January 28 2025
OASIS

Tips for Coding OASIS Medication Items (M2001, M2020, N0415)

by Lori Marmon PT, MBA, COS-C

Home health providers are aware of the need to stay on top of the medications that a patient is taking. Not only is the review of all medications a requirement of the Conditions of Participation, but the successful management of a patient’s medications can also impact a patient’s utilization of acute care facilities.

There are several OASIS items that collect data regarding a patient’s current status related to their medications. Understanding the guidance surrounding these items can influence the agency’s quality measures in addition to providing an accurate reflection of the patient’s status.

The following tips may be beneficial in ensuring accurate data collection practices.

M2001- Drug Regimen Review

Any identified potential or actual clinically significant mediation issue must reach a level of clinical significance that in the clinician’s professional judgment warrants notification of the physician/allowed practitioner (or physician-designee) for orders or recommendations by midnight of the next calendar day, at the latest.
Any circumstance that does not require this immediate attention is not considered a potential or actual clinically significant medication issue for the purpose of the drug regimen review items. If, for example, a medication alert triggered by an EMR software does not meet the definition of a potential (or actual) clinically significant medication issue, then it would not be reported as such when coding M2001 – Drug Regimen Review.
The Drug Regimen Review (DRR) for M2001 includes all medications, prescribed and over the counter, including nutritional supplements, vitamins, and herbals administered by any route (e.g., oral, topical, sublingual, and by infusion). The DRR also includes total parenteral nutrition (TPN) and oxygen, so don’t forget those in your DRR!

M2020- Management of Oral Medications

Refilling, ordering/reordering or obtaining the oral medications is NOT included for consideration in a patient’s ability to manage their oral medications. Any assistance or transportation required to get the medication(s) into the home is not considered when coding M2020.
If a patient uses an automated medication dispensing system with visual or audio reminders, but they can successfully and independently program/manage this device and take ALL oral medication(s) appropriately on the day of assessment, this patient would be scored Code 0 – Able to independently take the correct oral medications(s) and proper dosages at the correct times.
For a patient who resides in a facility, such as an assisted living facility (ALF), where the facility holds or locks up the patient’s medications, M2020 – Management of Oral Medications is not automatically assigned a specific code just because a patient resides in a facility, such as an assisted living facility (ALF). The assessing clinician uses clinical judgment to determine the patient’s current ability based on observation and assessment of the complexity of the patient’s overall drug regimen, as well as patient characteristics, including cognitive status, vision, strength, manual dexterity, and general mobility.

N0415- High Risk Drug Classes: Use and Indication

Flushes provided to keep an IV access port patent ARE NOT coded under N0415, Anticoagulant
The general OASIS convention “Day of Assessment” which is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home does not apply to N0415 – High-Risk Drug Classes: Use and Indication. Code a medication in N0415 that is part of a patient’s current reconciled drug regimen, even if it was not taken on the day of assessment.
Herbal and alternative medicine products should not be counted as medications (e.g., melatonin, chamomile, valerian root) for N0415. These products are considered to be dietary supplements by the Food and Drug Administration (FDA). Keep in mind that this is DIFFERENT than the guidance for M2001!

Keeping these tips in mind and coding each OASIS item based on the guidance for each individual item will assist in keeping the medication item responses accurate for data collection.

To learn more about accurate OASIS data collection, consider joining the gang at OASIS Answers at an upcoming Blueprint for OASIS Accuracy workshop near you.