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Is a transfer/discharge assessment required if the follow-up was completed in the five-day window?

Mon, Apr 12, 2010

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Is a transfer/discharge assessment required if the follow-up was completed in the five-day window?

Q: Is a transfer/discharge assessment required if the follow-up was completed in the five-day window and the patient goes into the hospital, following the completion of the recertification, also within the same five-day window?

A: A transfer assessment would be required if the patient was admitted to an inpatient facility for a period of 24 hours or longer for reasons other than diagnostic testing. What happens next depends on when the patient resumes services. If the patient resumes services within the five-day recertification window, a resumption of care (ROC) assessment would be completed and the Health Insurance Prospective Payment System (HIPPS) code generated from the ROC assessment would be used to determine payment for the subsequent 60-day episode.

If the patient is in the hospital at the end of the 60th day of the original episode and had a recertification assessment completed prior to the hospitalization, when the patient comes home determines whether a ROC or start of care (SOC) assessment is completed. If the patient resumes services on the first day of the new episode, the episode would be considered a continuous care episode if the ROC assessment generated the same HIPPS code as the recertification assessment that was completed prior to hospitalization. The patient would not need to be readmitted. However, if the HIPPS code from the ROC assessment is different from the recertification assessment (as is often the case after a hospitalization), or if the patient resumes services after the first day of the new episode, the episode would not be considered continuous and a new SOC would be necessary.

If a new SOC assessment is required because the patient is in the hospital at the end of day 60, a discharge assessment would not be required, since a discharge assessment should never follow a transfer assessment. For payment purposes, the agency would discharge the patient administratively as of the end of the original episode — on the 60th day, but the transfer assessment would be all that would be required for OASIS purposes.

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This post was written by:

Lu Post

Lu Post

Lu Post, RN, MN, COS-C, is president of Home Care Institute, LLC, a technology-based company with a focus on the development of home care and hospice educational resources. She is certified as a clinical OASIS Specialist from the OASIS Certificate and Competency Board, Inc. Lu earned her bachelor’s degree in nursing from Georgia State University and her master’s degree as a clinical nurse specialist from Emory University in Atlanta. She has served in a variety of senior leadership and educational roles in some of the largest home care and hospice organizations in the country for over 20 years.

2 Responses to “Is a transfer/discharge assessment required if the follow-up was completed in the five-day window?”

  1. betsy Says:

    What is the OASIS required? If a transfer w/o discharge was completed before patient goes to the hospital, but after discharge from hospital the patient select another provider to resume the services?

  2. Lu Post
    Lu Post Says:

    Hi Betsy, No other OASIS assessment would be required. You would simply perform an administrative discharge as required by your agency. The Transfer w/o discharge (RFA 6) would be the last assessment your agency needs to submit. Thanks, Lu


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