BCHHC Fundamentals

Analogy — The four coverage criteria below work like the legs of a table — remove any one and the whole thing collapses, regardless of how solid the other three are. A patient can be genuinely homebound and have a genuine skilled need, but without a signed physician's plan of care, the claim still doesn't stand.

Medicare Home Health — Four Coverage Criteria

ALL four must be met simultaneously:

1.Homebound: Leaving home requires considerable effort due to illness/injury

2.Skilled service: Requires SN, PT, OT, or SLP

3.Physician's care: Certified plan of care (Form 485) every 60 days

4.Reasonable and necessary: Appropriate for condition and goals

Who Fills OASIS?

Clinician	Can Complete OASIS

|-----------|------------------|

SN (RN/LPN)	✅ Yes
PT	✅ Yes
SLP/ST	✅ Yes
OT	⚠️ Conditional — can complete SOC OASIS only after another discipline (SN, PT, or SLP) has already established Medicare eligibility; can independently complete Discharge and Recertification OASIS

OASIS Assessment Types

Type	Trigger	Required Timing

|------|---------|----------------|

SOC (Start of Care)	First skilled visit	Within 5 calendar days
ROC (Resumption of Care)	Returns from inpatient	Within 48 hours (2 calendar days)
REC (Recertification)	Episode renewal	Near end of 60-day episode
SCIC (Significant Change in Condition)	Acute change, no hospitalisation	Within episode
DC (Discharge)	Last visit	At discharge

ICD-10-CM Key Conventions

•NEC (Not Elsewhere Classified): specific documentation, no specific code

•NOS (Not Otherwise Specified): vague documentation, use unspecified code

•Excludes1: cannot code together — mutually exclusive

•Excludes2: separate conditions — CAN code both if both present

•Code first: underlying condition before manifestation

•Use additional code: add detail (organism, laterality, drug use)

Primary Diagnosis Selection (Home Health)

•Must DIRECTLY relate to the skilled service need

•Must SUPPORT homebound status

•Must be the condition the skilled service is ACTIVELY TREATING

•Wrong primary diagnosis → wrong PDGM clinical group → wrong reimbursement

OASIS Data Collection Protocol

Start of Care (SOC)

The SOC OASIS captures baseline functional status when a patient first begins home health. The clinician assesses:

•Functional abilities (ambulation, transferring, bathing, dressing, eating, toileting)

•Cognitive and behavioral patterns

•Pain, vision, hearing, skin integrity

•Medications and medication management ability

•Equipment and supplies needed

OASIS M Codes — High-Yield Items

OASIS Item	What it Captures	PDGM Impact

|-----------|-----------------|-------------|

M1800-M1860	ADL/IADL function	Functional level (Low/Medium/High)
M1021/M1023	Primary/secondary diagnosis	Clinical group assignment
M1033	Risk for hospitalization	Comorbidity adjustment
M0090	Response date	Episode timing

Homebound Status — Documentation Standards

What Qualifies

A patient is homebound when leaving home requires a considerable and taxing effort due to illness, injury, or functional limitation. CMS requires specific documentation:

•The specific limitation (non-weight-bearing, severe dyspnea, cognitive impairment)

•The effort required (requires wheelchair, two-person assist, significant fatigue)

•Not just "patient is weak" or "patient is elderly"

Allowable Absences

Homebound patients may leave for:

•Medical appointments (physician, therapy, dialysis, chemotherapy)

•Religious services

•Adult day care programs

•Infrequent, short duration outings (barber, family event)

These do not break homebound status if documented appropriately.

ICD-10-CM — Quick Reference for Home Health

Code Structure Review

•Positions 1-3: Category (e.g., I50 = Heart failure)

•Position 4: Etiology or body part

•Position 5: Severity or laterality

•Position 6: Additional specificity

•Position 7: 7th character extensions (encounter type, laterality)

Placeholder X

When a code requires a 7th character but has fewer than 6 characters, the letter X fills empty positions:

T45.X1XA — Poisoning by unspecified drugs, accidental (initial encounter)

The first X fills position 4, the second X fills position 5.

Try It (2 Minutes)

Using the Who Fills OASIS table above:

1.A physical therapist wants to independently complete a patient's SOC OASIS. Is that allowed?

2.An occupational therapist wants to do the same, on a patient where PT has already established eligibility. Is that allowed?

3.If only OT services are ordered for a patient from day one (no SN, PT, or SLP ever involved), who would need to be brought in to get the SOC OASIS completed?

You should land on: yes for PT — explicitly listed as able to complete OASIS; yes for OT in this specific scenario too, since PT already established eligibility first — OT completing the SOC OASIS itself is allowed once that condition is met; but for question 3, the answer changes: if OT is the only service ordered from the start, no discipline has established eligibility yet, so an SN, PT, or SLP would still need to be brought in — OT alone can never be the sole qualifying service at Start of Care, even though it can complete the OASIS paperwork once someone else has already qualified the patient.

BCHHC Certification Prep — Fundamentals