August 26 2024
OASIS

What You May Not Know About Coding the SDOH Items

by Lori Marmon PT, MBA, COS-C

With OASIS-E came the addition of certain “Standardized Patient Assessment Data Elements” including those addressing certain Social Determinants of Health (SDOH). One of the main reasons for revising OASIS for version E, was to increase standardization across post-acute care (PAC) settings to uniformly collect social determinants of health data (OASIS Guidance Manual Chapter 1).

The effort to improve understanding of and address disparities in health care outcomes requires the availability of better data related to social determinants of health, including things like ethnicity, race, access to transportation for ongoing health care and medication, perceived lack of contact with other people, living alone or in a remote area or that poor health literacy is linked to lower levels of knowledge of health, worse outcomes, and the receipt of fewer preventive services, higher medical costs and rates of emergency department use (OASIS Guidance Manual).

Understanding this background, as well as providers desire for accuracy when coding OASIS, can lead to questions about how to select the correct response if a patient is presenting with confusion or not responding appropriately to questions related to the SDOH items. Providers can recognize that the value of the data may be compromised if the patient is not able to respond in a meaningful way.

For these SDOH items, we have guidance and things to consider when we are looking to accurately capture the coding for these post-acute care items.

First, for ALL these SDOH items, the first Response Specific Instruction is to “Ask the patient……”. That guidance directs us to start with the patient’s voice. If we have a situation where a patient is presenting with confusion or not responding to the questions appropriately, we will use our clinical judgement to make the determination if that the patient is “unable to respond” to these SDOH questions.

Now, once we have determined that, based on the SDOH question, the way we code each item depends on the guidance for that item.

For A1005- Ethnicity, A1010- Race and A1250- Transportation, a proxy may be used to provide the response if one is available and if a proxy is not available or does not have the information needed for the item, then the medical record documentation can be used.

For clarity, the assessing clinician determines who the appropriate proxy is based on the item specific guidance and the patient’s unique circumstances. This can include but is not limited to family, caregiver, friend, Power of Attorney (POA) or health care representative (CMS OASIS Q&As – Category 4b, Q660)

For B1300- Health Literacy and D0700- Social Isolation, these items are intended to be patient self-report only and no other source should be used to identify a response. So that means that once our clinical judgement has made the determination that the patient is “unable to respond”, for these two items, that can be our only coding response.

Considering all the SDOH items, we start with the patient’s voice for the response is key.

The next key factor is recognizing that we only move to another data source, when permissible by guidance, when by means of our clinical judgement we have made the determination that the patient is unable to respond for themselves. Maintaining the integrity of the data collection guidance for the SDOH items will allow for as much consistency as possible within these data elements which ideally will allow for improved comparison across all post-acute settings.