Home Heath

We currently have two claims from Humana where they are downgrading the HIPPS Codes on patients because the nurses answered M0100 (3)- Resumption of care (after inpatient stay). In each case, the hospital classified the stay as "Observation." One was a 2-day stay and the other, 3-day. The explanation states that "[h]ospital observation and outpatient stays are not considered eligible for the institutional designation."

According to the CMS Outcome and Assessment Information Set OASIS-E manual, Code 3 should be used "when the patient: Resumes care following an inpatient stay of 24 hours or longer for reasons other than diagnostic tests." The only other possible choice I see would be Code 5, Other follow-up, but this is described as occurring due to a MAJOR decline or improvement. One went to the ED secondary to a fall with a rib fracture, and the other secondary to PICC line dysfuntion and generalized weakness. 

I haven't been able to find what CMS defines as "Major." Can anyone provide guidance on the proper M0100 selection to use in these types of cases?

Thanks,

We currently have two claims from Humana where they are downgrading the HIPPS Codes on patients because the nurses answered M0100 (3)- Resumption of care (after inpatient stay). In each case, the hospital classified the stay as "Observation." One was a 2-day stay and the other, 3-day. The explanation states that "[h]ospital observation and outpatient stays are not considered eligible for the institutional designation."

According to the CMS Outcome and Assessment Information Set OASIS-E manual, Code 3 should be used "when the patient: Resumes care following an inpatient stay of 24 hours or longer for reasons other than diagnostic tests." The only other possible choice I see would be Code 5, Other follow-up, but this is described as occurring due to a MAJOR decline or improvement. One went to the ED secondary to a fall with a rib fracture, and the other secondary to PICC line dysfuntion and generalized weakness. 

I haven't been able to find what CMS defines as "Major." Can anyone provide guidance on the proper M0100 selection to use in these types of cases?

Thanks,

Hi Scott. I am not sure if your question was already answered. Patients need to be admitted as inpatient, for a Resumption of Care (ROC) OASIS to be appropriate. If a patient is under observation' status, regardless of the number of days in observation status, this is not considered as inpatient. In your scenario, the clinician would either complete a regular visit (and document about the observation stay) or complete an Other Follow Up OASIS, if applicable. Below is a snippet of the OASIS Q&As that may further explain my response. I hope this information helps. Thanks. 

We currently have two claims from Humana where they are downgrading the HIPPS Codes on patients because the nurses answered M0100 (3)- Resumption of care (after inpatient stay). In each case, the hospital classified the stay as "Observation." One was a 2-day stay and the other, 3-day. The explanation states that "[h]ospital observation and outpatient stays are not considered eligible for the institutional designation."

According to the CMS Outcome and Assessment Information Set OASIS-E manual, Code 3 should be used "when the patient: Resumes care following an inpatient stay of 24 hours or longer for reasons other than diagnostic tests." The only other possible choice I see would be Code 5, Other follow-up, but this is described as occurring due to a MAJOR decline or improvement. One went to the ED secondary to a fall with a rib fracture, and the other secondary to PICC line dysfuntion and generalized weakness. 

I haven't been able to find what CMS defines as "Major." Can anyone provide guidance on the proper M0100 selection to use in these types of cases?

Thanks,