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11/06/2018CODING INSTRUCTIONSM1028 Active DiagnosesA DASH is avalid responsefor this item. Code 1, Peripheral Vascular Disease (PVD) or Peripheral ArterialDisease (PAD), if the patient has an active diagnosis of PeripheralVascular Disease (PVD) or Peripheral Arterial Disease (PAD). Code 2, Diabetes Mellitus (DM), if the patient has an active diagnosisof Diabetes Mellitus (DM) indicated by any of the following diagnosiscodes: Code 3, None of the Above, if the patient does not have any of theactive diagnoses listed above.25CODING TIPSM1028 Active Diagnoses The physician (nurse practitioner, physician assistant, clinical nursespecialist, or other authorized licensed staff if allowable under statelicensure laws) may specifically indicate that a diagnosis is active. If there is documentation in the clinical record that a patient hasdiabetes mellitus, Select Response 2, Diabetes Mellitus (DM). If there is only documentation in the clinical record of a complicationsuch as nephropathy or neuropathy and there is no documentationthat the patient has diabetes, it should not be assumed thecomplication is associated with diabetes, and Response 2, DiabetesMellitus, should not be checked.2613

11/06/2018M1028 Active DiagnosesEXAMPLE 1 Mr. A is prescribed insulin for diabetes mellitus. He requires regular blood glucose monitoring to determine whether blood glucose goalsare achieved by the current medication regimen. The physician progress note documents diabetes mellitus.(M1028) Active Diagnoses – Comorbidities and Co-existing Conditions – Check all that applySee OASIS Guidance Manual for a complete list of relevant ICD-10 codes.1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)2 - Diabetes Mellitus (DM)3 - None of the above27M1028 Active DiagnosesEXAMPLE 2 During the SOC/ROC assessment, Mrs. K told Nurse J, RN that she has had diabetesfor 20 years. Nurse J reviewed the transfer documents from the acute care facility and all clinicalrecords on the patient but was unable find a documented diagnosis of DiabetesMellitus by physician, nurse practitioner, physician assistant or authorized licensedstaff member in their state. There is no documented diagnosis of PVD or PAD.(M1028) Active Diagnoses – Comorbidities and Co-existing Conditions – Check all that applySee OASIS Guidance Manual for a complete list of relevant ICD-10 codes.1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)2 - Diabetes Mellitus (DM)3 - None of the above2814

11/06/2018M1046 Influenza Vaccine Received, andM1056 Reason Pneumococcal Vaccine not receivedRESPONSE-SPECIFIC INSTRUCTIONS for M1046: Enter Response 5 if the influenza vaccine is contraindicated for medical reasons. Refer to the Centers for Disease Control and Prevention (CDC) website forinformation on contraindications for the influenza vaccine (See link in Chapter 5).RESPONSE-SPECIFIC INSTRUCTIONS for M1056: Enter Response 2 if pneumococcal vaccine administration is contraindicated forthis patient. Refer to the Centers for Disease Control and Prevention (CDC) website forinformation on contraindications for the pneumococcal vaccine (See link inChapter 5).29M1051 Pneumococcal Vaccine(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination(for example, pneumovax)?Enter Code1. No2. Yes [Go to M2005 at TRN, Go to M1242 at DC]3015

11/06/2018M1060 Height and Weight(M1060) Height and Weight – While measuring, if the number is X.1-X.4 round down; X.5 or greaterround upinchespoundsa. Height (in inches). Record most recent height measure since the most recentSOC/ROCb. Weight (in pounds). Base weight on most recent measure in last 30 days; measureweight consistently, according to standard agency practice (for example, in a.m.after voiding, before meal, with shoes off, etc.ITEM INTENT These items support calculation of the patient’s body mass index (BMI) using the patient’s heightand weight.TIME POINTS ITEM(S) COMPLETED Start of care Resumption of care31CODING INSTRUCTIONSHEIGHTM1060 Height and Weight Measure height in accordance with the agency’s policies and procedures. Measure and record the patient’s height to the nearest whole inch. Use mathematical rounding (i.e., if height measurement is X.5 inches or greater, roundheight upward to the nearest whole inch. If height measurement number is X.1 to X.4inches, round down to the nearest whole inch). For example, a height of 62.5 inches wouldbe rounded to 63 inches, and a height of 62.4 inches would be rounded to 62 inches. Only enter a height that has been directly measured by agency staff. Donot enter a height that is self-reported or derived from documentationfrom another provider setting.3216

11/06/2018CODING INSTRUCTIONSWEIGHTM1060 Height and Weight Weight should be measured in accordance with the agency’s policies and procedures. Measure and record the patient’s weight in pounds. Use mathematical rounding (e.g., if weight is X.5 pounds [lbs.] or more, roundweight upward to the nearest whole pound. If weight is X.1 to X.4 lbs., round downto the nearest whole pound). For example, a weight of 152.5 lbs. would be roundedto 153 lbs. and a weight of 152.4 lbs. would be rounded to 152 lbs. If agency staff weighs the patient multiple times during the assessment period, usethe first weight. Only enter a weight that has been directly measured by agency staff. Do notenter a weight that is self-reported or derived from documentation fromanother provider setting.33CODING TIPSM1060 Height and WeightA DASH is a validresponse for thisitem. When reporting height for a patient with bilateral lower extremityamputation, measure and record the patient’s current height (i.e., heightafter 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 ( – ) isappropriate. Document the rationale on the patient’s medical record. When there is an unsuccessful attempt to measure a patient’s height orweight, at SOC/ROC, and there is a documented agency-obtained height orweight from one or more previous home health visits, an agency-obtainedheight or weight from a documented visit conducted within the previous30-day window may be used to complete M1060 for this SOC/ROCassessment. Whenever possible, a current height and weight should be obtained by theagency as part of the SOC/ROC assessment.3417

11/06/2018Pressure Ulcer / Injury ReviewDeleted ItemsM1300 & M1302Pressure Ulcer RiskM1313Worsening of PressureUlcer StatusM1320Status of MostProblematic Pressure UlcerM1350Other Skin LesionsRemaining ItemsM1306Unhealed Pressure Ulcer/Injury atStage 2 of Higher or UnstageableM1307Oldest Stage 2 Pressure UlcerM1311Current Number Unhealed PressureUlcers/Injuries at Each StageM1322Current Number of Stage 1 PressureInjuriesM1324Most Problematic PressureUlcer/Injury Stage35Pressure Ulcer / Injury TerminologyStage 1Now called Pressure InjuryStage 2,3 & 4Now called Pressure UlcerDTIDeep Tissue InjuryUnstageable due to Slough/Eschar – Pressure UlcerUnstageableUnstageable due to Non-removable Dressing/Device – Pressure Ulcer/InjuryPressure Ulcer that was staged and now has a “scab” indicates it ishealing and therefore staging does not change.3618

11/06/2018Pressure Ulcers/Injuries at Each StageDEFINITIONSStage 2Stage 3Stage 4Stage 2 pressureulcers arecharacterized bypartial thickness lossof dermis presentingas a shallow openulcer with a red-pinkwound bed, withoutslough. May alsopresent as an intactor open/rupturedblister.Stage 3 pressure ulcersare characterized by fullthickness tissue loss.Subcutaneous fat may bevisible but bone, tendonor muscle is not exposed.Slough may be presentbut does not obscure thedepth of tissue loss. Mayinclude undermining ortunneling.Stage 4 pressure ulcersare characterized by fullthickness tissue losswith exposed bone,tendon or muscle.Slough or eschar may bepresent on some partsof the wound bed.Often includesundermining andtunneling.SLOUGH TISSUENon-viable yellow, tan,gray, green or browntissue; usually moist,can be soft, stringy andmucinous in texture.Slough may beadherent to the base ofthe wound or presentin clumps throughoutthe wound bed.ESCHAR TISSUEDead or devitalizedtissue that is hard orsoft in texture; usuallyblack, brown, or tan incolor, and may appearscab-like. Necrotictissue and eschar areusually firmly adherentto the base of thewound and often thesides/edges of thewound.If any bone, tendon or muscle or joint capsule (Stage 4 structures) isvisible, the pressure ulcer should be reported as a Stage 4 pressureulcer, regardless of the presence or absence of slough and/or eschar inthe wound bed.37Pressure Ulcer / Injury Guidance Skin assessment should be completed as close to that actual time ofthe SOC/ROC as possible Report pressure ulcer/injury stage (or whether unstageable) based on the firstskin assessment Do Not change OASIS coding if the ulcer/injury increases in numerical stage(worsens) or becomes stageable or unstageable within the assessment timeperiod Once a Stage 2, 3, or 4 pressure ulcer is completely covered with newepithelial tissue, it is considered healed and no longer reported as apressure ulcer A pressure ulcer treated with a skin graft is a surgical wound until thegraft edges are completely healed3819

11/06/2018Pressure Ulcer / Injury GuidancePressure ulcers/injuries that are known to be present but that are unobservable due to a dressing/device,such as a cast, that cannot be removed to assess the skin underneath. “Known” refers to whendocumentation is available that states a pressure ulcer/injury exists under the non-removabledressing/device.Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissuepresent 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, andthe anatomical depth of tissue damage can be visualized, numerically stage the ulcer, and do not codethis 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 thereforestage) cannot be determined. Only until enough slough and/or eschar is removed to expose the anatomicdepth of soft tissue damage involved, can the stage of the wound be determined.39Revised Item(M1306)Enter CodeM1306 Unhealed PU/Injury atStage 2 or HigherDoes this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated asUnstageable? (Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries)0 No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]1 YesIncorporated National Pressure Ulcer Advisory Panel (NPUAP) terminologyupdates to align with other PAC instruments.Item text revised: Replaced “excludes .healed Stage 2 pressure ulcers” with “excludes .allhealed pressure ulcers” Added Pressure ulcer/injuriesTIME POINTS ITEM(S) COMPLETED Start of careITEM INTENT Resumption of careIdentifies the presence or absence of Follow-upUnhealed Stage 2 or higher or Unstageable Discharge from agency – not topressure ulcers/injuries only.inpatient facility4020

11/06/2018M1307 Oldest Stage 2 Pressure Ulcer(M1307)Enter CodeThe Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2 pressure ulcers)12Was present at the most recent SOC/ROC assessmentDeveloped since the most recent SOC/ROC assessment. Record date pressure ulcer first identified:MonthDayYearNA No Stage 2 pressure ulcers are present at dischargeITEM INTENT The intent of this item is to a) identify theoldest Stage 2 pressure ulcer that is presentat the time of discharge and is not fullyepithelialized (healed), b) assess the length oftime this ulcer remained unhealed while thepatient received care from the home healthagency and c) identify patients who developStage 2 pressure ulcers while under the careof the agency.TIME POINTS ITEM(S) COMPLETEDDischarge from agency – not to inpatientfacility41M1311 Current Number of UnhealedPressure Ulcers/Injuries at Each StageRevised ItemM1311 updated and changed: Now shows time point versions for each time point an assessment iscompleted For SOC/ROC and Follow-up OASIS assessments Shows A1 to F1 For Discharge OASIS assessment Shows A1, A2, B1, B2, to F1, F2 SOC/ROC and Discharge information used to calculate revised pressureulcer measureA Dash is a Alignment with other PAC instruments Incorporated NPUAP terminology updates Skip pattern language and directions modifiedvalid responsefor DISCHARGEONLY.4221

11/06/2018M1311 Current Number of UnhealedPressure Ulcers/Injuries at Each StageRevised Item(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage (SOC/ROC)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 ulcersB1.Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is notexposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining andtunneling. Number of Stage 3 pressure ulcersC1.Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present onsome parts of the wound bed. Often includes undermining and tunneling.Number of Stage 4 pressure ulcersD1.Unstageable: Non-removable dressing/device: Known but not stageable due to non-removabledressing/deviceNumber of unstageable pressure ulcers/injuries due to non-removable dressing/deviceE1.Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by sloughand/or escharNumber of unstageable pressure ulcers due to coverage of wound bed by slough and/or escharF1.Unstageable: Deep tissue injuryNumber of unstageable pressure injuries presenting as deep tissue injuryEnterNumber43(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage (Discharge)Enter NumberA1. 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 oropen/ruptured blister. Number of Stage 2 pressure ulcers [If 0 – Go to M1311B1, Stage 3]A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC – enter how many were noted at the time of most recent SOC/ROCB1. 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 thedepth of tissue loss. May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 – Go to M1311C1, Stage 4]B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC – enter how many were noted at the time of most recent SOC/ROCC1. 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 includesundermining and tunneling. Number of Stage 4 pressure ulcers [If 0 – Go to M1311D1, Unstageable: Non-removable dressing/device]C2. Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC – enter how many were noted at the time of mostrecent SOC/ROCD1. Unstageable: Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers/injuriesdue to non-removable dressing/device [If 0 – Go to M1311E1, Unstageable: Slough and/or eschar]D2. Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC – enter how many were noted at the time of most recentSOC/ROCE1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcersdue to coverage of wound bed by slough and/or eschar [If 0 – Go to M1311F1, Unstageable: Deep tissue injury]E2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC – enter how many were noted at the time of most recent SOC/ROCF1. Unstageable: Deep tissue injury Number of unstageable pressure injuries presenting as deep tissue injury [If 0 – Go to M1324]F2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC – enter how many were noted at the time of most recent SOC/ROC4422

11/06/2018M1311 Current Number of UnhealedPressure Ulcers/Injuries at Each StageITEM INTENT This item identifies the number of pressure ulcers/injuries ateach stage (Stage 2, 3, and 4) and designated as Unstageable,that are observed on assessment. At discharge, this item also identifies if each pressureulcer/injury present on the discharge assessment was observedat the same stage at the time of the most recent SOC/ROC. Stage 1 pressure injuries and all healed pressure ulcers/injuriesare not reported in this item.TIME POINTS ITEMS COMPLETED Start of Care Resumption of Care Follow-up Discharge from agency – not to inpatientfacility45M1311 Current Number of UnhealedPressure Ulcers/Injuries at Each StageDetermining “Present at the most recent SOC/ROC” to answer M1311 For each pressure ulcer/injury observed and coded in items M1311A1-F1 on Discharge,determine whether that pressure ulcer/injury was observed at the same stage at the time ofthe most recent SOC/ROC, and did not form during this home health quality episode. If the pressure ulcer/injury was unstageable at SOC/ROC, but becomes numerically stageablelater, when completing the Discharge assessment, its “Present at the most recent SOC/ROC”stage should be considered the stage at which it first becomes numerically stageable. If it subsequently increases in numerical stage, do not report the higher stage ulcer as being“present at the most recent SOC/ROC” when completing the Discharge assessment. The general standard of practice for patients starting or resuming care is that patientassessments 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 numericalstage within the assessment time frame, the stage of the pressure ulcer/injury at the first skinassessment completed would be reported in M1311X1 at the SOC.4623

11/06/2018M1311 Current Number of UnhealedPressure Ulcers/Injuries at Each StageEXAMPLE 1The RN assesses Mr. J’s skin at the SOC and identifies a DTI with intact skin onhis left heel.This DTI remains unchanged until the RN skin assessment 10 days later,which reveals open skin pres

Understand OASIS M-item coding instructions to accurately code new and revised OASIS items Identify available resources for implementing OASIS-D 2. 11/06/2018 2 Why OASIS-D? Improving Medicare Post-Acute Care Transformation Act of 2014 Bipartisan bill signed into law by President Obama October 6, 2014