ventilator support was BiPAP.
o Code O0110G3, CPAP, if the non-invasive mechanical ventilator support was CPAP.
Code O0110H1, IV medications, if any medication or biological is given by intravenous push,
epidural pump, or drip through a central or peripheral port in this item. Do not include flushes to keep an
IV access port patent, or IV fluids without medication here. Epidural, intrathecal, and baclofen pumps may
be checked here, as they are similar to IV medications in that they must be monitored frequently and they
involve continuous administration of a substance. Subcutaneous pumps are not included in this item. Do
not include IV medications of any kind that were administered during dialysis or chemotherapy. Dextrose
50% and/or Lactated Ringers given IV are not considered medications, and should not be included here.
o Code O0110H2, Vasoactive medications, if at least one of the IV medications was a
vasoactive medication.
o Code O0110H3, Antibiotics, if at least one of the IV medications was an antibiotic.
o

•

•
•

•

•

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o Code O0110H4, Anticoagulation, if at least one of the IV medications was an IV anticoagulant.
Do not include subcutaneous administration of anticoagulant medications.
o Code O0110H10, Other, if at least one of the IV medications was not an IV vasoactive
medication, IV antibiotic, or IV anticoagulant. Examples include IV analgesics (e.g., morphine) and
IV diuretics (e.g., furosemide).
Code O0110I1, Transfusions, if any blood or any blood products (e.g., platelets, synthetic blood
products), are administered directly into the bloodstream in this item. Do not include transfusions that
were administered during dialysis or chemotherapy.
Code O0110J1, Dialysis, if peritoneal or renal dialysis occurs in the home or at a facility. IV
medication, and blood transfusions administered during dialysis are considered part of the dialysis
procedure and are not to be coded under items K0520A (Parenteral/IV feeding), O0110H1 (IV
medications), or O0110I1 (transfusions). This item is also checked if the patient performs their own
dialysis.
o Code O0110J2, Hemodialysis, if the dialysis was hemodialysis. In hemodialysis the patient’s
blood is circulated directly through a dialysis machine that uses special filters to remove waste
products and excess fluid from the blood.
o Code O0110J3, Peritoneal dialysis, if the dialysis was peritoneal dialysis. In peritoneal
dialysis, dialysate is infused into the peritoneal cavity and the peritoneum (the membrane that
surrounds many of the internal organs of the abdominal cavity) and serves as a filter to remove the
waste products and excess fluid from the blood.
Code O0110O1, IV Access, if a catheter is inserted into a vein for a variety of clinical reasons,
including long-term medication administration, hemodialysis, large volumes of blood or fluid, frequent
access for blood samples, intravenous fluid administration, total parenteral nutrition (TPN), or in some
instances the measurement of central venous pressure.
o Code O0110O2, Peripheral, if IV access is peripheral access (catheter is placed in a peripheral
vein) and remains peripheral.
o Code O0110O3, Midline, if IV access is midline access. Midline catheters are inserted into the
antecubital (or other upper arm) vein and do not reach all the way to a central vein such as the
superior vena cava.
o Code O0110O4, Central (e.g., PICC, tunneled, port), if IV access is centrally located (e.g.,
peripherally inserted central catheter [PICC], tunneled, port).
Code O0110Z1, None of the above, if none of the above treatments, procedures, or programs apply.
Dash is a valid response for this item.
o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

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Examples
1. The patient’s referral information indicates that they were discharged from an acute care facility following
an inpatient stay for bacterial pneumonia that required placement of a tracheostomy. At start of care, the
patient requires intermittent oxygen and assistance with trach care. Their tracheal suctioning needs are PRN.
The patient has intermittent desaturations due to mucus plugging that have required use of a tracheostomy
mask at a FiO2 of greater than 40% intermittently. The patient has orders for 1 more week of IV antibiotics,
which are being delivered via a PICC line.
Coding: Check boxes O0110C1 (Oxygen Therapy), O0110C3 (Intermittent), and O0110C4 (Highconcentration), O0100D1 (Suctioning) and O0110D3 (As Needed), O0110E1 (Tracheostomy Care),
O0110H1 (IV Medications) and O0110H3 (Antibiotics), and O0110O1 (IV Access) and O0110O4
(Central).
Rationale: The patient is receiving intermittent oxygen, high-concentration oxygen delivery, as needed
suctioning, tracheostomy care, and IV antibiotics via a PICC line at start of care.
2. A patient has advanced prostate cancer and is receiving radiation and oral chemotherapy medication to treat
the prostate cancer. They are being admitted today, following an inpatient stay for an acute pulmonary
embolism. Their discharge orders include enoxaparin subcutaneously for continued anticoagulation. The
patient does not have orders for other IV medications but still has a port in place.
Coding: Check boxes O0110A1 (Chemotherapy), O0110A3 (Chemotherapy, Oral), O0110B1
(Radiation), and O0110O1 (IV Access) and O0110O4 (Central).
Rationale: O0110H4 (Anticoagulation) is not checked because enoxaparin is administered
subcutaneously, not intravenously. Even though the patient’s port is not being accessed currently, they
still have one and therefore O0110O1 (IV Access) and O0110O4 (Central) should be checked. The
patient is also receiving oral chemotherapy and radiation so O0110A1 (Chemotherapy), O0110A3 (oral),
and O0110B1 (Radiation) should be selected.
3. A patient has multiple myeloma and was discharged from an acute hospitalization after a pathologic
vertebral fracture with significant pain. On admission to home health, referral documentation and physician
orders include palliative radiation, lenalidomide orally for chemotherapy, and notes that frequent
transfusions are required not related to the chemotherapy. They have a port for pamidronate infusions due to
hypercalcemia.
Coding: Check boxes O0110A1 (Chemotherapy), O0110A3 (Oral), and O0110B1 (Radiation),
O0110I1 (Transfusions), O0110H1 (IV Medications) and O0110H10 (Other) and O0110O1 (IV Access)
and O0110O4 (Central).
Rationale: The patient is receiving oral chemotherapy (lenalidomide), radiation, transfusions, an IV
medication (pamidronate), which falls under “other” IV medications, and has a port. The transfusions
are noted to not be related to chemotherapy, and as such should be coded separately.
4. During the home health start of care assessment, the assessing clinician learns that a patient has sleep apnea
and requires a CPAP device to be worn when sleeping. The patient’s spouse sets-up the humidifier element
of the CPAP and the patient puts on the CPAP mask prior to falling asleep.

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Coding: Check boxes O0110G1 (Non-invasive Mechanical Ventilator) and O0110G3 (CPAP).
Rationale: The patient is able to breathe on their own and wears the CPAP mask when sleeping to
manage the sleep apnea.

M1041: Influenza Vaccine Data Collection Period:

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
Discharge from agency

Response-Specific Instructions
• Review the clinical record to identify the date of the most recent SOC or ROC.
• 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.

Coding Instructions
Code 0, No, if no part of the care episode (from SOC/ROC to Transfer/Discharge) occurred during the
time period from October 1 and March 31.
• Code 1, Yes, if part of the care episode (from SOC/ROC to Transfer/Discharge) occurred during the
time period from October 1 and March 31.
• Dash is not a valid response for this item.
•

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M1046: Influenza Vaccine Received

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
Discharge from agency

Response-Specific Instructions
Interview the patient and/or caregiver, review the clinical record, and/or ask the physician or other health
care provider.  
• Refer to the Centers for Disease Control and Prevention (CDC) website for detailed guidelines on the
influenza vaccine, including information about medical contraindications (Response 5), age and condition
guidelines (Response 6), and information regarding vaccine availability and potential shortages (Response
7). A link to CDC Guidelines can be found in Appendix E of this manual. It is the agency’s responsibility
to make current guidelines available to clinicians.

•

Coding Instructions
Code 1, Yes, if your agency provided the influenza vaccine to the patient during this episode of care
(SOC/ROC to Transfer/Discharge).
• Code 2, Yes, if your agency provided the influenza vaccine to the patient for this year’s flu season prior
to this episode, in a prior episode or at a flu clinic run by your agency (a roster billing situation).
o For example, if the SOC/ROC for this episode was in winter, but your agency provided the
vaccine in the fall (during a prior episode) when the vaccine became available.
• Code 3, Yes, 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.
• Code 4, No, if the patient and/or healthcare proxy (for example, someone with power of attorney) was
offered the vaccine and refused. Note: It is not required that your agency offer the vaccine. Enter
Response 4 only if the patient was offered the vaccine and it was refused.
•

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Code 5, No, if the influenza vaccine is contraindicated for medical reasons.
Code 6, No, if the patient does not meet age/condition guidelines for the influenza vaccine.
Code 7, No, only in the event that the vaccine is unavailable due to a CDC-declared shortage.
Code 8, No, 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
vaccine.
• Dash is not a valid response for this item.

•
•
•
•

Coding Tips
•

Codes 1, 2 or 3 may be entered even if the influenza vaccine for this year’s flu season was provided prior
to October 1 (that is, influenza vaccine was made available early).

M2200: Therapy Need

Item Intent
Identifies the total number of planned therapy visits (physical, occupational, or speech therapy combined).

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

Response-Specific Instructions
•
•
•

•

Review physician’s/allowed practitioner’s orders, referral information, plan of care, and other available
documentation.
Enter a number that is “zero filled and right justified.” For example, 11 visits should be reported as “011.”
Therapy visits must (a) relate directly and specifically to a treatment regimen established by the
physician/allowed practitioner through consultation with the therapist(s), and (b) be reasonable and
necessary to the treatment of the patient’s illness or injury.
While CMS will no longer use M2200 to influence payment under PDGM, other payers may be using this
data in their PPS-like payment models. In such cases, agencies should follow instructions from individual
payers directing data collection.
o Agencies may code M2200 Therapy Need with NA – Not Applicable for assessments where the data
is not required for the patient’s payer (including all Medicare FFS assessments).
o Continue to report the number of therapy visits that are planned for the 60-day certification period,
unless otherwise directed by the individual payer.

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The qualifying service does not have to be rendered prior to the other Medicare covered home health
services ordered in the Plan of Care. For example, if a patient 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.
For multidisciplinary cases – Nursing and Therapy may collaborate to answer this item. The PT, OT,
and/or SLP may communicate the number of visits ordered by the physician to the RN completing this
item.

Coding Instructions
• Code NA, Not Applicable, when this assessment will not be used to determine a case mix group for
other payers using a Medicare PPS-like model.
• Dash is not a valid response for this item.

Coding Tips
• 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 certification period should be reported.

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SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL SETTING
Introduction

This section includes one item to identify interventions that were included in the physician-ordered plan of care
and implemented.

M2401: Intervention Synopsis
M2401. Intervention Synopsis
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? (Mark only one box in each row.)
Plan/Intervention

No
Yes
↓Check only one box in each row↓

b.

Falls prevention interventions

0

1

NA

c.

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

0

1

NA

d.

Intervention(s) to monitor and
mitigate pain

0

1

NA

e.

Intervention(s) to prevent
pressure ulcers

0

1

NA

f.

Pressure ulcer treatment based on
principles of moist wound healing

0

1

NA

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

Item Intent
Identifies if specific interventions 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.

Time Points Item(s) Completed
Transfer
Discharge from agency

Response-Specific Instructions
•
•

First, review the physician’s orders and the Plan of Care to identify if the specific interventions are
included.
Then, determine if the interventions were implemented by reviewing the clinical record, including but not
limited to the clinical assessments, and communication notes.

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•

Consider interventions implemented any time during the quality episode (at the time of, or at any time
since the most recent SOC/ROC assessment, to the time the Discharge or Transfer assessment is
completed).

•

The problem-specific interventions referenced in this item may or may not directly correlate with stated
requirements in the Conditions of Participation.
Interventions provided by home health agency staff, including the assessing clinician, may be reported in
this item.
o 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 Code “Yes” for row b: Falls prevention interventions. The M0090 - Date Assessment
Completed should report the date the last information used to complete the comprehensive
assessment and determine OASIS coding was gathered by the assessing clinician and documentation
of the specific information/responses was completed.
For row d, BOTH of the interventions (monitor and mitigate pain) must be both on the physician-ordered
Plan of Care AND implemented for “Yes” to be selected.

•

•

Coding Instructions
Enter one Code (Yes, No or Not Applicable) for each row: b, c, d, e and f.
Code Yes, if the physician-ordered Plan of Care includes the specified best practice interventions listed
in each row, AND there is evidence of implementation in the clinical record, by the time the Discharge or
Transfer assessment was completed.
o Code "Yes" to M2401 b - e, if the specified clinical interventions were included in the physician
ordered Plan of Care and implemented at the time of or at any time since the most recent SOC/ROC
assessment whether or not a formal assessment was performed.
• Code 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.
• Code NA, according to the instructions in the last column of the item, for each row.
• Dash is not a valid response for this item.
•

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Coding Tips
•
•

•
•
•

Falls prevention interventions (Row b) may include, but are not limited to environmental modifications,
strengthening exercises, and consultation with the physician regarding medication concerns.
Interventions for depression (Row c) may include but are not limited to 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.
Interventions to monitor and mitigate pain (Row d) may include but are not limited to medication,
massage, visualization, and biofeedback.
Interventions to prevent pressure ulcers (Row e) may include but are not limited to teaching on frequent
position changes, proper positioning to relieve pressure, careful skin assessment and hygiene, use of
pressure-relieving devices such as enhanced mattresses, etc.
Pressure ulcer treatments based on principles of moist wound healing (Row f) may include but are not
limited to moisture retentive dressings.

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Glossary and Common Acronyms

APPENDIX A: GLOSSARY AND COMMON ACRONYMS
GLOSSARY
Term
Activities of Daily Living

Abbreviation

Definition

ADLs

Activities of daily living are those
needed for self-care and include
activities such as bathing,
dressing, grooming, oral care,
mobility (e.g., ambulation),
toileting, eating, transferring, and
communicating.

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.

Adequate Lighting

Lighting that is sufficient or
comfortable for a person with
normal vision to see fine detail.

Assessment Timeframe

The maximum number of days
allowed to complete the
comprehensive assessment
including OASIS (if applicable).

Assessing Clinician

The single person assuming
responsibility for accurately
completing and signing a
comprehensive assessment.

Body Mass Index

BMI

Number calculated from a person's
weight and height. BMI is a
reliable indicator of body fat. BMI
is used as a screening tool to
identify possible weight problems
for adults.

Brief Interview for Mental
Status

BIMS

The BIMS is a structured cognitive
interview.

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Term

Abbreviation

Category Cue

Code of Federal Regulations

Definition
Phrase that puts a word in context
to help with learning and to serve
as a hint that helps prompt the
patient. The category cue for sock
is “something to wear.” The
category cue for blue is “a color.”
For bed, the category cue is “a
piece of furniture.”

CFR

A codification of the general and
permanent rules published in the
Federal Register by the Executive
departments and agencies of the
Federal Government.

Collaboration

Data collection strategy allowing
the assessing clinician to consider
information from the patient,
caregivers, and other healthcare
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 OASIS data
collection.

Comprehensive Assessment

Assessment, review and
documentation of the patient’s
medical, rehabilitative, functional,
cognitive, psychosocial and
discharge planning status and
needs. Includes a drug regimen
review. Required for all patients in
the Medicare certified Home
Health Agency. Must include
OASIS items for required patients.

Confusion Assessment Method

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CAM

An instrument that screens for
overall cognitive impairment as
well as features to distinguish
delirium or reversible confusion
from other types of cognitive
impairments.

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Term

Abbreviation

Definition
Adapted from: Inouye SK, et al.
Ann Intern Med. 1990; 113: 941948. Confusion Assessment
Method. Copyright 2003, Hospital
Elder Life Program, LLC. Not to
be reproduced without permission.
(https://www.hospitalelderlifeprog
ram.org/delirium-instruments/ )

Contact with Physician/allowed
practitioner (or PhysicianDesignee)

Communication to the
physician/allowed practitioner (or
physician-designee) to convey an
identified potential or actual
clinically significant medication
issue, AND a response from the
physician/allowed practitioner (or
physician-designee) 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/allowed
practitioner (or physiciandesignee), or indirectly through
physician’s office staff on behalf
of the physician/allowed
practitioner (or physiciandesignee), in accordance with the
legal scope of practice.

Day of Assessment

Deep Tissue Injury

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The 24 hours immediately
preceding the home visit and the
time spent by the clinician in the
home.
DTI

A purple or maroon localized area
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Term

Abbreviation

Definition
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.

Delirium

A mental disturbance
characterized by new or acutely
worsening confusion, disordered
expression of thoughts, change in
level of consciousness or
hallucinations.

Delusion

A fixed, false belief not shared by
others that the patient holds even
in the face of evidence to the
contrary.

Discharge

DC

The assessment time point
completed within 2 calendar days
of the discharge date.

Disorganized Thinking

Having thoughts that are
fragmented or not logically
connected.

Dose

Total
amount/strength/concentration of a
medication given at one time or
over a period of time. The
individual dose is the
amount/strength/concentration
received at each administration.
The amount received over a 24hour period may be referred to as
the “daily dose.”

Drug Regimen Review

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DRR

The drug regimen review in postacute 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

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Term

Abbreviation

Definition
clinically significant medication
issues.

Electronic Health
Record/Electronic Medical
Record

EHR/EMR

An electronic version of a patient’s
medical history that is maintained
by the provider over time.

Epithelialization

Regeneration of the epidermis
across a wound surface.

Eschar Tissue

Dead or devitalized tissue that is
hard or soft in texture; usually
black, brown, or tan in color, and
may appear scab-like. Necrotic
tissue and eschar are usually
firmly adherent to the base of the
wound and often the sides/edges of
the wound.

Fall

Unintentional change in position
coming to rest on the ground,
floor, or onto the next lower
surface (e.g., onto a bed, chair, or
bedside mat). The fall may be
witnessed, 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 (e.g.,
a patient pushes another patient).
An intercepted fall is considered a
fall. 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.
However, an anticipated loss of
balance resulting from a
supervised therapeutic intervention
where the patient’s balance is
being intentionally challenged
during balance training is not
considered a fall.

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Term

Abbreviation

Definition

Feeding Tube

Presence of any type of tube that
can deliver food/ nutritional
substances/ fluids/ medications
directly into the gastrointestinal
system. Examples include, but are
not limited to, nasogastric tubes,
gastrostomy tubes, jejunostomy
tubes, percutaneous endoscopic
gastrostomy (PEG) tubes.

Fluctuation

The behavior tends to come and go
and/or increase or decrease in
severity. The behavior may
fluctuate over the course of the
interview or during the assessment
period. Fluctuating behavior may
be noted by the assessing clinician,
reported by staff or family or
documented in the medical record.

Follow-up (Recertification)

The assessment time point
completed within the last 5
calendar days of every 60-day
period
The assessment time point
completed within 2 calendar days
of identification of a significant
change in patient’s condition

Follow-up (Other)

Hallucination

A perception in a conscious and
awake state, of something in the
absence of external stimuli. May
be auditory or visual or involve
smells, tastes, or touch.

Health Information Exchange

HIE

An organization used by provider
agencies to electronically
exchange patients’ health
information, including medical
records, current reconciled
medication lists, etc.

Health Insurance Portability
and Accountability Act of 1996

HIPAA

Federal law that gives the
Department of Health and Human
Services (DHHS) the authority to
mandate regulations that govern

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Term

Abbreviation

Definition
privacy, security, and electronic
transactions standards for health
care information.

Health Literacy

Health literacy is the degree to
which individuals have the
capacity to obtain, process, and
understand basic health
information and services needed to
make appropriate health decisions.

Hospice Services

A program for terminally ill
persons where an array of services
is provided for the palliation and
management of terminal illness
and related conditions. The
hospice must be licensed by the
state as a hospice provider and/or
certified under the Medicare
program as a hospice provider.

Inattention

Reduced ability to maintain
attention to external stimuli and to
appropriately shift attention to new
external stimuli. Patient seems
unaware or out of touch with
environment (e.g., dazed, fixated
or darting attention).

Initial Assessment

The visit used to determine the
immediate care and support needs
of the patient; and, for Medicare
patients to determine eligibility for
the Medicare Home Health benefit
including homebound status.

Injury (Except Major)

Includes skin tears, abrasions,
lacerations, superficial bruises,
hematomas, and sprains; or any
fall-related injury that causes the
patient to complain of pain.

Injury Related to a Fall

Any documented injury that
occurred as a result of, or was
recognized within a short period of
time (e.g., hours to a few days)

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Term

Abbreviation

Definition
after the fall and attributed to the
fall.

International Classification of
Diseases – 10 – Clinical
Modification

ICD-10-CM

A morbidity classification
published by the United States for
classifying diagnoses and reasons
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).

Internet Quality Improvement
and Evaluation System

iQIES

An internet-based system for state
survey agency functions. This
system replaces QIES, CASPER
and ASPEN legacy systems. The
system is used by providers and
vendors to submit OASIS data.

Level of Consciousness

Alert: startles easily to any sound
or touch.
Drowsy/Lethargic: repeatedly
dozes off when you are asking
questions but responds to voice or
touch.
Stuporous: very difficult to arouse
and keep aroused for the
interview.
Comatose: cannot be aroused
despite shaking and shouting.

Major Injury

Includes bone fractures, joint
dislocations, closed head injuries
with altered consciousness,
subdural hematoma.

Means of Providing a Current
Reconciled Medication List

Providing the current reconciled
medication list at the time of
transfer or discharge can be
accomplished by any means,
including active means (e.g., by
mail, electronically, or verbally)
and more passive means (e.g., a

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Glossary and Common Acronyms

Term

Abbreviation

Definition
common electronic health record
(EHR), giving providers access to
a portal).

Mechanically Altered Diet

A diet specifically prepared to
alter the texture or consistency of
food to facilitate oral intake.
Examples include soft solids,
puréed foods, ground meat, and
thickened liquids. A mechanically
altered diet should not
automatically be considered a
therapeutic diet.

Medicaid

A Federal and State program
subject to the provisions of
Title XIX of the Social Security
Act that pays for specific kinds of
medical care and treatment for
low-income families.

Medicare

A health insurance program
administered by CMS under
provisions of Title XVIII of the
Social Security Act for people
aged 65 and over, for those who
have permanent kidney failure,
and for certain people with
disabilities. Medicare Part A: The
part of Medicare that covers
inpatient hospital services and
services furnished by other
institutional health care providers,
such as nursing facilities, home
health agencies, and hospices.
Medicare Part B: The part of
Medicare that covers services of
doctors, suppliers of medical items
and services, and various types of
outpatient services.

Medicare Beneficiary Identifier

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MBI

CMS replacement for the Social
Security number (SSN)-based
Health Insurance Claim Number

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Appendix A

Glossary and Common Acronyms

Term

Abbreviation

Definition
(HICN) for Medicare
beneficiaries.

Medication Follow-Up

National Provider Identifier

The process of contacting a
physician/allowed practitioner (or
physician-designee) to
communicate the identified
medication issue and, to the extent
possible, completing all
physician/allowed practitioner (or
physician-designee)
prescribed/recommended actions
by midnight of the next calendar
day at the latest.
NPI

A unique federal number that
identifies providers of health care
services.

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.

Non-Removable Dressing/Device

Examples of a non-removable
dressing/device include a dressing
that is not to be removed per
physician’s order (such as those
used in negative pressure wound
therapy [NPWT], an orthopedic
device, or a cast).

Nonsensical Response

Any response that is unrelated,
incomprehensible, or incoherent; it
is not informative with respect to
the item being rated

Other Diagnoses

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, even if

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Glossary and Common Acronyms

Term

Abbreviation

Definition
the condition is not the focus of
any home health treatment itself.

Parenteral/IV Feeding

Introduction of a nutritive
substance into the body by means
other than the intestinal tract (e.g.,
subcutaneous, intravenous).

Patient Driven Groupings Model

PDGM

A payment model for the home
health prospective payment system
that became effective January 1,
2020. The model relies heavily on
clinical characteristics and other
patient information to place home
health periods of care into
meaningful payment categories
and eliminates the use of therapy
service thresholds.

Patient Health Questionnaire (2Item through 9-Item)

PHQ-2 to 9©

A validated interview that screens
for symptoms of depression. It
provides a standardized severity
score and a rating for evidence of a
depressive disorder.
Copyright © Pfizer Inc. All rights
reserved. Reproduced with
permission.

Portal

A portal is a secure online website
that gives providers, patients, and
others convenient, 24-hour access
to personal health information
from anywhere with an Internet
connection.

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
physician-designee
communication and completion of
prescribed/recommended actions
by midnight of the next calendar
day (at the latest).

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Glossary and Common Acronyms

Term

Abbreviation

Definition
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.

Pressure Ulcer/Injury

Localized injury to the skin and/or
underlying tissue usually over a
bony prominence, as a result of
intense and/or prolonged pressure,
or pressure in combination with
shear and/or friction. The pressure
ulcer/injury can present as intact
skin or an open ulcer and may be
painful.

Primary Diagnosis

The chief reason the patient is
receiving home care and the
diagnosis most related to the
current home health Plan of Care.

Prospective Payment System

PPS

Qualified Clinician

Resumption of Care

OASIS-E Guidance Manual
Effective 1/1/2023
Centers for Medicare & Medicaid Services

ROC

A payment system, developed for
Medicare home health agencies,
which pays agencies an allinclusive rate for all services.
Payment is determined by a case
mix classification system that
categorizes patients by the type
and intensity of resources used.
Clinicians allowed to complete
comprehensive assessments and
collect OASIS data. For the
purposes of OASIS data
collection, CMS defines a
qualified clinician as a Registered
Nurse, Physical Therapist,
Occupational Therapist, and
Speech-Language Pathologist.
The assessment time point
completed within 2 calendar days
of the facility discharge date, or
knowledge of patient’s return
home, or the physician-ordered
ROC date

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Glossary and Common Acronyms

Term
Start of Care

Abbreviation

Definition

SOC

The assessment time point
completed on or within 5 calendar
days after the SOC date.

Slough Tissue

Non-viable yellow, tan, gray,
green or brown tissue; usually
moist, can be soft, stringy and
mucinous in texture. Slough may
be adherent to the base of the
wound or present in clumps
throughout the wound bed.

Social Isolation

Social isolation refers to an actual
or perceived lack of contact with
other people, such as living alone
or residing in a remote area.
The Single Item Literacy Screener
is licensed under a Creative
Commons AttributionNonCommercial 4.0 International
License.

Social Security Number

Stage 1 Pressure Injury

OASIS-E Guidance Manual
Effective 1/1/2023
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SSN

A tracking number assigned to an
individual by the U.S. Federal
government for taxation, benefits,
and identification purposes.
An observable, pressure-related
alteration of intact skin whose
indicators, as compared with an
adjacent or opposite area on the
body, may include changes in one
or more of the following
parameters: skin temperature
(warmth or coolness); tissue
consistency (firm or boggy);
sensation (pain, itching); and/or a
defined area of persistent redness
in lightly pigmented skin. In
darker skin tones, the injury may
appear with persistent red, blue or
purple hues.

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Glossary and Common Acronyms

Term

Abbreviation

Definition

Stage 2 Pressure Ulcer

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 or
bruising. May also present as an
intact or open/ruptured serumfilled blister.

Stage 3 Pressure Ulcer

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.

Stage 4 Pressure Ulcer

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.

Temporal Orientation

In general, the ability to place
oneself in correct time. For the
BIMS, it is the ability to indicate
the correct date in current
surroundings.

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Appendix A

Glossary and Common Acronyms

Term

Abbreviation

Definition

Therapeutic Diet

A therapeutic diet is a diet
intervention prescribed by a
physician or other authorized
allowed practitioner that provides
food or nutrients via oral, enteral
and parenteral routes as part of
treatment of disease or clinical
condition to modify, eliminate,
decrease, or increase identified
micro- and macro-nutrients in the
diet.

Time Period Under
Consideration (Look Back
Period)

The time period under
consideration is the look back
period to use when coding each
OASIS item. For most items, the
look back period is the Day of
Assessment. For other items, the
look back period is different, such
as “in the last 14 days”, or “at the
time of or since the most recent
SOC/ROC”.

Timed Voiding

Timed voiding is scheduled
toileting assistance or prompted
voiding to manage incontinence
based on identified patterns.
Timed voiding is a compensatory
strategy; it does not cure
incontinence.

Total Severity Score

A summary of the Patient Health
Questionnaire frequency scores
that indicates the extent of
potential depression symptoms.
The score does not diagnose a
mood disorder but provides a
standard of communication
between clinicians and mental
health specialists.

Z Codes

ICD-10-CM provides codes to
deal with encounters for
circumstances other than a disease
or injury. The Factors Influencing

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Glossary and Common Acronyms

Term

Abbreviation

Definition
Health Status and Contact with
Health Services codes (Z00–Z99)
are provided to deal with
occasions when circumstances
other than a disease or injury are
recorded as diagnosis or problems.

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Appendix A

Glossary and Common Acronyms

Common Acronyms
Acronym
ADLs
AFO
BBA-97
BIMS
BIPA
BMI
CAHPS
CAM
CCN
CFR
CMI
CMS
CPAP
CWF
CY
DAH
DME
DRR
DTI
EHR/EMR
FR
FU
FY
HCBS
HHA
HICN
HIE
HIPAA
HIQH
IADLs
ICD
ICD-10-CM
IFC
IOM
iQIES
IRF
IRF-PAI
LCDS
LPN/LVN
LTCH
LUPA

Definition
Activities of Daily Living
Ankle Foot Orthosis
Balanced Budget Act of 1997
Brief Interview for Mental Status
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act. (BIPA)
of 2000
Body mass index
Consumer Assessment of Healthcare Providers and Systems
Confusion Assessment Method
CMS Certification Number
Code of Federal Regulations
Case Mix Index
Centers for Medicare and Medicaid Services
Continuous Positive Airway Pressure
Common Working File
Calendar Year
Death at home
Durable Medical Equipment
Drug Regimen Review
Deep Tissue Injury
Electronic Health Record/Electronic Medical Record
Final Rule
Follow-Up
Fiscal Year
Home and Community-Based Services
Home Health Agency
Health Insurance Claim Number
Health Information Exchange
Health Insurance Portability and Accountability Act of 1996
Health Insurance Query for Home Health
Instrumental Activities of Daily Living
International Classification of Diseases
International Classification of Diseases 10, Clinical Modification
Interim Final Rule with Comment
Internet-Only Manual
Internet Quality Improvement and Evaluation System
Inpatient Rehabilitation Facility
Inpatient Rehabilitation Facility Patient Assessment Instrument
Long term Care Hospital CARE Data Set
Licensed Practical Nurse/Licensed Vocational Nurse
Long-Term Care Hospital
Low Utilization Payment Adjustment

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Appendix A

Acronym
MAC
MBI
MDS
MSW
NPI
NQF
OASIS
OBQI
OMB
OT
OTC
PAC
PDGM
PHQ©
POC
POS
PPS
PT
Pub.100-1
Pub.100-12
Pub.100-2
Pub.100-4
Pub.100-7
Pub.100-8
QM
RN
ROC
SLP
SNF
SOC
SOM
SSN
TPN
UTI

Glossary and Common Acronyms

Definition
Medicare Administrative Contractor
Medicare Beneficiary Identifier
Minimum Data Set
Medical Social Worker
National Provider Identifier
National Quality Forum
Outcome and Assessment Information Set
Outcome-Based Quality Improvement
Office of Management and Budget
Occupation Therapist
Over the Counter
Post-Acute Care
Patient Driven Groupings Model
Patient Health Questionnaire
Plan of Care
Point of Service
Prospective Payment System
Physical Therapist
Medicare General Information, Eligibility, and Entitlement IOM
State Medicaid IOM
Medicare Benefit IOM
Medicare Claims Processing IOM
Medicare State Operation IOM
Medicare Program Integrity IOM
Quality Measure
Registered Nurse
Resumption of Care
Speech-Language Pathologist
Skilled Nursing Facility
Start of Care
State Operations Manual
Social Security Number
Total Parenteral Nutrition
Urinary Tract Infection

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Appendix B

OASIS-E Items, Time Points, and Uses

APPENDIX B: OASIS-E ITEMS, TIME POINTS, AND USES
The following key should be used for the Item Uses column:
A = Administrative
Q = Quality
PRA = Potential Quality Measure Risk Adjustment
$PDGM = Payment (PDGM)
$VBP = Payment (HHVBP)
The following key should be used for the Time Points columns:
SOC = Start of Care
ROC = Resumption of Care
FU = Follow-Up
TRN = Transfer
DC = Discharge
DAH = Death at Home
Section
SECTION A
PATIENT
TRACKING

SECTION A
ADMINISTRATIVE
INFORMATION

Item

Description

SOC

ROC

FU

TRN

DC

DAH

Item
Uses

M0018
M0010
M0014

National Provider Identifier (NPI)
CMS Certification Number
Branch State

X
X
X

A
A
A

M0016

Branch ID Number

X

A

M0020

Patient ID Number

X

A

M0030

Start of Care Date

X

A, Q

M0032

Resumption of Care Date

X

A, Q

M0040

Patient Name

X

A

M0050

Patient State of Residence

X

A

M0060

Patient ZIP Code

X

A

M0064

Social Security Number

X

A

M0063

Medicare Number

X

A

M0065

Medicaid Number

X

A

M0069

Gender

X

PRA

M0066

Birth Date

X

PRA

A1005

Ethnicity

X

A

A1010

Race

X

A

M0150

Current Payment Source for Home
Care
Language

X

A, PRA

X

A

Discipline of Person Completing
Assessment
Date Assessment Completed

X

X

X

X

X

X

A

X

X

X

X

X

X

A, Q

M0100

This Assessment is Currently Being
Completed for the Following Reason

X

X

X

X

X

X

Q, PRA,
$VBP

M0906

Discharge/Transfer/Death Date

X

X

X

Q

A1110
M0080
M0090

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Appendix B
Section

OASIS-E Items, Time Points, and Uses
Item

FU

TRN

DC

DAH

X

X

Q

M0104

Date of Referral

X

X

Q

M0110

Episode Timing

X

X

Item
Uses

X

A1250

Transportation

X

X

M1000

Inpatient Facilities

X

X

Q, PRA

M1005

Inpatient Discharge Date

X

X

Q, A

M2301

Emergent Care

X

X

Q

M2310

Reason for Emergent Care

X

X

Q

M2410

To which Inpatient Facility has the
patient been admitted?
Discharge Disposition

X

X

Q

X

Q, $VBP

X

B0200

Provision of Current Reconciled
Medication List to Subsequent
Provider at Transfer
Provision of Current Reconciled
Medication List to Subsequent
Provider at Discharge
Route of Current Reconciled
Medication List Transmission to
Subsequent Provider
Provision of Current Reconciled
Medication List to Patient at
Discharge
Route of Current Reconciled
Medication List Transmission to
Patient
Hearing

X

PRA

B1000

Vision

X

PRA

B1300

Health Literacy

X

X

X

PRA

C0100

X

X

X

PRA

C0200

Should Brief Interview for Mental
Status (C0200-C0500) be
Conducted?
Repetition of Three Words

X

X

X

PRA

C0300

Temporal Orientation

X

X

X

PRA

C0400

Recall

X

X

X

PRA

C0500

BIMS Summary Score

X

X

X

PRA

C1310

X

X

X

PRA

M1700

Signs and Symptoms of Delirium
(from CAM©)
Cognitive Functioning

X

X

X

M1710

When Confused

X

X

X

M1720

When Anxious

X

X

X

D0150

Patient Mood Interview (PHQ-2 to 9

X

X

X

Q, PRA,
$VBP
Q, PRA,
$VBP
Q, PRA,
$VBP
PRA

D0160

Total Severity Score

X

X

X

PRA

D0700

Social Isolation

X

X

X

PRA

A2121
A2122
A2123
A2124

SECTION D
MOOD

ROC

Date of Physician-Ordered Start of
Care (Resumption of Care)

A2120

SECTION C
COGNITIVE
PATTERNS

SOC

M0102

M2420

SECTION B
HEARING,
SPEECH, and
VISION

Description

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X

PRA

Q
X

X

X

Q

X

Q

X

Q

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Appendix B

OASIS-E Items, Time Points, and Uses
SOC

ROC

Cognitive, Behavioral, and
Psychiatric Symptoms
Frequency of Disruptive Behavior
Symptoms

X

X

X

Item
Uses
Q, PRA

X

X

X

PRA

M1100

Patient Living Situation

X

X

M2102

Types and Sources of Assistance

X

X

M1800

Grooming

X

X

M1810

Current Ability to Dress Upper
Body

X

M1820

Current Ability to Dress Lower
Body

M1830

Section

Item

SECTION E
BEHAVIOR

M1740

SECTION F
PREFERENCES for
CUSTOMARY
ROUTINE
ACTIVITIES
SECTION G
FUNCTIONAL
STATUS

SECTION GG
FUNCTIONAL
ABILITIES AND
GOALS

M1745

Description

FU

TRN

DC

DAH

PRA
X

Q, PRA

X

X

X

X

X

X

X

X

X

Bathing

X

X

X

X

M1840

Toilet Transferring

X

X

X

X

M1845

Toileting Hygiene

X

X

M1850

Transferring

X

X

X

X

M1860

Ambulation/Locomotion

X

X

X

X

GG0100

X

X

GG0110

Prior Functioning: Everyday
Activities
Prior Device Use

Q,
$PDGM,
$VBP,
PRA
Q,
$PDGM,
$VBP,
PRA
Q,
$PDGM,
$VBP,
PRA
Q,
$PDGM,
$VBP,
PRA
Q,
$PDGM,
$VBP,
PRA
Q, PRA,
$VBP
Q,
$PDGM,
$VBP,
PRA
Q,
$PDGM,
$VBP,
PRA
PRA

X

X

PRA

GG0130

Self-Care
GG0130A. Eating

X

X

X

X

Q, PRA

GG0130B. Oral hygiene

X

X

X

X

Q, PRA

GG0130C. Toileting hygiene

X

X

X

X

Q, PRA

GG0130E. Shower/bathe self

X

X

X

PRA

GG0130F. Upper body dressing

X

X

X

PRA

GG0130G. Lower body dressing

X

X

X

PRA

GG0130H. Putting on/taking off
footwear
Mobility

X

X

X

PRA

GG0170

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X

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Appendix B
Section

OASIS-E Items, Time Points, and Uses
Item

Description
GG0170A. Roll left and right
GG0170B. Sit to lying
GG0170C. Lying to sitting on side of
bed
GG0170D. Sit to stand
GG0170E. Chair/bed-to-chair
transfer
GG0170F. Toilet transfer
GG0170G. Car transfer
GG0170I. Walk 10 feet
GG 0170J. Walk 50 feet with two
turns

SOC

ROC

FU

X

X

X

X

Item
Uses
PRA

X

X

X

X

Q, PRA

X

X

X

X

Q, PRA

X

X

X

X

Q, PRA

X

X

X

X

Q, PRA

X

X

X

X

Q, PRA

X

X

X

PRA

X

X

X

X

PRA

X

X

X

X

Q, PRA

X

X

X

Q, PRA

X

X

X

X

PRA

X

X

X

X

PRA

X

X

X

X

PRA

X

X

X

PRA

X

X

x

PRA

X

X

X

X

Q, PRA

X

X

X

X

Q, PRA

X

X

X

Q, PRA

X

X

X

Q, PRA

X

X

X

Q, PRA

X

X

X

Q

TRN

DC

DAH

GG0170K. Walk 150 feet
GG0170L. Walking 10 feet on
uneven surfaces
GG0170M. 1 step (curb)
GG0170N. 4 steps
GG0170O. 12 steps
GG0170P. Pick up object
GG0170Q. Use wheelchair/scooter
GG0170R. Wheel 50 feet with two
turns
GG0170RR. Indicate the type of
wheelchair or scooter used
GG0170S. Wheel 150 feet

SECTION H
BOWEL and
BLADDER

SECTION I
ACTIVE
DIAGNOSES

M1600

GG0170SS. Indicate the Type of
wheelchair or scooter used
Has this patient been treated for a
Urinary Tract Infection in the past
14 days?

M1610

Urinary Incontinence or Urinary
Catheter Presence

X

X

M1620

Bowel Incontinence Frequency

X

X

M1630

Ostomy for Bowel Elimination

X

X

PRA

M1021

Primary Diagnosis

X

X

PRA

M1023

Other Diagnoses

X

X

PRA

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PRA
X

Q, PRA

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Appendix B
Section

OASIS-E Items, Time Points, and Uses
Item

ROC

X

X

M1033

Active Diagnoses – Comorbidities
and Co-existing Conditions
Risk for Hospitalization

X

X

J0510

Pain Effect on Sleep

X

X

X

$PDGM,
PRA
PRA

J0520

X

X

X

PRA

X

X

X

PRA

J1800

Pain Interference with Therapy
Activities
Pain Interference with Day-to-Day
Activities
Any Falls Since SOC/ROC

J1900

Number of Falls

M1400

When is patient SOB?

X

X

SECTION K
SWALLOWING/
NUTRITIONAL
STATUS

M1060

Height and Weight

X

X

K0520

Nutritional Approaches

X

M1870

Feeding or Eating

X

SECTION M
SKIN
CONDITIONS

M1306

Unhealed Pressure Ulcer/Injury at
Stage 2 or Higher

X

X

M1307

Oldest Stage 2 Pressure Ulcer

M1311

Current Number of Unhealed
Pressure Ulcers/Injuries at Each
Stage
Current Number of Stage 1 Pressure
Injuries
Stage of Most Problematic Unhealed
Pressure Ulcer that is Stageable
Stasis Ulcer

X

X

X

X

X

X

X

Q

X

X

X

PRA

M1332

Current Number of Stasis Ulcers
Observable

X

X

M1334

Status of Most Problematic Stasis
Ulcer Observable

X

X

X

Q, PRA

M1340

Does this patient have a Surgical
Wound
Status of Most Problematic Surgical
Wound Observable

X

X

X

Q

X

X

X

Q, PRA

X

X

X

PRA

M2001

High Risk Drug Classes: Use and
Indication
Drug Regimen Review

X

X

Q

M2003

Medication Follow-up

X

X

Q

M2005

Medication Intervention

M2010

Patient/Caregiver High-Risk Drug
Education

X

X

M2020

Management of Oral Medications

X

X

M2030

Management of Injectable
Medications
Special Treatments, Procedures, and
Programs
Influenza Vaccine Data Collection
Period

X

X

X

X

SECTION J
HEALTH
CONDITIONS

J0530

M1322
M1324
M1330

M1342
SECTION N
MEDICATIONS

SECTION O
SPECIAL
TREATMENT,

N0415

O0110
M1041

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FU

TRN

DC

DAH

Item
Uses
PRA

SOC

M1028

Description

X

X

X

X

Q

X

X

X

Q

X

Q, PRA,
$VBP
PRA

X

X

PRA

X

X
X

Q, PRA,
$VBP
Q, PRA

X

Q

X

Q, PRA

X

PRA

PRA

X

X

X

Q
Q

X

X

Q, PRA,
$VBP
PRA

X

PRA

X

Q

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Appendix B

OASIS-E Items, Time Points, and Uses

Section

Item

Description

PROCEDURES, and
PROGRAMS

M1046

Influenza Vaccine Received

M2200

Therapy Need (# visits)

SECTION Q
PARTICIPATION
in ASSESSMENT
and GOAL
SETTING

M2401

Intervention Synopsis

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SOC

X

ROC

FU

TRN

DC

DAH

X

X

Q

X

X

Q

Item
Uses

X

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OASIS-E Instruments

APPENDIX C: OASIS-E INSTRUMENTS
OASIS-E All Items
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
All Items
Section A

Administrative Information

M0018. National Provider Identifier (NPI) for the attending physician who has signed the plan of care

M0010. CMS Certification Number

M0014. Branch State

M0016. Branch ID Number

M0020. Patient ID Number

M0030. Start of Care Date

M0032. Resumption of Care Date

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M0040. Patient Name

M0050. Patient State of Residence
M0060. Patient ZIP Code

M0064. Social Security Number

M0063. Medicare Number

M0065. Medicaid Number

M0069. Gender
Enter
Code

1. Male
2. Female

M0066. Birth Date

A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓

Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, another Hispanic, Latino, or Spanish origin
X. Patient unable to respond
Y. Patient declines to respond

A1010. Race
What is your race?
↓

Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I.
Vietnamese
J.
Other Asian
K. Native Hawaiian

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A1010. Race
What is your race?
L.
M.
N.
X.
Y.
Z.

Guamanian or Chamorro
Samoan
Other Pacific Islander
Patient unable to respond
Patient declines to respond
None of the above

M0150. Current Payment Sources for Home Care
↓

Check 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

A1110. Language
Enter Code

A.

What is your preferred language?

B.

Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

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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
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

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

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.

M0104. Date of Referral
Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.

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.

A1250. Transportation (NACHC ©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X. Patient unable to respond
Y. Patient declines to respond
Adapted from: NACHC© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health
Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use
by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part or whole without written consent from
NACHC.
↓

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M1000. From which of the following Inpatient Facilities was the patient discharged within the past 14 days?
↓

Check 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 ➔ Skip to B0200, Hearing at SOC,
Skip to B1300, Health Literacy at ROC

M1005. Inpatient Discharge Date (most recent)

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 ➔ Skip to M2410, Inpatient Facility
Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission
Unknown ➔ Skip to M2410, Inpatient Facility

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

Check 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

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]

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

Patient remained in the community (without formal assistive services) ➔ Skip to A2123, Provision of Current Reconciled
Medication List to Patient at Discharge
2. Patient remained in the community (with formal assistive services) ➔ Continue to A2121, Provision of Current
Reconciled Medication List to Subsequent Provider at Discharge
3. Patient transferred to a non-institutional hospice ➔ Continue to A2121, Provision of Current Reconciled Medication List
to Subsequent Provider at Discharge
4. Unknown because patient moved to a geographic location not served by this agency ➔ Skip to A2123, Provision of
Current Reconciled Medication List to Patient at Discharge
UK Other unknown ➔ Skip to A2123, Provision of Current Reconciled Medication List to Patient at Discharge
1.

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A2120. Provision of Current Reconciled Medication List to Subsequent Provider at Transfer
At the time of transfer to another provider, did your agency provide the patient’s current reconciled medication list to the
subsequent provider?
Enter Code

0.
1.
2.

No – Current reconciled medication list not provided to the subsequent provider ➔ Skip to J1800, Any Falls Since
SOC/ROC
Yes – Current reconciled medication list provided to the subsequent provider ➔ Continue to A2122, Route of Current
Reconciled Medication List Transmission to Subsequent Provider
NA – The agency was not made aware of this transfer timely ➔ Skip to J1800, Any Falls Since SOC/ROC

A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your agency provide the patient’s current reconciled medication list to the
subsequent provider?
Enter Code

0.
1.

No – Current reconciled medication list not provided to the subsequent provider ➔ Skip to B1300, Health Literacy
Yes – Current reconciled medication list provided to the subsequent provider ➔ Continue to A2122. Route of Current
Reconciled Medication List Transmission to Subsequent Provider

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Route of Transmission
A.

Electronic Health Record

B.

Health Information Exchange

C.

Verbal (e.g., in-person, telephone, video conferencing)

D.

Paper-based (e.g., fax, copies, printouts)

E.

Other Methods (e.g., texting, email, CDs)

↓

Check all that apply

↓

After completing A2122, Skip to B1300, Health Literacy at Discharge

A2123. Provision of Current Reconciled Medication List to Patient at Discharge
At the time of discharge, did your agency provide the patient’s current reconciled medication list to the patient, family and/or
caregiver?
Enter Code

0.
1.

No– Current reconciled medication list not provided to the patient, family, and/or caregiver ➔ Skip to B1300, Health
Literacy
Yes – Current reconciled medication list provided to the patient, family, and/or caregiver ➔ Continue to A2124, Route
of Current Reconciled Medication List Transmission to Patient.

A2124. Route of Current Reconciled Medication List Transmission to Patient
Indicate the route(s) of transmission of the current reconciled medication list to the patient, family, and/or caregiver.
Route of Transmission
↓
A.
B.
C.
D.
E.

Check all that apply

↓

Electronic Health Record
Health Information Exchange
Verbal (e.g., in-person, telephone, video conferencing)
Paper-based (e.g., fax, copies, printouts)
Other Methods (e.g., texting, email, CDs)

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Section B

Hearing, Speech, and Vision

B0200. Hearing
Enter Code

B1000. Vision
Enter Code

Ability to hear (with hearing aid or hearing appliances if normally used)
0. Adequate – no difficulty in normal conversation, social interaction, listening to TV
1. Minimal difficulty – difficulty in some environments (e.g., when person speaks softly, or setting is noisy)
2. Moderate difficulty – speaker has to increase volume and speak distinctly
3. Highly impaired – absence of useful hearing

Ability to see in adequate light (with glasses or other visual appliances)
0. Adequate – sees fine detail, such as regular print in newspapers/books
1. Impaired – sees large print, but not regular print in newspapers/books
2. Moderately impaired – limited vision; not able to see newspaper headlines but can identify objects
3. Highly impaired – object identification in question, but eyes appear to follow objects
4. Severely impaired – no vision or sees only light, colors or shapes; eyes do not appear to follow objects

B1300. Health Literacy (From Creative Commons ©)
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your
doctor or pharmacy?
Enter Code

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Patient declines to respond
8. Patient unable to respond
The Single Item Literacy Screener is licensed under a Creative Commons Attribution Noncommercial 4.0 International License.

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
Enter Code

0.
1.

No (patient is rarely/never understood) ➔ Skip to C1310, Signs and Symptoms of Delirium (from CAM ©)
Yes ➔ Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code

Ask patient: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The
words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of
furniture"). You may repeat the words up to two more times.

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C0300. Temporal Orientation (Orientation to year, month, and day)
Enter Code

Enter Code

Enter Code

C0400. Recall
Enter Code

Enter Code

Enter Code

Ask patient: "Please tell me what year it is right now."
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Ask patient: "What month are we in right now?"
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask patient: "What day of the week is today?"
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct

Ask patient: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
0. No – could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
B. Able to recall “blue”
0. No – could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
C. Able to recall “bed”
0. No – could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required

C0500. BIMS Summary Score
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

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C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
A. Acute Onset of Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously present,
does not fluctuate
2. Behavior present, fluctuates
(comes and goes, changes in
severity)

↓ Enter Codes in Boxes
B. Inattention – Did the patient have difficulty focusing attention, for example, being
easily distractible or having difficulty keeping track of what was being said?

Disorganized thinking – Was the patient's thinking disorganized or incoherent
(rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject)?
D. Altered level of consciousness – Did the patient have altered level of consciousness,
as indicated by any of the following criteria?

vigilant – startled easily to any sound or touch

lethargic – repeatedly dozed off when being asked questions, but responded to
voice or touch

stuporous – very difficult to arouse and keep aroused for the interview

comatose – could not be aroused
Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program,
LLC. Not to be reproduced without permission.
C.

M1700. Cognitive Functioning
Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for
simple commands.
Enter Code

0.
1.
2.
3.
4.

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

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

0.
1.
2.
3.
4.
NA

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

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

Section D

0.
1.
2.
3.
NA

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

Mood

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D0150. Patient Mood Interview (PHQ-2 to 9)
Say to patient: "Over the last 2 weeks, have you been bothered by any of the following problems?"

If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
Symptom
Symptom
0. No (enter 0 in column 2)
0. Never or 1 day
Presence
Frequency
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
9. No response (leave column
2. 7-11 days (half or more of the days)
↓ Enter Scores in ↓
3. 12-14 days (nearly every day)
2 blank).
Boxes
A.

Little interest or pleasure in doing things

B.

Feeling down, depressed, or hopeless

If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the PHQ interview.
C.

Trouble falling or staying asleep, or sleeping too much

D.

Feeling tired or having little energy

E.

Poor appetite or overeating

F.

Feeling bad about yourself – or that you are a failure or have let yourself or your family down

G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so
fidgety or restless that you have been moving around a lot more than usual
I.

Thoughts that you would be better off dead, or of hurting yourself in some way

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

D0160. Total Severity Score
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if
unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

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Section E

Behavior

M1740. Cognitive, Behavioral, and Psychiatric Symptoms that are demonstrated at least once a week (Reported or Observed):
↓ Check 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

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.

Section F

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

Preferences for Customary Routine Activities

M1100. Patient Living Situation
Which of the following best describes the patient's residential circumstance and availability of assistance?
Around the
Clock

Living Arrangement
A.
B.
C.

Patient lives alone
Patient lives with other person(s) in the
home
Patient lives in congregate situation (for
example, assisted living, residential care
home)

01

Availability of Assistance
Occasional/
Regular
Regular
Short-Term
Daytime
Nighttime
Assistance
↓ Check one box only ↓
02
03
04

No Assistance
Available
05

06

07

08

09

10

11

12

13

14

15

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 (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
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M2102. Types and Sources of Assistance
Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to
provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code

a.

Enter Code

c.

Enter Code

d.

Enter Code

f.

Section G

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
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
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
Supervision and safety (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

Functional Status

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

0.
1.
2.
3.

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

M1810. Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, frontopening 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.

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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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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.

Section GG

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.

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:
↓ Enter Codes in Boxes
3. Independent – Patient completed all the
A. Self Care: Code the patient’s need for assistance with bathing, dressing,
activities by themself, with or without an
using the toilet, and eating prior to the current illness, exacerbation, or
assistive device, with no assistance from a
injury.
helper.
B. Indoor Mobility (Ambulation): Code the patient’s need for assistance
2. Needed Some Help – Patient needed partial
with walking from room to room (with or without a device such as cane,
assistance from another person to complete
crutch or walker) prior to the current illness, exacerbation, or injury.
any activities.
C. Stairs: Code the patient’s need for assistance with internal or external
1. Dependent – A helper completed all the
stairs (with or without a device such as cane, crutch, or walker) prior to
activities for the patient.
the current illness, exacerbation, or injury.
8. Unknown
D. Functional Cognition: Code the patient’s need for assistance with
9. Not Applicable
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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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 themself 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 condition or safety concerns
1.
2.
SOC/ROC
Discharge
Performance
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 insert
and remove dentures into and from 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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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 FollowUp, 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 themself 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 condition or safety concerns

4.
Follow-up
Performance
Enter Codes
in Boxes

↓
A.
B.
C.

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.
Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from mouth, and manage denture soaking and rinsing with use of equipment.
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 themself 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 condition 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 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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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 themself 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 condition or safety concerns
1.
2.
SOC/ROC
Discharge
Performance
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 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.

D.
E.

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

F.

Toilet transfer: 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.
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)

I.
J.
K.

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

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

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 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.
L.

O.

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

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SOC/ROC GG0170. Mobility – Continued
1.
SOC/ROC
Performance

2.
Discharge
Goal

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 M1600, Urinary Tract Infection
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

P.

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 themself 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 condition or safety concerns

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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.
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.

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 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.

D.
E.

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

F.

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

I.

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).

J.

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.
M. 1 step (curb): The ability to go up and down a curb 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?

L.

N.

4 steps: The ability to go up and down four steps with or without a rail.
Does patient use wheelchair and/or scooter?
0. No ➔Skip to M1033, Risk for Hospitalization
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.
Q.

R.

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 themself 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:

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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.
07.
09.
10.
88.

Patient refused
Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
Not attempted due to medical condition 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 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 transfer: 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.
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).

I.
J.
K.

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

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

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 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.
L.

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 M1600, Urinary Tract Infection
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.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

R.

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 H

Bladder and Bowel

M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0.
1.
NA
UK

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

M1610. Urinary Incontinence or Urinary Catheter Presence
Enter Code

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)

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 DC]

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

Section I

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.

Active Diagnoses

M1021. Primary Diagnosis & M1023. Other Diagnoses

Column 1
Diagnoses (Sequencing of diagnoses should reflect the seriousness of
each condition and support the disciplines and services provided)

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

M1021. Primary Diagnosis
a.

___________________________________

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M1023. Other Diagnoses
b.

___________________________________

c.

___________________________________

d.

___________________________________

e.

___________________________________

f.

___________________________________

M1028. Active Diagnoses – Comorbidities and Co-existing Conditions
↓

Check all that apply
1. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
2. Diabetes Mellitus (DM)
3. None of the above

Section J

Health Conditions

M1033. Risk for Hospitalization
Which of the following signs or symptoms characterize this patient as at risk for hospitalization?
↓

Check 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

J0510. Pain Effect on Sleep
Enter Code

Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night"
0. Does not apply – I have not had any pain or hurting in the past 5 days ➔ Skip to M1400, Short of Breath at SOC/ROC; Skip
to J1800, Any Falls Since SOC/ROC at DC
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to
pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly

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J0520. Pain Interference with Therapy Activities
8.

Unable to answer

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: "Over the past 5 days, how often you have limited your day-to-day activities (excluding rehabilitation therapy
sessions) because of pain?"
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

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 to M1400, Short of Breath at DC; Skip to M2005, Medication Intervention at TRN and DAH
1. Yes ➔Continue to J1900, Number of Falls Since SOC/ROC

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

M1400. When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0.
1.
2.
3.
4.

Section K

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)

Swallowing/Nutritional Status

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

A.

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

B.

Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to
standard agency practice (for example, in a.m. after voiding, before meal, with shoes off, etc.)

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SOC/ROC
K0520. Nutritional Approaches

1. On Admission
Check all of the nutritional approaches that apply on admission
A.
B.
C.
D.
Z.

Parenteral/IV feeding
Feeding tube (e.g., nasogastric or abdominal (PEG))
Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
None of the above

Discharge
K0520. Nutritional Approaches
4.
5.
A.
B.
C.
D.
Z.

Last 7 days
Check all of the nutritional approaches that were received in the last 7 days
At discharge
Check all of the nutritional approaches that were being received at discharge
Parenteral/IV feeding
Feeding tube (e.g., nasogastric or abdominal (PEG))
Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
None of the above

1.
On Admission
Check all that apply ↓

4.
5.
Last 7 days
At discharge
↓
Check all that apply
↓

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.

Section M

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.

Skin Conditions

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 ➔ Skip to M1322, Current Number of Stage 1 Pressure Injuries at SOC/ROC; Skip to M1324, Stage of Most Problematic
Unhealed Pressure Ulcer/Injury that is Stageable at DC
Yes

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

1.
2.

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

NA No Stage 2 pressure ulcers are present at discharge

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SOC/ROC
M1311. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number

Enter Number

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 non-removable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

Enter Number

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

Enter Number

F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

Discharge
M1311. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number
Enter Number

Enter Number
Enter Number

Enter Number
Enter Number

Enter Number
Enter Number

Enter Number
Enter Number

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 ➔Skip 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 ➔Skip 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 ➔Skip 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 non-removable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device – If 0 ➔Skip 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 ➔Skip 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 ➔Skip to M1324, Stage of Most
Problematic Unhealed Pressure Ulcer/Injury that is Stageable
F2. Number of these unstageable pressure injuries 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

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

M1330. Does this patient have a Stasis Ulcer?
Enter Code

0.
1.
2.
3.

No ➔Skip to M1340, Surgical Wound
Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY
Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device) ➔
Skip to M1340, Surgical Wound

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

1.
2.
3.
4.

One
Two
Three
Four or more

M1334. Status of Most Problematic Stasis Ulcer that is Observable
Enter Code

1.
2.
3.

Fully granulating
Early/partial granulation
Not healing

M1340. Does this patient have a Surgical Wound?
Enter Code

0.
1.
2.

No ➔Skip to N0415, High-Risk Drug Classes: Use and Indication
Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device ➔ Skip to N0415, High-Risk Drug
Classes: Use and Indication

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

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Section N

Medications

SOC/ROC and Discharge
N0415. High-Risk Drug Classes: Use and Indication
1.

Is taking
Check if the patient is taking any medications by pharmacological
classification, not how it is used, in the following classes

Indication noted
If Column 1 is checked, check if there is an indication noted for all
medications in the drug class
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
2.

J.

Hypoglycemic (including insulin)

Z.

None of the Above

1. Is Taking
2. Indication Noted
↓
Check all that apply
↓

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 ➔ Skip to M2010, Patient/Caregiver High-Risk Drug Education
Yes – Issues found during review
NA – Patient is not taking any medications ➔ Skip to O0110, Special Treatments, Procedures, and Programs

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

0.
1.

No
Yes

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

0.
1.
9.

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

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

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

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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

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.
2. Able to take medication(s) at the correct times if given reminders by another person at the appropriate times
3. Unable to take medication unless administered by another person.
NA No oral medications prescribed.
0.
1.

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

Section O

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.
2. Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the
injection
3. Unable to take injectable medication unless administered by another person.
NA No injectable medications prescribed.
0.
1.

Special Treatment, Procedures, and Programs

SOC/ROC
O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.

a. On Admission
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications

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SOC/ROC
O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.

OASIS-E Instruments
a. On Admission
Check all that apply
↓

H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the Above

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Discharge
O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.

c. At Discharge
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2 IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. 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.

No ➔ Skip to M2401, Intervention Synopsis
Yes ➔ Continue to M1046, Influenza Vaccine Received

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

1.
2.
3.
4.
5.
6.
7.
8.

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

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.)

Section Q

Participation in Assessment and Goal Setting

M2401. Intervention Synopsis
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? (Mark only one box in each row.)
Plan/Intervention

No
Yes
↓Check only one box in each row↓

b.

Falls prevention interventions

0

1

NA

c.

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

0

1

NA

d.

Intervention(s) to monitor and
mitigate pain

0

1

NA

e.

Intervention(s) to prevent
pressure ulcers

0

1

NA

f.

Pressure ulcer treatment based on
principles of moist wound healing

0

1

NA

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

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OASIS-E Patient Tracking Sheet
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
Patient Tracking Sheet
Section A

Administrative Information

M0018. National Provider Identifier (NPI) for the attending physician who has signed the plan of care

M0010. CMS Certification Number
M0014. Branch State

M0016. Branch ID Number

M0020. Patient ID Number
M0030. Start of Care Date

M0032. Resumption of Care Date

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M0040. Patient Name

M0050. Patient State of Residence
M0060. Patient ZIP Code

M0064. Social Security Number

M0063. Medicare Number

M0065. Medicaid Number

M0069. Gender
Enter
Code

1. Male
2. Female

M0066. Birth Date

A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓

Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, another Hispanic, Latino, or Spanish origin
X. Patient unable to respond
Y. Patient declines to respond

A1010. Race
What is your race?
↓

Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I.
Vietnamese
J.
Other Asian
K. Native Hawaiian

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A1010. Race
What is your race?
L.
M.
N.
X.
Y.
Z.

Guamanian or Chamorro
Samoan
Other Pacific Islander
Patient unable to respond
Patient declines to respond
None of the above

M0150. Current Payment Sources for Home Care
↓

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

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OASIS-E Start of Care
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
Start of Care (SOC)
Section A

Administrative Information

M0018. National Provider Identifier (NPI) for the attending physician who has signed the plan of care

M0010. CMS Certification Number

M0014. Branch State
M0016. Branch ID Number

M0020. Patient ID Number
M0030. Start of Care Date

M0040. Patient Name

M0050. Patient State of Residence

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M0060. Patient ZIP Code

M0064. Social Security Number

M0063. Medicare Number

M0065. Medicaid Number

M0069. Gender
Enter
Code

1. Male
2. Female

M0066. Birth Date

A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓

Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, another Hispanic, Latino, or Spanish origin
X. Patient unable to respond
Y. Patient declines to respond

A1010. Race
What is your race?
↓

Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I.
Vietnamese
J.
Other Asian
K. Native Hawaiian
L. Guamanian or Chamorro
M. Samoan
N. Other Pacific Islander
X. Patient unable to respond
Y. Patient declines to respond
Z. None of the above

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M0150. Current Payment Sources for Home Care
↓

Check 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

A1110. Language
Enter Code

B.

What is your preferred language?

B.

Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

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
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

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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.

M0104. Date of Referral
Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.

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.

A1250. Transportation (NACHC ©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X. Patient unable to respond
Y. Patient declines to respond
Adapted from: NACHC© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health
Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use
by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part or whole without written consent from
NACHC.
↓

M1000. From which of the following Inpatient Facilities was the patient discharged within the past 14 days?
↓

Check 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 ➔ Skip to B0200 Hearing

M1005. Inpatient Discharge Date (most recent)

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Section B

Hearing, Speech, and Vision

B0200. Hearing
Enter Code

B1000. Vision
Enter Code

Ability to hear (with hearing aid or hearing appliances if normally used)
0. Adequate – no difficulty in normal conversation, social interaction, listening to TV
1. Minimal difficulty – difficulty in some environments (e.g., when person speaks softly, or setting is noisy)
2. Moderate difficulty – speaker has to increase volume and speak distinctly
3. Highly impaired – absence of useful hearing

Ability to see in adequate light (with glasses or other visual appliances)
0. Adequate – sees fine detail, such as regular print in newspapers/books
1. Impaired – sees large print, but not regular print in newspapers/books
2. Moderately impaired – limited vision; not able to see newspaper headlines but can identify objects
3. Highly impaired – object identification in question, but eyes appear to follow objects
4. Severely impaired – no vision or sees only light, colors or shapes; eyes do not appear to follow objects

B1300. Health Literacy (From Creative Commons ©)
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your
doctor or pharmacy?

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Patient declines to respond
8. Patient unable to respond
The Single Item Literacy Screener is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License.
Enter Code

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
Enter Code

0.
1.

No (patient is rarely/never understood) ➔ Skip to C1310, Signs and Symptoms of Delirium (from CAM ©)
Yes ➔ Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code

Ask patient: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The
words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of
furniture"). You may repeat the words up to two more times.

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C0300. Temporal Orientation (Orientation to year, month, and day)
Enter Code

Enter Code

Enter Code

C0400. Recall
Enter Code

Enter Code

Enter Code

Ask patient: "Please tell me what year it is right now."
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Ask patient: "What month are we in right now?"
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask patient: "What day of the week is today?"
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct

Ask patient: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
0. No – could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
B. Able to recall “blue”
0. No – could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
C. Able to recall “bed”
0. No – could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required

C0500. BIMS Summary Score
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

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C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
A. Acute Onset of Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously present,
does not fluctuate
2. Behavior present, fluctuates
(comes and goes, changes in
severity)

↓ Enter Codes in Boxes
B. Inattention – Did the patient have difficulty focusing attention, for example, being
easily distractible or having difficulty keeping track of what was being said?

Disorganized thinking – Was the patient's thinking disorganized or incoherent
(rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject)?
D. Altered level of consciousness – Did the patient have altered level of consciousness,
as indicated by any of the following criteria?

vigilant – startled easily to any sound or touch

lethargic – repeatedly dozed off when being asked questions, but responded to
voice or touch

stuporous – very difficult to arouse and keep aroused for the interview

comatose – could not be aroused
Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program,
LLC. Not to be reproduced without permission.
C.

M1700. Cognitive Functioning
Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for
simple commands.
Enter Code

0.
1.
2.
3.
4.

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

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

0.
1.
2.
3.
4.
NA

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

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

Section D

0.
1.
2.
3.
NA

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

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
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Say to patient: "Over the last 2 weeks, have you been bothered by any of the following problems?"

If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
Symptom
Symptom
0. No (enter 0 in column 2)
0. Never or 1 day
Presence
Frequency
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
9. No response (leave
2. 7-11 days (half or more of the days)
↓Enter Scores in Boxes↓
column2 blank).
3. 12-14 days (nearly every day)
A.

Little interest or pleasure in doing things

B.

Feeling down, depressed, or hopeless

If either D150A2 or D150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the PHQ interview.
C.

Trouble falling or staying asleep, or sleeping too much

D.

Feeling tired or having little energy

E.

Poor appetite or overeating

F.

Feeling bad about yourself – or that you are a failure or have let yourself or your family down

G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so
fidgety or restless that you have been moving around a lot more than usual
I.

Thoughts that you would be better off dead, or of hurting yourself in some way

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

D0160. Total Severity Score
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if
unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

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Section E

Behavior

M1740. Cognitive, Behavioral, and Psychiatric Symptoms that are demonstrated at least once a week (Reported or Observed):
↓

Check 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

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.

Section F

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

Preferences for Customary Routine Activities

M1100. Patient Living Situation
Which of the following best describes the patient's residential circumstance and availability of assistance?
Around the
Clock

Living Arrangement
A.
B.
C.

Patient lives alone
Patient lives with other person(s) in the
home
Patient lives in congregate situation (for
example, assisted living, residential care
home)

01

Availability of Assistance
Occasional/
Regular
Regular
Short-Term
Daytime
Nighttime
Assistance
↓Check one box only↓
02
03
04

No Assistance
Available
05

06

07

08

09

10

11

12

13

14

15

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 (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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Section G

Functional Status

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

0.
1.
2.
3.

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

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

0.
1.
2.
3.

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

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

0.
1.
2.
3.

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

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

0.
1.
2.

3.
4.
5.
6.

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

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

0.
1.
2.
3.
4.

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

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M1845. Toileting Hygiene
Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet,
commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.
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.

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.

Section GG

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.

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 all the
activities by themself, 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
any activities.
1. Dependent – A helper completed all 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, and eating prior to the current illness, 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

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

Mechanical lift
Walker
Orthotics/Prosthetics
None of the above

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 themself 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 condition or safety concerns
1.
2.
SOC/ROC
Discharge
Performance
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 insert
and remove dentures into and from 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
notinclude 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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OASIS-E Instruments

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 themself 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 condition or safety concerns
1.
2.
SOC/ROC
Discharge
Performance
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 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.

D.
E.

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

F.

Toilet transfer: 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.
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)

I.
J.
K.

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

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

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 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.
L.

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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).
1.
2.
SOC/ROC
Discharge
Performance
Goal
↓Enter Codes in Boxes↓

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 M1600, Urinary Tract Infection
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

P.

Section H

Bladder and Bowel

M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0.
1.
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown

M1610. Urinary Incontinence or Urinary Catheter Presence
Enter Code

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)

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

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.

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Section I

OASIS-E Instruments

Active Diagnoses

M1021. Primary Diagnosis & M1023. Other Diagnoses

Column 1
Diagnoses (Sequencing of diagnoses should reflect the seriousness of
each condition and support the disciplines and services provided)

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

M1021. Primary Diagnosis
a.

___________________________________

M1023. Other Diagnoses
b.

___________________________________

c.

___________________________________

d.

___________________________________

e.

___________________________________

f.

___________________________________

M1028. Active Diagnoses – Comorbidities and Co-existing Conditions
↓

Check all that apply
1. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
2. Diabetes Mellitus (DM)
3. None of the above

Section J

Health Conditions

M1033. Risk for Hospitalization
Which of the following signs or symptoms characterize this patient as at risk for hospitalization?
↓

Check 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

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J0510. Pain Effect on Sleep
Enter Code

Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night"
0. Does not apply – I have not had any pain or hurting in the past 5 days ➔ Skip to M1400, Short of Breath
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to
pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: "Over the past 5 days, how often you have limited your day-to-day activities (excluding rehabilitation therapy
sessions) because of pain?"
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

M1400. When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0.
1.
2.
3.
4.

Section K

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)

Swallowing/Nutritional Status

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

A.

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

B.

Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to
standard agency practice (for example, in a.m. after voiding, before meal, with shoes off, etc.)

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K0520. Nutritional Approaches

1. On Admission
Check all of the nutritional approaches that apply on admission
A.
B.
C.
D.
Z.

Parenteral/IV feeding
Feeding tube (e.g., nasogastric or abdominal (PEG))
Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
None of the above

1.
On Admission
Check all that apply

↓

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.

Section M

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.

Skin Conditions

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 ➔ Skip to M1322, Current Number of Stage 1 Pressure Injuries
Yes

M1311. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number

Enter Number

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 non-removable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

Enter Number

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

Enter Number

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

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

M1330. Does this patient have a Stasis Ulcer?
Enter Code

0.
1.
2.
3.

No ➔Skip to M1340, Surgical Wound
Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY
Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device) ➔
Skip to M1340, Surgical Wound

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

1.
2.
3.
4.

One
Two
Three
Four or more

M1334. Status of Most Problematic Stasis Ulcer that is Observable
Enter Code

1. Fully granulating
Early/partial granulation
3. Not healing

M1340. Does this patient have a Surgical Wound?
Enter Code

0.
1.
2.

No ➔Skip to N0415, High-Risk Drug Classes: Use and Indication
Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device ➔ Skip to N0415, High-Risk Drug
Classes: Use and Indication

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

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Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1.

Is taking
Check if the patient is taking any medications by pharmacological
classification, not how it is used, in the following classes

Indication noted
If Column 1 is checked, check if there is an indication noted for all
medications in the drug class
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the Above
2.

1. Is Taking
2. Indication Noted
↓
Check all that apply
↓

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 ➔ Skip to M2010, Patient/Caregiver High-Risk Drug Education
Yes – Issues found during review
NA – Patient is not taking any medications ➔ Skip to O0110, Special Treatments, Procedures, and Programs

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

0.
1.

No
Yes

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

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

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

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.
2. Able to take medication(s) at the correct times if given reminders by another person at the appropriate times
3. Unable to take medication unless administered by another person.
NA No oral medications prescribed.

0.
1.

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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

Section O

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.
2. Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the
injection
3. Unable to take injectable medication unless administered by another person.
NA No injectable medications prescribed.

0.
1.

Special Treatment, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.

a. On Admission
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above

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O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.

OASIS-E Instruments
a. On Admission
Check all that apply
↓

Z1. None of the Above

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.)

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OASIS-E Instruments

OASIS-E Resumption of Care
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
M0032. Resumption of Care Date

Resumption of Care (ROC)

M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

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
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

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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.

M0104. Date of Referral
Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.

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.

A1250. Transportation (NACHC ©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X. Patient unable to respond
Y. Patient declines to respond
Adapted from: NACHC© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health
Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use
by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part or whole without written consent from
NACHC.
↓

M1000. From which of the following Inpatient Facilities was the patient discharged within the past 14 days?
↓

Check 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 ➔ Skip to B1300, Health Literacy

M1005. Inpatient Discharge Date (most recent)

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Section B

Hearing, Speech, and Vision

B1300. Health Literacy (From Creative Commons ©)
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your
doctor or pharmacy?

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Patient declines to respond
8. Patient unable to respond
The Single Item Literacy Screener is licensed under a Creative Commons Attribution Noncommercial 4.0 International License.
Enter Code

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
Enter Code

0.
1.

No (patient is rarely/never understood) ➔ Skip to C1310, Signs and Symptoms of Delirium (from CAM ©)
Yes ➔ Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code

Ask patient: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The
words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of
furniture"). You may repeat the words up to two more times.

C0300. Temporal Orientation (Orientation to year, month, and day)
Enter Code

Enter Code

Enter Code

Ask patient: "Please tell me what year it is right now."
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Ask patient: "What month are we in right now?"
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask patient: "What day of the week is today?"
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct

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C0400. Recall
Enter Code

Enter Code

Enter Code

OASIS-E Instruments
Ask patient: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
0. No – could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
B. Able to recall “blue”
0. No – could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
C. Able to recall “bed”
0. No – could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required

C0500. BIMS Summary Score
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
A. Acute Onset of Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously present,
does not fluctuate
2. Behavior present, fluctuates
(comes and goes, changes in
severity)

↓ Enter Codes in Boxes
B. Inattention – Did the patient have difficulty focusing attention, for example, being
easily distractible or having difficulty keeping track of what was being said?

Disorganized thinking – Was the patient's thinking disorganized or incoherent
(rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject)?
D. Altered level of consciousness – Did the patient have altered level of consciousness,
as indicated by any of the following criteria?

vigilant – startled easily to any sound or touch

lethargic – repeatedly dozed off when being asked questions, but responded to
voice or touch

stuporous – very difficult to arouse and keep aroused for the interview

comatose – could not be aroused
Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program,
LLC. Not to be reproduced without permission.
C.

M1700. Cognitive Functioning
Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for
simple commands.
Enter Code

0.
1.
2.
3.
4.

Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.
Requires prompting (cueing, 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.

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

0.
1.
2.
3.
4.
NA

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

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

Section D

0.
1.
2.
3.
NA

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

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
Say to patient: "Over the last 2 weeks, have you been bothered by any of the following problems?"

If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
Symptom
Symptom
0. No (enter 0 in column 2)
0. Never or 1 day
Presence
Frequency
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
9. No response (leave column
2. 7-11 days (half or more of the days)
↓Enter Scores in Boxes↓
2 blank).
3. 12-14 days (nearly every day)
A.

Little interest or pleasure in doing things

B.

Feeling down, depressed, or hopeless

If either D150A2 or D150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the PHQ interview.
C.

Trouble falling or staying asleep, or sleeping too much

D.

Feeling tired or having little energy

E.

Poor appetite or overeating

F.

Feeling bad about yourself – or that you are a failure or have let yourself or your family down

G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so
fidgety or restless that you have been moving around a lot more than usual
I.

Thoughts that you would be better off dead, or of hurting yourself in some way

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

D0160. Total Severity Score
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if
unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

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D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Section E

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

Behavior

M1740. Cognitive, Behavioral, and Psychiatric Symptoms that are demonstrated at least once a week (Reported or Observed):
↓

Check 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

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.

Section F

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

Preferences for Customary Routine Activities

M1100. Patient Living Situation
Which of the following best describes the patient's residential circumstance and availability of assistance?

Living Arrangement
A.
B.
C.

Patient lives alone
Patient lives with other person(s) in the
home
Patient lives in congregate situation (for
example, assisted living, residential care
home)

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Around the
Clock
01

Availability of Assistance
Occasional/
Regular
Regular
Short-Term
Daytime
Nighttime
Assistance
↓Check one box only↓
02
03
04

No Assistance
Available
05

06

07

08

09

10

11

12

13

14

15

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M2102. Types and Sources of Assistance
Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to
provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code

f.

Section G

Supervision and safety (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

Functional Status

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

0.
1.
2.
3.

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

M1810. Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, frontopening 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.

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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.

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

0.

1.
2.
3.
4.
5.
6.

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

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Section GG

OASIS-E Instruments

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 all the
activities by themself, 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
any activities.
1. Dependent – A helper completed all 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, and eating prior to the current illness, 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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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 themself 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 condition or safety concerns
1.
2.
SOC/ROC
Discharge
Performance
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 insert
and remove dentures into and from 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
notinclude 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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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 themself 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 condition or safety concerns
1.
2.
SOC/ROC
Discharge
Performance
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 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.

D.
E.

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

F.

Toilet transfer: 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.
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)

I.
J.
K.

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

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

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 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.
L.

O.

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

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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).
1.
2.
SOC/ROC
Discharge
Performance
Goal
↓Enter Codes in Boxes↓

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 M1600, Urinary Tract Infection
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

Section H

Bladder and Bowel

M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0.
1.
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown

M1610. Urinary Incontinence or Urinary Catheter Presence
Enter Code

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)

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

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.

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Section I

OASIS-E Instruments

Active Diagnoses

M1021. Primary Diagnosis & M1023. Other Diagnoses

Column 1
Diagnoses (Sequencing of diagnoses should reflect the seriousness of
each condition and support the disciplines and services provided)

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

M1021. Primary Diagnosis
a.

___________________________________

M1023. Other Diagnoses
b.

___________________________________

c.

___________________________________

d.

___________________________________

e.

___________________________________

f.

___________________________________

M1028. Active Diagnoses – Comorbidities and Co-existing Conditions
↓

Check all that apply
1. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
2. Diabetes Mellitus (DM)
3. None of the above

Section J

Health Conditions

M1033. Risk for Hospitalization
Which of the following signs or symptoms characterize this patient as at risk for hospitalization?
↓

Check 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

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OASIS-E Instruments

J0510. Pain Effect on Sleep
Enter Code

Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night"
0. Does not apply – I have not had any pain or hurting in the past 5 days ➔ Skip to M1400, Short of Breath
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to
pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: "Over the past 5 days, how often you have limited your day-to-day activities (excluding rehabilitation therapy
sessions) because of pain?"
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

M1400. When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0.
1.
2.
3.
4.

Section K

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)

Swallowing/Nutritional Status

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

A.

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

B.

Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to
standard agency practice (for example, in a.m. after voiding, before meal, with shoes off, etc.

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OASIS-E Instruments

K0520. Nutritional Approaches

1. On Admission
Check all of the nutritional approaches that apply on admission

A.
B.
C.
D.
Z.

Parenteral/IV feeding
Feeding tube (e.g., nasogastric or abdominal (PEG))
Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
None of the above

1.
On Admission
Check all that apply

↓

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.

Section M

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.

Skin Conditions

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 ➔ Skip to M1322, Current Number of Stage 1 Pressure Injuries
Yes

M1311. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number

Enter Number

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 non-removable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

Enter Number

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

Enter Number

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

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

M1330. Does this patient have a Stasis Ulcer?
Enter Code

0.
1.
2.
3.

No ➔Skip to M1340, Surgical Wound
Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY
Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device) ➔
Skip to M1340, Surgical Wound

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

1.
2.
3.
4.

One
Two
Three
Four or more

M1334. Status of Most Problematic Stasis Ulcer that is Observable
Enter Code

1.
2.
3.

Fully granulating
Early/partial granulation
Not healing

M1340. Does this patient have a Surgical Wound?
Enter Code

0.
1.
2.

No ➔Skip to N0415, High-Risk Drug Classes: Use and Indication
Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device ➔ Skip to N0415, High-Risk Drug
Classes: Use and Indication

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

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Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1.

Is taking
Check if the patient is taking any medications by pharmacological
classification, not how it is used, in the following classes

Indication noted
If Column 1 is checked, check if there is an indication noted for all
medications in the drug class
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the Above
2.

1. Is Taking
2. Indication Noted
↓
Check all that apply
↓

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 ➔ Skip to M2010, Patient/Caregiver High-Risk Drug Education
Yes – Issues found during review
NA – Patient is not taking any medications ➔ Skip to O0110, Special Treatments, Procedures, and Programs

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

0.
1.

No
Yes

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

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

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.
2. Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the
injection
3. Unable to take injectable medication unless administered by another person.
NA No injectable medications prescribed.

0.
1.

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Section O

OASIS-E Instruments

Special Treatment, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.

a. On Admission
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the Above

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.)

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OASIS-E Follow-up
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

Follow-up (FU)

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

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
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

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

1.
2.
UK
NA

Section G

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

Functional Status

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

0.
1.
2.
3.

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

M1810. Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, frontopening 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.

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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.

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

0.

1.
2.
3.
4.
5.
6.

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

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Section GG

Functional Abilities and Goals

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 themself 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 condition or safety concerns

4.
Follow-up
Performance
Enter Codes
in Boxes

↓
A.
B.
C.

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

4.

Follow-up
Performance
Mobility
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 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 transfer: The ability to get on and off a toilet or commode.

I.

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).

J.

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.
M. 1 step (curb): The ability to go up and down a curb 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?
L.

N.

4 steps: The ability to go up and down four steps with or without a rail.

Does patient use wheelchair and/or scooter?
0. No ➔Skip to M1033, Risk for Hospitalization
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.
Q.

R.

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Section J

Health Conditions

M1033. Risk for Hospitalization
Which of the following signs or symptoms characterize this patient as at risk for hospitalization?
↓

Check 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

Section M

Skin Conditions

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
Yes

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OASIS-E Transfer
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
Transfer to an Inpatient facility (TRN)

Section A

Administrative Information

M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

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
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

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

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 ➔ Skip to M2410, Inpatient Facility
Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission
Unknown ➔ Skip to M2410, Inpatient Facility

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

Check 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

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

5.
6.
7.
8.

Hospital
Rehabilitation facility
Nursing home
Hospice

A2120. Provision of Current Reconciled Medication List to Subsequent Provider at Transfer
At the time of transfer to another provider, did your agency provide the patient’s current reconciled medication list to the
subsequent provider?
Enter Code

0.
1.
2.

No – Current reconciled medication list not provided to the subsequent provider ➔ Skip to J1800, Any Falls Since
SOC/ROC
Yes – Current reconciled medication list provided to the subsequent provider ➔ Continue to A2122, Route of Current
Reconciled Medication List Transmission to Subsequent Provider
NA – The agency was not made aware of this transfer timely ➔ Skip to J1800, Any Falls Since SOC/ROC

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Route of Transmission
A.

Electronic Health Record

B.

Health Information Exchange

C.

Verbal (e.g., in-person, telephone, video conferencing)

D.

Paper-based (e.g., fax, copies, printouts)

E.

Other Methods (e.g., texting, email, CDs)

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Check all that apply

↓

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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 to M2005, Medication Intervention
1. Yes ➔Continue to J1900, Number of Falls Since SOC/ROC

J1900. Number of Falls Since SOC/ROC, whichever is more recent

↓ 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

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

Section N

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.

Section O

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

Special Treatment, Procedures, and Programs

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.

No ➔ Skip to M2401, Intervention Synopsis
Yes ➔ Continue to M1046, Influenza Vaccine Received

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

1.
2.
3.
4.
5.
6.
7.
8.

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

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Section Q

OASIS-E Instruments

Participation in Assessment and Goal Setting

M2401. Intervention Synopsis
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? (Mark only one box in each row.)
Plan/Intervention

No
Yes
↓Check only one box in each row↓

b.

Falls prevention interventions

0

1

NA

c.

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

0

1

NA

d.

Intervention(s) to monitor and
mitigate pain

0

1

NA

e.

Intervention(s) to prevent
pressure ulcers

0

1

NA

f.

Pressure ulcer treatment based on
principles of moist wound healing

0

1

NA

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

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OASIS-E Death at Home
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
Death at Home (DAH)

Section A

Administrative Information

M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

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
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

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

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 to M2005, Medication Intervention
1. Yes ➔Continue to J1900, Number of Falls Since SOC/ROC

J1900. Number of Falls Since SOC/ROC, whichever is more recent

↓ 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

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

Section N

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

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OASIS-E Discharge from Agency
PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
Discharge from Agency (DC)

Section A

Administrative Information

M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

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
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

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

A1250. Transportation (NACHC ©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X. Patient unable to respond
Y. Patient declines to respond
Adapted from: NACHC © 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its
partners, and authorized recipients. Do not publish, copy, or distribute this information in part or whole without written consent from NACHC.
↓

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 ➔ Skip to M2410, Inpatient Facility
Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission
Unknown ➔ Skip to M2410, Inpatient Facility

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

Check 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

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

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

Patient remained in the community (without formal assistive services) ➔ Skip to A2123, Provision of Current Reconciled
Medication List to Patient at Discharge
2. Patient remained in the community (with formal assistive services) ➔ Continue to A2121, Provision of Current
Reconciled Medication List to Subsequent Provider at Discharge
3. Patient transferred to a non-institutional hospice ➔ Continue to A2121, Provision of Current Reconciled Medication List
to Subsequent Provider at Discharge
4. Unknown because patient moved to a geographic location not served by this agency ➔ Skip to A2123, Provision of
Current Reconciled Medication List to Patient at Discharge
UK Other unknown ➔ Skip to A2123, Provision of Current Reconciled Medication List to Patient at Discharge

1.

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A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your agency provide the patient’s current reconciled medication list to the
subsequent provider?
Enter Code

0.
1.

No – Current reconciled medication list not provided to the subsequent provider ➔ Skip to B1300, Health Literacy
Yes – Current reconciled medication list provided to the subsequent provider ➔ Continue to A2122. Route of Current
Reconciled Medication List Transmission to Subsequent Provider

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Route of Transmission

↓

A.

Electronic Health Record

B.

Health Information Exchange

C.

Verbal (e.g., in-person, telephone, video conferencing)

D.

Paper-based (e.g., fax, copies, printouts)

E.

Other Methods (e.g., texting, email, CDs)

Check all that apply

↓

After completing A2122, Skip to B1300, Health Literacy

A2123. Provision of Current Reconciled Medication List to Patient at Discharge
At the time of discharge, did your agency provide the patient’s current reconciled medication list to the patient, family and/or
caregiver?
Enter Code

0.
1.

No – Current reconciled medication list not provided to the patient, family, and/or caregiver ➔ Skip to B1300, Health
Literacy
Yes – Current reconciled medication list provided to the patient, family, and/or caregiver ➔ Continue to A2124, Route
of Current Reconciled Medication List Transmission to Patient.

A2124. Route of Current Reconciled Medication List Transmission to Patient
Indicate the route(s) of transmission of the current reconciled medication list to the patient, family, and/or caregiver.
Route of Transmission
↓
A.
B.
C.
D.
E.

Check all that apply

↓

Electronic Health Record
Health Information Exchange
Verbal (e.g., in-person, telephone, video conferencing)
Paper-based (e.g., fax, copies, printouts)
Other Methods (e.g., texting, email, CDs)

Section B

Hearing, Speech, and Vision

B1300. Health Literacy (From Creative Commons ©)
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your
doctor or pharmacy?

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Patient declines to respond
8. Patient unable to respond
The Single Item Literacy Screener is licensed under a Creative Commons Attribution Noncommercial 4.0 International License.
Enter Code

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Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
Enter Code

0.
1.

No (patient is rarely/never understood) ➔ Skip to C1310, Signs and Symptoms of Delirium (from CAM ©)
Yes ➔ Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code

Ask patient: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The
words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of
furniture"). You may repeat the words up to two more times.

C0300. Temporal Orientation (Orientation to year, month, and day)
Enter Code

Enter Code

Enter Code

Ask patient: "Please tell me what year it is right now."
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Ask patient: "What month are we in right now?"
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask patient: "What day of the week is today?"
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct

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C0400. Recall
Enter Code

Enter Code

Enter Code

OASIS-E Instruments
Ask patient: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
0. No – could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
B. Able to recall “blue”
0. No – could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
C. Able to recall “bed”
0. No – could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required

C0500. BIMS Summary Score
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
A. Acute Onset of Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously present,
does not fluctuate
2. Behavior present, fluctuates
(comes and goes, changes in
severity)

↓ Enter Codes in Boxes
B. Inattention – Did the patient have difficulty focusing attention, for example, being
easily distractible or having difficulty keeping track of what was being said?

Disorganized thinking – Was the patient's thinking disorganized or incoherent
(rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject)?
D. Altered level of consciousness – Did the patient have altered level of consciousness,
as indicated by any of the following criteria?

vigilant – startled easily to any sound or touch

lethargic – repeatedly dozed off when being asked questions, but responded to
voice or touch

stuporous – very difficult to arouse and keep aroused for the interview

comatose – could not be aroused
Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program,
LLC. Not to be reproduced without permission.
C.

M1700. Cognitive Functioning
Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for
simple commands.
Enter Code

0.
1.
2.
3.
4.

Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.
Requires prompting (cueing, 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.

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M1710. When Confused
Reported or Observed Within the Last 14 days.
Enter Code

0.
1.
2.
3.
4.
NA

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

M1720. When Anxious
Reported or Observed Within the Last 14 days.
Enter Code

Section D

0.
1.
2.
3.
NA

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

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
Say to patient: "Over the last 2 weeks, have you been bothered by any of the following problems?"

If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
Symptom
Symptom
0. No (enter 0 in column 2)
0. Never or 1 day
Presence
Frequency
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
9. No response (leave column
2. 7-11 days (half or more of the days)
↓Enter Scores in Boxes↓
2 blank).
3. 12-14 days (nearly every day)
A.

Little interest or pleasure in doing things

B.

Feeling down, depressed, or hopeless

If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the PHQ interview.
C.

Trouble falling or staying asleep, or sleeping too much

D.

Feeling tired or having little energy

E.

Poor appetite or overeating

F.

Feeling bad about yourself – or that you are a failure or have let yourself or your family down

G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so
fidgety or restless that you have been moving around a lot more than usual
I.

Thoughts that you would be better off dead, or of hurting yourself in some way

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

D0160. Total Severity Score
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if
unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

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D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Section E

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

Behavior

M1740. Cognitive, Behavioral, and Psychiatric Symptoms that are demonstrated at least once a week (reported or observed)
↓

Check 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

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

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OASIS-E Instruments

Section F

Preferences for Customary Routine Activities

M2102. Types and Sources of Assistance
Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to
provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code

a.

Enter Code

c.

Enter Code

d.

Enter Code

f.

Section G

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
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
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
Supervision and safety (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

Functional Status

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

0.
1.
2.
3.

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

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

0.

1.
2.
3.

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

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

0.
1.
2.
3.

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

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

0.
1.
2.

3.
4.
5.
6.

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

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

0.
1.
2.
3.
4.

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

M1845. Toileting Hygiene
Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet,
commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.
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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M1860. Ambulation/Locomotion
Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

0.

1.
2.
3.
4.
5.
6.

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

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Section GG

OASIS-E Instruments

Functional Abilities and Goals

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 themself 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 condition 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 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.

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 themself 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.

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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 condition or safety concerns

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.
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 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 transfer: 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.
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).

I.
J.
K.

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

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

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 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.
L.

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 M1600, Urinary Tract Infection
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.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual

R.

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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.
2.
S.

Motorized

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 H

Bladder and Bowel

M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0. No
1. Yes
NA Patient on prophylactic treatment

M1620. Bowel Incontinence Frequency
Enter Code

Section J

0.
1.
2.
3.
4.
5.
NA

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

Health Conditions

J0510. Pain Effect on Sleep
Enter Code

Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night"
0. Does not apply – I have not had any pain or hurting in the past 5 days ➔ Skip to J1800, Any Falls Since SOC/ROC
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to
pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

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OASIS-E Instruments

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: "Over the past 5 days, how often you have limited your day-to-day activities (excluding rehabilitation therapy
sessions) because of pain?"
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

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 to M1400, Short of Breath
1. Yes ➔Continue to J1900, Number of Falls Since SOC/ROC

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

M1400. When is the patient dyspneic or noticeably Short of Breath?
Enter Code

Section K

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)

Swallowing/Nutritional Status

K0520. Nutritional Approaches
4.
5.
A.
B.
C.
D.
Z.

Last 7 days
Check all of the nutritional approaches that were received in the last 7 days
At discharge
Check all of the nutritional approaches that were being received at discharge
Parenteral/IV feeding
Feeding tube (e.g., nasogastric or abdominal (PEG))
Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
None of the above

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4.
5.
Last 7 days
At discharge
↓
Check all that apply
↓

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M1870. Feeding or Eating
Current ability to feed self meals and snacks safely. Note: This refers only to the process of eating, chewing, and swallowing, not
preparing the food to be eaten.
Enter Code

0.
1.

2.
3.
4.
5.

Section M

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.

Skin Conditions

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 ➔ Skip to M1324, Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable
Yes

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

1.
2.

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

NA No Stage 2 pressure ulcers are present at discharge

M1311. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number
Enter Number

Enter Number
Enter Number

Enter Number
Enter Number

Enter Number
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 ➔Skip 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 ➔Skip 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 ➔Skip 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 non-removable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device – If 0 ➔Skip 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

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

Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar – If 0 ➔Skip to M1311F1,
Unstageable: Deep tissue injury

Enter Number

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

Enter Number

F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury – If 0 ➔Skip to M1324, Stage of Most
Problematic Unhealed Pressure Ulcer/Injury that is Stageable

Enter Number

F2. Number of these unstageable pressure injuries 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

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

M1330. Does this patient have a Stasis Ulcer?
Enter Code

0.
1.
2.
3.

No ➔Skip to M1340, Surgical Wound
Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY
Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device) ➔
Skip to M1340, Surgical Wound

M1334. Status of Most Problematic Stasis Ulcer that is Observable
Enter Code

1.
2.
3.

Fully granulating
Early/partial granulation
Not healing

M1340. Does this patient have a Surgical Wound?
Enter Code

0.
1.
2.

No ➔Skip to N0415, High-Risk Drug Classes: Use and Indication
Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device ➔ Skip to N0415, High-Risk Drug
Classes: Use and Indication

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

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Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1.

Is taking
Check if the patient is taking any medications by pharmacological
classification, not how it is used, in the following classes

Indication noted
If Column 1 is checked, check if there is an indication noted for all
medications in the drug class
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the Above
2.

1. Is Taking
2. Indication Noted
↓
Check all that apply
↓

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

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

Section O

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.
2. Able to take medication(s) at the correct times if given reminders by another person at the appropriate times
3. Unable to take medication unless administered by another person.
NA No oral medications prescribed.

0.
1.

Special Treatment, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.

c. At Discharge
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2 IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous

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OASIS-E Instruments

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.

c. At Discharge
Check all that apply
↓

C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. 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.

No ➔ Skip to M2401, Intervention Synopsis
Yes ➔ Continue to M1046, Influenza Vaccine Received

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

1.
2.
3.
4.
5.
6.
7.
8.

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

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Section Q

OASIS-E Instruments

Participation in Assessment and Goal Setting

M2401. Intervention Synopsis
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? (Mark only one box in each row.)
Plan/Intervention

No

Not Applicable

Yes

↓Check only one box in each row↓
b.

Falls prevention interventions

0

1

NA

c.

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

0

1

NA

d.

Intervention(s) to monitor and
mitigate pain

0

1

NA

e.

Intervention(s) to prevent
pressure ulcers

0

1

NA

f.

Pressure ulcer treatment based on
principles of moist wound healing

0

1

NA

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

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Appendix D

Description of Changes from OASIS-D to OASIS-E

APPENDIX D: DESCRIPTION OF CHANGES FROM OASIS-D TO
OASIS-E
OASIS-E is a major revision to the OASIS instrument and guidance manual resulting in significant instrument
redesign and manual reorganization.
The Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014, enacted October 6,
2014, directs the Secretary of Health and Human Services to “specify quality measures on which Post-Acute
Care (PAC) providers are required under the applicable reporting provisions to submit standardized patient
assessment data” in several quality measure domains including incidence of falls with major injury, skin
integrity and changes in skin integrity, medication reconciliation, functional status, transfer of health
information and care preferences when an individual transitions, and resource use and other measures 6.
To align the items across the PAC settings, multiple new standardized items have been added to OASIS-E,
sections have been added or renamed, items have been reorganized within the sections, and the format for item
specific guidance (Chapter 3) has changed.
OASIS-E reflects revisions based on proposals finalized in the Calendar Year (CY) 2019 Home Health (HH)
Final Rule [CMS-1689-FC] effective January 1, 2020, and CY 2022 HH Final Rule, CMS [CMS-1747-F and
CMS-553-F] effective January 1, 2023. The OASIS-D1 instrument, effective January 1, 2020, included minor
revisions consisting of the addition of two existing items to the Follow-up assessment instrument (M1033 –
Risk for Hospitalization and M1800 – Grooming), with corresponding revisions to the All-Items instrument.
Additional guidance revisions included a change from “required” to “optional” data collection at certain time
points for 23 existing OASIS items. The 2019 OASIS-D Guidance Manual was not revised; however, CMS
published an OASIS-D1: OASIS Update for CY 2020 document that highlighted changes related to this optional
data collection. With OASIS-E, made effective January 1, 2023, the items that were made optional with OASISD1 were removed from the specified time points. M2016 – Patient/Caregiver Drug Education Intervention was
also removed from the OASIS instrument. OASIS-E includes the addition of certain Standardized Patient
Assessment Data Elements including those addressing certain Social Determinants of Health (SDOH). It is
notable that the January 1, 2023 implementation of OASIS-E represents a two-year delay from the original
compliance date finalized in the CY 2020 HH PPS final rule. This delay accompanied additional OASIS
flexibilities that CMS provided to support home health agencies during the COVID-19 public health
emergency- CY 2019 HH Final Rule, [CMS 1689-FC] effective January 1, 2020
This appendix includes a table outlining the changes made to the OASIS-E instrument compared to the previous
OASIS-D Instrument (Table D.1).
Table D.1 presents an overview of changes made to the OASIS items and instrument for the transition from
OASIS-D to OASIS-E. The table columns and headings are explained below.
1. OASIS-E item section: Section in the OASIS-E where the item is located.

6 Centers for Medicare & Medicaid Services, ‘IMPACT Act of 2014 Data Standardization & Cross Setting Measures’, CMS.gov, Page last updated
03/23/2021, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Actof-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-Measures

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Description of Changes from OASIS-D to OASIS-E

2. OASIS-E item number: Item number in the OASIS-E. If an NA appears, this indicates a corresponding
item does not exist in OASIS E.
3. OASIS-D item number: Item number in the OASIS-D. If an NA appears, this indicates a corresponding
item did not exist in OASIS-D.
4. Item Description: A brief description of the item.
5. 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.
• Item Text – if the question or response option text is changed, “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.
6. Item/Instrument Change Description: This column contains a brief description of the changes that
have been made to relevant items.
Table D.1: Description of Item Changes from OASIS-D to OASIS-E
OASIS-E
Item #
M0018
M0010
M0014
M0016
M0020
M0030
M0032
M0040
M0050
M0060
M0063
M0064
M0065
M0069
M0066
NA
A1005
A1010
M0150

OASIS-D
Item #
M0018
M0010
M0014
M0016
M0020
M0030
M0032
M0040
M0050
M0060
M0063
M0064
M0065
M0069
M0066
M0140
NA
NA
M0150

OASIS-E
Item #
M0080

OASIS-D
Item #
M0080

M0090
M0100

M0090
M0100

Section A. Administrative Information: Patient Tracking
Item Description

National Provider Identifier (NPI)
CMS Certification Number
Branch State
Branch ID Number
Patient ID Number
Start of Care Date
Resumption of Care Date
Patient Name
Patient State of Residence
Patient Zip Code
Medicare Number
Social Security Number
Medicaid Number
Gender
Birth Date
Race/Ethnicity
Ethnicity
Race
Current Payment Source for Home
Care

New
Item

Item
Text

Skip
Pattern

Removed

X
X

Section A. Administrative Information

Item Description

Discipline of Person Completing
Assessment
Date Assessment Completed
This Assessment is Currently Being
Completed for the Following Reason

OASIS-E Guidance Manual
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New
Item

Item/Instrument Change
Description

Item
Text

Skip
Pattern

X

Item/Instrument Change
Description

Skip text removed

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Appendix D

Description of Changes from OASIS-D to OASIS-E

Section A. Administrative Information

OASIS-E
Item #
M0102

OASIS-D
Item #
M0102

Item Description

M0104
M0110
M0906
M1000

M0104
M0110
M0906
M1000

Date of Referral
Episode Timing
Discharge/Transfer/Death Date
Inpatient Facilities

M1005
A1110
A1250
M2301
M2310
M2410

M1005
NA
NA
M2301
M2310
M2410

M2420
A2120

M2420
NA

A2121

NA

A2122

NA

A2123

NA

A2124

NA

Inpatient Discharge Date
Language
Transportation
Emergent Care
Reason for Emergent Care
To which Inpatient Facility has the
patient been admitted
Discharge Disposition
Provision of Current Reconciled
Medication List to Subsequent
Provider at Transfer
Provision of Current Reconciled
Medication List to Subsequent
Provider at Discharge
Route of Current Reconciled
Medication List Transmission to
Subsequent Provider
Provision of Current Reconciled
Medication List to Patient at
Discharge
Route of Current Reconciled
Medication List Transmission to
Patient

OASIS-E
Item #
B0200
B1000

OASIS-D
Item #
NA
NA

Item Description
Hearing
Vision

New
Item
X
X

NA
B1300

M1200
NA

Vision
Health Literacy

X

Date of Physician-Ordered Start of
Care (Resumption of Care)

New
Item

Item
Text
X

Skip
Pattern
X

Item/Instrument Change
Description
Text edit:
• NA response updated to
include ROC
Skip text updated

X

X

Text edit:
• “Mark all that apply” is
replaced with “Check all
that apply”
Skip text updated

X

Skip text updated

X

Skip text added

X
X

X
X
X
X
X

Section B. Hearing, Speech, Vision

OASIS-E Guidance Manual
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Item
Text

Skip
Pattern

Item/Instrument Change
Description
Note: B1000 Vision is a new
item REPLACING M1200
Vision
Removed

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Description of Changes from OASIS-D to OASIS-E

Section C. Cognitive Patterns

OASIS-E
Item #
C0100

OASIS-D
Item #
NA

Item Description

C0200
C0300
C0400
C0500
C1310

NA
NA
NA
NA
NA

M1700
M1710
M1720

M1700
M1710
M1720

OASIS-E
Item #
NA

OASIS-D
Item #
M1730

Depression Screening

D0150

NA

Patient Mood Interview (PHQ 2-9)

X

D0160
D0700

NA
NA

Total Severity Score
Social Isolation

X
X

OASIS-E
Item #
M1740

OASIS-D
Item #
M1740

Item Description

M1745

M1745

OASIS-E
Item #
M1100
M2102

OASIS-D
Item #
M1100
M2102

OASIS-E
Item #
M1800
M1810
M1820

OASIS-D
Item #
M1800
M1810
M1820

M1830

M1830

Should Brief Interview for Mental
Status (C0200-C0500) be Conducted
Repetition of Three Words
Temporal Orientation
Recall
BIMS Summary Score
Signs and Symptoms of Delirium
(from CAM©)
Cognitive Functioning
When Confused
When Anxious

New
Item
X

New
Item

Section E. Behavior

Cognitive, Behavioral, and
Psychiatric Symptoms
Frequency of Disruptive Behavior
Symptoms

Skip
Pattern

Item/Instrument Change
Description

Item
Text

Skip
Pattern

Item/Instrument Change
Description
Removed

X
X
X
X
X

Section D. Mood

Item Description

Item
Text

New
Item

Note: D0150 Patient Mood
Interview (PHQ 2-9) is a new
item REPLACING M1730
Depression Screening

Item
Text

Skip
Pattern

Item/Instrument Change
Description

Section F. Preferences for Customary Routine Activities
Item Description

Patient Living Situation
Types and Sources of Assistance

New
Item

Item
Text

Section G. Functional Status

Item Description

Grooming
Current Ability to Dress Upper Body
Current Ability to Dress Lower
Body
Bathing

OASIS-E Guidance Manual
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New
Item

Item
Text

Skip
Pattern

Item/Instrument Change
Description

Skip
Pattern

Item/Instrument Change
Description
Added to FU (with OASIS-D1)

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Description of Changes from OASIS-D to OASIS-E

OASIS-E
Item #

OASIS-D
Item #

M1845
M1850
M1860
NA

M1845
M1850
M1860
M1910

M1840

M1840

Section G. Functional Status

Item Description

Toilet Transferring
Toileting Hygiene
Transferring
Ambulation/Locomotion
Falls Risk Assessment

New
Item

Item
Text

Skip
Pattern

Removed

Section GG. Functional Abilities & Goals
Item Description

OASIS-E
Item #
GG0100

OASIS-D
Item #
GG0100

GG0110
GG0130

GG0110
GG0130

Prior Device Use
Self-Care

X

GG0170

GG0170

Mobility

X

Prior Functioning: Everyday
Activities

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Item/Instrument Change
Description

New
Item

Item
Text
X

Skip
Pattern

X

Item/Instrument Change
Description
Text edits:
• “all” added to code options
3 – Independent and 1 –
Dependent
• “any” added to code option
2 – Needed Some Help
• “Him/herself” changed to
“themself.”
• GG0100A, Self Care,
reworded to read "...using
the toilet, and eating
prior...”
Text edits:
• GG0130B, Oral hygiene;
“remove and replace”
changed to “insert and
remove” in SOC, ROC,
and All Items versions
• Coding instructions:
“Him/herself” changed to
“themself.”
Text edits:
• GG0170C, Lying to
sitting; “Feet flat on the
floor” phrase removed
• GG0170M, 1 step,
reworded to read “...curb
or up and down one step”
• Coding instructions:
“him/herself” changed to
“themself.”

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Description of Changes from OASIS-D to OASIS-E

Section H. Bladder and Bowel

OASIS-E
Item #
M1600

OASIS-D
Item #
M1600

Item Description

M1610

M1610

M1620

M1620

Has this patient been treated for a
Urinary Tract Infection in the past 14
days?
Urinary Incontinence or
Urinary Catheter Presence
Bowel Incontinence Frequency

M1630

M1630

Ostomy for Bowel Elimination

OASIS-E
Item #
M1021
M1023
M1028

OASIS-D
Item #
M1021
M1023
M1028

Item Description

OASIS-E
Item #
M1033
NA

OASIS-D
Item #
M1033
M1242

J0510

NA

J0520

NA

J0530

NA

Pain Interference with Day-to-Day
Activities

J1800

J1800

Any Falls Since SOC/ROC

J1900
M1400

J1900
M1400

Number of Falls
When is patient dyspneic or SOB?

OASIS-E
Item #
M1060

OASIS-D
Item #
M1060

New
Item

Item
Text

X

Risk for Hospitalization
Frequency of Pain Interfering with
patient’s activity or movement
Pain Effect on Sleep

Pain Interference with Therapy
Activities

Text edit:
• “Omit ‘UK’ option on FU”
text removed
No longer collected at FU
No longer collected at FU

New
Item

Item
Text

Section J. Health Conditions

Item Description

New
Item

Item
Text

Skip
Pattern

Item/Instrument Change
Description
No longer collected at FU
No longer collected at FU

Skip
Pattern

Item/Instrument Change
Description
Added to FU (with OASIS-D1)
Removed

X

X

X

X

Height and Weight

OASIS-E Guidance Manual
Effective 1/1/2023
Centers for Medicare & Medicaid Services

Note: J0510 Pain Effect on
Sleep is a new item
REPLACING M1242
Frequency of Pain Interfering
Note: J0520 Pain Interference
with Therapy Activities is a
new item REPLACING M1242
Frequency of Pain Interfering
Note: J0530 Pain Interference
with Day-to-Day Activities is a
new item REPLACING M1242
Frequency of Pain Interfering
Skip text updated
No longer collected at FU

Section K. Swallowing/Nutritional Status
Item Description

Item/Instrument Change
Description

No longer collected at FU

Section I. Active Diagnoses

Primary Diagnosis
Other Diagnoses
Active Diagnoses – Comorbidities
and Co-existing Conditions

Skip
Pattern

New
Item

Item
Text

Skip
Pattern

Item/Instrument Change
Description

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Description of Changes from OASIS-D to OASIS-E

Section K. Swallowing/Nutritional Status

NA

M1030

Therapies the patient receives at
home
Nutritional Approaches
Feeding or Eating

K0520
M1870

NA
M1870

OASIS-E
Item #
M1306

OASIS-D
Item #
M1306

M1307
M1311

M1307
M1311

M1322

M1322

M1324

M1324

M1330

M1330

M1332

M1332

M1334

M1334

M1340

M1340

M1342

M1342

Status of Most Problematic Surgical
Wound Observable

OASIS-E
Item #
N0415

OASIS-D
Item #
NA

Item Description

M2001
M2003
M2005
M2010

M2001
M2003
M2005
M2010

NA

M2016

M2020
M2030

M2020
M2030

OASIS-E
Item #
O0110

OASIS-D
Item #
NA

X

Section M. Skin Conditions

Item Description

Unhealed Pressure Ulcer/Injury at
Stage 2 or Higher
Oldest Stage 2 Pressure Ulcer
Current Number of Unhealed
Pressure Ulcers/Injuries at Each
Stage
Current Number of Stage 1
Pressure Injuries
Stage of Most Problematic Unhealed
Pressure Ulcer that is Stageable
Stasis Ulcer

New
Item

Item
Text

Skip
Pattern

Item/Instrument Change
Description
Skip text updated
Skip text updated
No longer collected at FU
No longer collected at FU
No longer collected at FU
Skip text updated

No longer collected at FU
No longer collected at FU

Current Number of Stasis Ulcers
Observable
Status of Most Problematic Stasis
Ulcer Observable
Surgical Wound

No longer collected at FU
X

Section N. Medications

High Risk Drug Classes: Use and
Indication
Drug Regimen Review
Medication Follow-up
Medication Intervention
Patient/Caregiver High-Risk Drug
Education
Patient/Caregiver Drug Education
Intervention
Management of Oral Medications
Management of Injectable
Medications

Removed

New
Item
X

Item
Text

Skip
Pattern
X

Skip text updated
No longer collected at FU
No longer collected at FU

Item/Instrument Change
Description
Skip text updated

Removed
No longer collected at FU

Section O. Special Treatments, Procedures, and Programs
Item Description

Special Treatments, Procedures, and
Programs

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New
Item
X

Item
Text

Skip
Pattern

Item/Instrument Change
Description

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Appendix D

Description of Changes from OASIS-D to OASIS-E

M1041

M1041

M1046
M2200
NA
NA

M1046
M2200
M1051
M1056

OASIS-E
Item #
M2401

OASIS-D
Item #
M2401

Section O. Special Treatments, Procedures, and Programs
Influenza Vaccine Data Collection
Period
Influenza Vaccine Received
Therapy Need (# visits)
Pneumococcal Vaccine
Reason Pneumococcal Vaccine not
received

X

Skip text updated

No longer collected at FU
Removed
Removed

Section Q. Participation in Assessment and Goal Setting
Item Description

Intervention Synopsis

OASIS-E Guidance Manual
Effective 1/1/2023
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New
Item

Item
Text
X

Skip
Pattern

Item/Instrument Change
Description
Text edit:
• Row A - Diabetic foot care
removed

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Appendix D

Description of Changes from OASIS-D to OASIS-E

Summary of Substantive Guidance Changes from OASIS-D to OASIS-E
At times CMS provides new or refined OASIS coding instruction. When guidance changes occur, the newer
guidance supersedes previously published guidance and providers are directed to utilize the most recent
guidance.
Examples of the more substantive guidance refinements that have been added to the OASIS-E Guidance
Manual are summarized here. A focused review of Chapter 3 of this manual is encouraged to gain context and
details regarding these and other guidance refinements which have occurred since OASIS-D.
General Response Specific Instructions for GG0130/GG0170, guidance on how to code an activity when only a
portion of the activity has been completed has been added:
•

If the patient only completes a portion of the activity (e.g., performs a partial bath or transfers into but
not out of a vehicle) and does not complete the entire activity during the assessment time frame, use
clinical judgment to determine if the situation allows the clinician to adequately assess the patient’s
ability to complete the activity. If the clinician determines that this observation is adequate, code based
on the type and amount of assistance the patient requires to complete the ENTIRE activity. If the
clinician determines the partial activity does not provide adequate information to support determination
of a performance code, select an appropriate “activity not attempted” code.

Illustrations of how this guidance concept might be applied can be found in Chapter 3 coding instructions for
GG0130E – Shower/ bathe self and GG0170G – Car transfer:
•

Use clinical judgment to determine if completing a partial bath or simulating the shower/bath allows
the clinician to adequately assess the patient’s ability to complete the activity of shower/bathe self
(GG0130E). If the clinician determines that this observation is adequate, code based on the type and
amount of assistance required to complete the shower/bathing activity.

•

Clinicians may use professional judgment to determine if observing a patient performing a portion of
the car transfer activity (e.g., getting into the car) allows the clinician to adequately assess the patient’s
ability to complete the entire GG0170G – Car transfer activity (transferring in and out of a car). If the
clinician determines that this observation is adequate, code based on the type and amount of assistance
the patient required to complete the activity.

Other examples of guidance added to specific GG activities include:
•

An update to coding tips for GG0170C – Lying to sitting on side of bed, corresponding to edits made to
the OASIS item language:
o It is not required that the patient’s feet be flat on the floor to consider the activity as being
completed. Note that the reference to the patient having their feet flat on the floor has been
removed from GG0170C in the OASIS-E instrument.

•

Guidance refinements for what is specifically assessed during GG0170G – Car transfer:
o

•

If the patient remains in a wheelchair and does not transfer in and out of a car or van seat, the
activity is not considered completed and the appropriate “activity not attempted” code would be
used.

Clarifying statements on when the walking versus wheelchair activities can be considered complete and
how a helper may assist a patient in complete the activities:
o

The walking activities cannot be completed without some level of patient participation that
allows patient ambulation to occur for the entire stated distance. A helper cannot complete a
walking activity for a patient.

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Appendix D

o

Description of Changes from OASIS-D to OASIS-E

A helper can assist a patient to complete the wheelchair distance or make turns if required.
When a patient is unable to wheel the entire distance themselves the activity can still be
completed, and a performance code can be determined based on the type and amount of
assistance required from the helper to complete the entire activity.

Guidance statements were added to the OASIS-E manual pages for M1033 – Risk for Hospitalization to clarify
when certain response options should be selected. Examples include:
•

Multiple hospitalizations (Response 3) defines hospitalization as the patient being admitted for 24 hours
or longer to an inpatient acute bed for more than just diagnostic testing.

•

Medications (Response 7) include prescribed and over-the-counter (OTC) medications, nutritional
supplements, vitamins, and homeopathic and herbal products administered by any route and as noted on
the reconciled medication profile. Medications may also include total parenteral nutrition (TPN) and
oxygen.

Guidance modifying the definition of “formal assistive services” M2420 – Discharge Disposition was updated
to support new Transfer of Health Quality Measures:
•

Code 2, Patient remained in the community (with formal assistive services), now applies if, after
discharge from your agency the patient remained a non-inpatient setting, receiving skilled services from
another Medicare certified home health agency, (with or without other assistive services), or when an
agency completes a discharge and new SOC OASIS due to a pay source change for a patient.

Guidance was updated related to allowing orders to be received from select non-physician practitioners, as it
impacts OASIS items where the presence of a physician’s order affects the item coding:
•

Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act amended section
1861(aa)(5) of the Act, allowing nurse practitioners (NPs), clinical nurse specialists (CNSs), and
physician assistants (PAs) to certify eligibility and provide orders for home health services, where not
prohibited by State Law. Accordingly, when coding OASIS items where the presence of a physician’s
order affects the item coding, orders from these allowed practitioners would satisfy the condition of
having a physician’s order.

Illustrations of how this guidance concept might be applied can be found in Chapter 3 coding instructions for
M0102 – Date of Physician-ordered SOC/ROC, M0104 – Date of Referral, M1021 – Primary Diagnosis, and
M1023 – Other Diagnoses:
•

The date specified by a physician/allowed practitioner 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).

•

When coding OASIS items where the presence of a physician’s order affects the item coding, orders
from an allowed practitioner including physician assistant, nurse practitioner, or other advanced
practice nurse would satisfy the condition of having a physician’s order

•

A valid referral is considered received when the agency has received adequate information about a
patient (such as name, address/contact info, and diagnosis and/or general home care needs) to initiate
patient assessment and confirmed that the referring physician/allowed practitioner or another
physician/allowed practitioner, will provide the plan of care and ongoing orders.

•

The assessing clinician determine the primary and other home health diagnoses based on the assessment
findings, information in the medical record including but not limited to physician/non-physician
practitioner orders, medication list and referral information, and, input from the physician/nonphysician practitioner.

CMS invites stakeholders to review all guidance manual pages for new and refined guidance statements, and
reference as needed to support OASIS data accuracy.
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Appendix E

References and Resources

APPENDIX E: REFERENCES AND RESOURCES
This appendix provides information on print and electronic resources available to support you in OASIS
accuracy, quality of care, patient 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: Guidance on OASIS coding and documentation of the OASIS responses; Home
Health Quality Measures including, but not limited to: quality manuals, quality measures, measure
calculation including Quality of Patient Care Stars, Care Compare), risk adjustment, public reporting,
and Quality Assessment Only (QAO)/Pay for Reporting (P4R).
•

Excludes All Inquiries For the Home Health Value Based Purchasing (HHVBP) Expanded
Model which may be directed to [email protected]

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-andPolicies/eRulemaking/index.html
e-CFR: Electronic Code of Federal Regulations - https://www.ecfr.gov/cgibin/retrieveECFR?gp=&SID=689910789421528509d5af9867d06e0d&mc=true&n=pt42.5.484&r=PAR
T&ty=HTML
Internet Quality Improvement and Evaluation System (iQIES) - Information and assistance
with OASIS submission https://qtso.cms.gov/providers.
iQIES Help Desk - E-mail: [email protected]. Phone: 1-877-201-4721 Hours: Monday-Friday 7:00
a.m. - 7:00 p.m. Central Time.
Home Health Quality Reporting Program (HHQRP)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits
Home Health Quality Reporting Training
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Training

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Appendix E

References and Resources

OASIS Q&As and Reference Manuals) (OASIS Quarterly Q&As, OASIS Static Q&As,
CASPER HHA Reporting User’s Manual, CMSnet Installation Guide & FAQs, jHAVEN
User’s Guide) - https://qtso.cms.gov/providers/home-health-agency-hha-providers/reference-manuals
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.)
• How to Stay Informed
The Medicare Learning Network® - http://www.cms.hhs.gov/MLNGenInfo/
Medicare.gov - What Medicare Covers: Home health patient rights
https://www.medicare.gov/what-medicare-covers/home-health-patient-rights
National Provider Identifier (NPI) Registry - https://npiregistry.cms.hhs.gov/

Guidelines and Best Practices
Vaccination Guidelines
Influenza Vaccine Guidelines: https://www.cdc.gov/flu/professionals/vaccination/vaccine_safety.htm
Wound Care
The National Pressure Injury Advisory Panel – NPIAP: Educational and Clinical Resources
https://npiap.com/page/resources

Healthcare Technology
National Quality Forum and Health Information Technology
http://www.qualityforum.org/HealthIT/
Office of the National Coordinator for Health Information Technology (ONC)
Home Page: http://www.healthit.gov
About ONC: 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

ICD-10-CM Official Guidelines for Coding and Reporting
ICD-10-CM Release
https://icd10cmtool.cdc.gov/?fy=FY2020
https://www.cdc.gov/nchs/icd/icd10cm.htm
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References and Resources

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 Plus - http://www.nlm.nih.gov/medlineplus/druginformation.html
Caregivers
AARP Family Caregiving - Caregiving Tools
https://www.aarp.org/home-family/caregiving/caregiving-tools/
Next Step in Care - 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
Journal Article: Nursing Home Assessment of Cognitive Impairment: Development and Testing of
a Brief Instrument of Mental Status
https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/j.1532-5415.2008.01944.x
Confusion Assessment Method (CAM) Assessment
https://www.hospitalelderlifeprogram.org/delirium-instruments/
Depression Recognition & Assessment in Older Home Care Patients
Journal Article: Training Nursing Staff to Recognize Depression in Home Healthcare. Full text link:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684961/

Risk Assessment Tools
Obesity – Body Mass Index (BMI)
National Heart, Lung, and Blood Institute
https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Behavioral Health
SAMHSA-HRSA Center for Integrated Health Solutions link
https://www.integration.samhsa.gov/clinical-practice/screening-tools
Pain
Wong-Baker FACES® http://wongbakerfaces.org
Brief Pain Inventory
https://www.mdanderson.org/research/departments-labs-institutes/departmentsdivisions/symptomresearch/symptom-assessment-tools/brief-pain-inventory.html

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References and Resources

Falls
MAHC 10 – Fall Risk Assessment Tool
https://www.homecaremissouri.org/projects/falls/documents/Oct2012FINALValidatedFallriskassessmen
ttool.pdf

Professional Organizations
American Nurses Association (ANA) - http://www.nursingworld.org/
American Occupational Therapy Association (AOTA) - http://www.aota.org/
American Physical Therapy Association (APTA) - http://www.apta.org/
American Speech-Language-Hearing Association (ASHA) - 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 - https://innovations.ahrq.gov/
AHRQ’s Quality Measures Database - 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 Care
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
https://www.ncbi.nlm.nih.gov/books/NBK2631/
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/
PSNET Patient Safety Network https://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/
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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 include: 1) Home Health Agency Medicare-certification surveys, 2)
the quality measures on the consumer-focused Care Compare website, 3) the quality measures used in the Home
Health Quality of Patient Care Star Ratings, 4) the quality measures used in the Centers for Medicare &
Medicaid Services (CMS) Home Health Value- Based Purchasing (HHVBP) Model, and 5) the Quality
Assessment Only (QAO) Metric used in home health pay-for- reporting (P4R). The OASIS instrument also
plays a pivotal role in post-acute care quality improvement 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 promoted a quality improvement process for home health called Outcome-Based
Quality Improvement (OBQI). OBQI used OASIS-based quality measures as the foundation for home health
quality improvement activities. 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 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. In 2021, CMS retired the Home Health
Compare website and launched the Care Compare website (https://www.medicare.gov/care-compare). With
Care Compare, CMS merged multiple setting-specific Compare sites into one consumer-friendly site that
features information from providers across the continuum. At the time of the launch of Care Compare, CMS
also launched another website related to publicly reported data: the Provider Data Catalog (PDC)
(https://data.cms.gov/provider-data). While Care Compare is a consumer-focused tool, PDC is a resource
geared toward providers, vendors, and researchers. The PDC website includes downloadable data from the Care
Compare site as well as additional measure-specific information.

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 Ambulation- Locomotion”, “Stabilization in Grooming,” “Improvement in Bed Transferring,”
etc. These measures are important to patients as they symbolize quality of life and independence in a home
setting. Quality measures also benefit clinicians by promotion of best practice interventions. Home health care
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quality is reflected in measures of agency best practices such as “Drug Regimen Review Conducted with
Follow-Up for Identified Issues.”
Agencies can 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 internet Quality Improvement and
Evaluation System (iQIES) reports, agencies can compare, or benchmark, their current performance to their
prior performance on each quality measure and compare their performance to a national reference rate.

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 and
change can be positive (improvement), negative (worsening) or neutral (no change). Outcome of care
measures are one tool for examining changes in patient condition or functioning 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.
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 quality 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 outcome quality
measures are: Improvement in Management of Oral Medications and Stabilization in Bathing. For example, did
the patient’s ability to manage their oral medications improve by the time they finished working with the home
health agency? A rate of 80% for that quality measure means that 80% of the time, the patients’ ability to
manage their oral medications improved from the start to the end of their home care episode.
A utilization outcome is a type of quality measure that reflects use of health care services presumably resulting
from a change in the patient’s health status. Examples of utilization outcomes include quality measures that
identify hospital admission, use of hospital emergency department services, and discharge to the community.
Utilization measures were initially computed using only OASIS data; however, current and potential future
measures may be computed using Medicare FFS claims data. A complete list of quality measures and measure
descriptions are available on the CMS Home Health Quality Reporting Program 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 they are 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.
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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.
A quality measure may also have exclusions specific to that measure. Measure exclusions are noted on the
Home Health Quality Measure Tables and in the Home Health Quality Measure User’s Manual (found on the
Home Health Quality Reporting Program website.)
Examples – Outcome Measures
Quality
Measure
Name
Improvement
in
AmbulationLocomotion

Stabilization
in Grooming

Measure
Consumer
Description
Language (on Care
Compare)
How often patients Percentage of
got better at walking home health
or moving around.
quality episodes
during which the
patient improved in
ability to ambulate.

NA – This measure
is not publicly
reported.

Percentage of
home health
quality episodes
during which
patients improved
or stayed the
same in ability to
groom self.

Measure Focus
(Numerator)

OASIS Items Used in
Measure Calculation

Number of home
health quality
episodes where the
value recorded on
the discharge
assessment indicates
less impairment in
ambulation/locomoti
on 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
Items Used to
Compute Change:
(M1800) Grooming.
Items Used to
Compute Exclusions:
(M1700)
Cognitive
Functioning
(M1710) When
Confused
(M1720) When Anxious

Number of home
health quality
episodes 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.

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 immunization rates.
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Process items represent actions taken by home health care providers that are designed to favorably impact
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 processes of care 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.
Example – Process Measures
Quality
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
quality episodes
during which
patients
received
influenza
immunization
for the current
flu season.

Number of home
health quality
episodes 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
As home health quality initiatives have evolved over the years, the OBQI process has also evolved. Today,
agencies may decide to use other quality improvement methodologies in addition to or in place of OBQI.
Examples include Six Sigma, Lean Methodology, and PDSA (Plan, Do, Study, Act).

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Although agencies may choose not 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

A majority of current home health quality measures are based on OASIS data. In addition to the OASIS- based
quality measures, there are home health quality measures derived from Medicare FFS 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
(such as benchmarking vendors, state collaboratives, etc.), or quality reports generated from their electronic
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.

QUALITY EPISODES
Quality episodes are used in the calculation of the quality measures. Quality episodes are not the same as
certification periods or Patient-Driven Groupings Model (PDGM) payment periods. A quality episode begins
with either a Start of Care or Resumption of Care assessment and ends with a Transfer, Death at home, or
Discharge assessment. A quality episode does not include Recertification (follow-up) or Other Follow-up
assessments and may span payment periods.
A quality episode is measured from:
• Start of Care to the Transfer OR
• Start of Care to the Death at Home OR
• Start of Care to the Discharge
• Resumption of Care to the Transfer OR
• Resumption of Care to the Death at Home OR
• Resumption of Care to the Discharge
For example, let’s look at a patient who was admitted on 1/1/23 and transferred to an inpatient facility on
1/15/23, then had a resumption of care on 1/20/23 and was discharged from the agency on 2/1/23. In this
example, this patient had two quality episodes. The first quality episode began with the start of care on 1/1/23
and ended with the transfer to an inpatient facility on 1/15/23. The second quality episode began with the
resumption of care on 1/20/23 and ended with the discharge on 2/1/23.

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 quality measures, we use the OASIS items for
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this calculation. To calculate quality measures, we also need to understand the measure definition for each
individual measure. The Quality Measure Tables found on the CMS Home Health Quality Reporting Program
website include information on the measure numerator, denominator, and measure exclusions for each home
health quality measure (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits).
EXAMPLE: IMPROVEMENT IN DYSPNEA
Measure Definition: The “Improvement in Dyspnea” quality measure is the “Percentage of home health
quality episodes during which the patient became less short of breath or dyspneic.”
OASIS Item(s) Used in Quality Measure Calculation: The quality 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 quality measures is to determine the patients that are eligible
for the measure. In this example, this quality measure excludes home health quality episodes 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 quality 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 quality
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 quality measure calculation.
Improvement: To improve in this quality measure, a patient must move from a higher numeric score on the
OASIS response scale at start of care or resumption of care to a lower numeric score at discharge (e.g., M1400
start of care score of “3” and discharge score of “2” would be an improvement). The following table depicts
how an individual patient’s score at the beginning of a quality episode (start of care or resumption of care) and
at the end of a quality episode (discharge for this quality measure) would be calculated for the Improvement in
Dyspnea measure:
OASIS RESPONSES & QUALITY MEASURE CALCULATION FOR IMPROVEMENT IN
DYSPNEA MEASURE
Start of Care
OR
Resumption of Care
0
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Discharge
0–4

Calculation
Excluded

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Start of Care
Discharge
Calculation
OR
Resumption of Care
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
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 quality measure numerator and denominator.
The numerator for this quality measure is the number of cases where improvement occurred. In the
“Improvement in Dyspnea” measure, the numerator is number of home health quality episodes 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 quality
measure. Therefore, the denominator is every patient in the reporting period that is not excluded from the
measure. In the “Improvement in Dyspnea” quality measure, the denominator is the number of home health
quality episodes 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” quality measure, home health
quality episodes for which the patient, at start/resumption of care, was not short of breath at any time, are
excluded from this quality 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.
For a high-level overview of how data elements are used within CMS assessment instruments to construct
quality measures, refer to training resources at the Home Health Quality Reporting Training webpage at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Training.
MEASURING STABILIZATION
In our example, we noted that with improvement in OASIS-based quality 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 quality measures are calculated for “improvement”
and/or “stabilization.” For example, there is a measure for “Improvement in Bathing” and there is also a quality
measure for “Stabilization in Bathing.” How then is “stabilization” measured? For the OASIS-based quality
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).
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As the stabilization quality measures include all patients who have stabilized AND all patients who have
improved, the measure rates for the stabilization quality measures are much higher than the corresponding
improvement quality measure rates. For example, at the time of development of this manual, the “Improvement
in Bathing” national reference rate was approximately 82%. However, the “Stabilization in Bathing” national
reference rate was 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. Home health agencies can obtain these reports from iQIES.
Information on obtaining OASIS-based quality measure reports can be found on CMS’s QIES Technical
Support Office (QTSO) website https://www.qtso.cms.gov/hhatrain.html.
Report Title
1. Agency Patient-Related
Characteristics (Case
Mix) Report

2. Outcome Report

Report Description
The average value of each OASIS
patient-related characteristics (patient
attributes or circumstances) measure
for quality episodes that ended during
a specified period for the agency,
along with national observed values
for the same period.
End Results Outcome measures,
Utilization Outcome measures, and
Claims Based Outcome measures
are reported;
End Results Outcomes are computed
only for quality episodes ending with
a discharge from agency (RFA = 09);
OASIS-based utilization Outcome is
computed for quality episodes
ending with a transfer to an inpatient
facility (RFA = 06 or 07), or a
discharge from the agency (RFA =
09);
Significance levels are presented for
each quality measure when the
sample size corresponding to the
quality measure is at least
10. If the agency had nine or fewer
patients on whom the outcome
measure could be computed validly,
statistical significance is not
provided.

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Report Uses
Agencies can use this report as a
companion to their Outcome
Report and their Process
Measures Report.

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.

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Report Title
3. Potentially Avoidable
Event Report

4. Potentially Avoidable
Event: Patient Listing
Report

5. Process Measures Report

6. Agency Patient-Related
Characteristics (Case
Mix) Tally Report

OASIS and Quality Improvement

Report Description
Lists each of the Potentially
Avoidable Event Measures and
statistics for each quality measure;
Significance levels are presented for
each quality measure when the sample
size; corresponding to the quality
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.
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.
Provides the number and percentage
of each OASIS process quality
measure followed for quality
episodes that ended during a specified
period for the agency, along with
national observed values for the same
period:
Significance levels are presented for
each quality measure when the sample
size; Corresponding to the quality
measure is at least
10. If the agency had nine or fewer
patients on whom the process quality
measure could be computed validly,
statistical significance is not
provided.
Details the patient-related
characteristics of each quality episode
that ended during a specified period
for the agency.

OASIS-E Guidance Manual
Effective 1/1/2023
Centers for Medicare & Medicaid Services

Report Uses
Agencies are encouraged to
review this report no less
frequently than quarterly and may
choose to review monthly.

Agencies are encouraged to
review this report no less
frequently than quarterly and may
choose to review monthly.
Agencies can use this report to
monitor their OASIS-based
process quality measures.
Agencies are encouraged to
review this report no less
frequently than quarterly and may
choose to review monthly for
optimal monitoring of quality
measures.

Agencies can use this report to
drill- down to the individual
patient-level to identify cases that
triggered for each of the indicators
on the Agency- Patient -Related
Characteristics (Case Mix) Report.

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Appendix F

OASIS and Quality Improvement

Report Title
7. Outcome Tally Report

Report Description
Details the quality episodes that
ended during a specified period for a
select agency and were used to
calculate the Outcome Reports.

8. Process Tally Report

Details the quality episodes that
ended during a specified period for a
select agency and were used to
calculate the Process Measures
Reports.

9. Care Compare Home
Health Provider
Preview Report

This report is a preview of the
agency’s Care Compare data.

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 quality measures used to
compute the Quality of Patient Care
Star Rating.

11. Quality Assessment Only
(QAO) Performance
Reports

CMS provides a quarterly Quality
Assessments Only (QAO)
Performance Report and a year- end
Historical Quality Assessments Only
(QAO) Performance Report. This
report is based on OASIS assessments
submitted by an HHA during the

OASIS-E Guidance Manual
Effective 1/1/2023
Centers for Medicare & Medicaid Services

Report Uses
Agencies can use this report to
drill- down to the individual
patient-level to identify cases that
triggered for each of the quality
measures on the Outcome Report.
Agencies may find this report
useful in investigating unfavorable
OASIS- based outcome measures.
Agencies can use this report to
drill- down to the individual
patient-level to identify cases that
triggered for each of the quality
measures on the Process Measures
Report.
Agencies may find this report
useful in investigating unfavorable
OASIS- based process measures.
This report is placed in the
agency’s iQIES folders no less
than 3 months prior to the Care
Compare update to allow the
agency to preview their Care
Compare data and contact CMS
with any potential data issues.
This report is placed in the
agency’s iQIES folders no less
than 3 months prior to the Care
Compare quarterly refresh to
allow the agency to preview their
data. Agencies that have proof that
there are errors in calculating your
Quality of Patient Care Star
Rating may request a review of
their rating by submitting that
proof to CMS.
Agencies can use these reports to
monitor their compliance with
Home Health pay-for-reporting
requirements.

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Appendix F

Report Title

12. Home Health Review and
Correct Reports

OASIS and Quality Improvement

Report Description
applicable reporting period as it
relates to compliance with OASIS
submission requirements for the
Annual Payment Update (APU).

These reports are available quarterly
and then updated weekly to provide
confidential agency-level and patientlevel performance for the OASISbased publicly reported quality
measures.

Report Uses

Agencies can use these reports in
conjunction with the other iQIES
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 relationship 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 quality 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.
A subset of the OASIS-based outcome quality measures is risk adjusted. The OASIS-based process quality
measures are not risk adjusted.
Additional information on home health risk adjustment methodology is available on the CMS Home Health
Quality Reporting Program website and in the Home Health Quality Reporting Program Measure Calculations
and Reporting User’s Manual found in the Quality Measures section of the Home Health Quality Reporting
Program website.

OASIS-E Guidance Manual
Effective 1/1/2023
Centers for Medicare & Medicaid Services

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