All About Accuracy Coding & OASIS, LLC will complete audits for you remotely, through a connection to their software system. All information gathered from you while doing business related tasks shall remain confidential per HIPAA guidelines. The Process and Review components are outlined below:
Our clients can either notify All About Accuracy Coding & OASIS, LLC of records that are ready for OASIS review by submitting a list of patient episodes to All About Accuracy Coding & OASIS, LLC through our secure email, or have our Team Leaders pull charts from the QA Manager, whichever is easiest for the client.
Occasionally, All About Accuracy Coding & OASIS, LLC will identify situations where we require additional information in order to complete these reviews. This can be the result of incomplete, contradictory, or missing information. In these cases, All About Accuracy Coding & OASIS, LLC will communicate directly with the agency staff.
Our nurses will enter all diagnosis codes and correct the OASIS items in question. For every item corrected on the OASIS, the coder will submit a teaching tip and rationale for these changes. Coder will review the 485 for accurate interventions and goals. Coder will send comments back to the client if the 485 needs to be updated, but coder does not correct the 485. Recommendations will be returned to Agency for the clinician’s approval or denial of the changes made. This will be done within 24 hours from the receipt of the assessment from the Client. Please note- any charts received after 10am will roll over to the following work day as our coders get their assignments for the day first thing in the morning.
Our Registered Nurses will perform the Start-of-Care, Resumption of Care, and Recertification reviews to provide recommendations for changes to OASIS answers and review overall OASIS documentation consistency to support appropriate reimbursement for the episode of care. The following areas of the clinical record, if available, will be reviewed:
• History & Physical - Review physician’s narrative of health issues prompting the most recent hospitalization, as well as listed co-morbidities to aid in the assignment of diagnosis codes. All assigned diagnosis codes must be supported by physician documentation. Physician documentation may also assist in identifying the patient’s prior functional level, current functional level, integumentary status, neurological issues, visual deficits, pain, and other systems/issues to help support responses to OASIS M items.
• Referral Documentation - This interagency document is used to help define the reason for the current referral for home health care. This will aid in the assignment of diagnosis codes.
• Discharge Summary - The Discharge Summary will be reviewed to determine the most current information regarding active diagnosis, as well as which treated diagnoses were considered resolved at the time of discharge.
• Admission Narrative Note - The information in the narrative note is used to support OASIS M items as well as diagnosis coding. All About Accuracy Coding & OASIS, LLC will consider procedure codes utilized by the admitting source or the agency but will not code inpatient procedures outside of those provided.
• Medication Profile - Medication profiles are used to help determine applicable diagnoses. Though codes are never assigned strictly due to the presence of medications, they may prompt the coder to question the presence of otherwise unlisted diagnoses.
• Plan of Care - The Plan of Care may be used to support some diagnosis codes, such as presence of orders for therapeutic drug monitoring or care of catheters or intravenous sites. Interventions and orders within the plan may also assist in the identification of other diagnosis codes and completion of some OASIS items, such as the presence of goals related to specific disease processes.
• Comprehensive Assessment Including All OASIS Items - Agency responses to OASIS items are compared to what the reviewer finds supported by documentation elsewhere for consistency. The comprehensive assessment is utilized to support diagnosis coding as well as OASIS responses. Documentation should be consistent and not contradictory.