by Kerry Termine, DPT, HCS-D, CHS-C, COS-C
M2001 – Drug Regimen Review identifies if a drug regimen review was conducted at start of care/resumption of care (SOC/ROC), and whether any potential or actual clinically significant medication issues were found.
OASIS guidance states that all staff are expected to function within the scope of their practice and state licensure, and some state practice acts have taken a position that a home health therapist (PT, OT, SLP) may not independently complete a drug regimen review.
The question then arises, when a therapist is completing a SOC or ROC, how can a drug regimen review be completed and how should M2001 be coded?
Some HHAs have reported that when this situation arises, the therapist is entering a dash (-) for the drug regimen items.
While a dash is a valid response for M2001, it indicates “no information,” and CMS expects dash use to be a rare occurrence. For M2001, a dash should be reserved to times when elements of a drug regimen review were skipped, indicating a drug regimen review was not completed.
An alternative option for these situations is to utilize a collaborative process with a qualified/designated drug regimen reviewer.
Collaboration allows the assessing clinician to consider information from the patient, caregivers, and other healthcare personnel, including the physician, pharmacist and/or other agency staff who have had direct contact with the patient or had some other means of gathering information to contribute to OASIS data collection.
In fact, guidance for M2001 states that it is allowable for a second clinician to complete the drug regimen review (DRR) in its entirety and collaborate with the assessing clinician, however it is expected that an in-person assessment would be included as appropriate in the process. For example, if a physical therapist completing a SOC is unable to complete a drug regimen review per their state laws, the HHA could have an RN or a pharmacist complete a drug regimen review, and the therapist could then utilize collaboration to code M2001 with a response other than a dash (-).
Agency policy and practice will determine the agency’s processes and documentation expectations. It is important to remember that when utilizing collaboration, the M0090 – Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed. Additionally, when used, collaboration must occur within the assessment timeframe and be consistent with data collection guidance.
It should be noted that in situations where nursing is admitting for a therapy only patient, the nurse could not complete or even start the comprehensive assessment (including drug review tasks) prior to the SOC date.
Interested in learning about the most recent OASIS-E2 guidance that impacts quality measures and risk adjustment? Consider joining OASIS Answers at an upcoming Blueprint for OASIS Accuracy workshop.
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