SECTION K: SWALLOWING/NUTRITIONAL STATUS

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Section K: Swallowing/Nutritional Status SECTION K: SWALLOWING/NUTRITIONAL STATUS Introduction

This section includes three items. Height and weight to calculate body mass, nutritional approaches and assessment of the ability to eat, chew and swallow food.

M1060: Height and Weight

Item Intent

These items support calculation of the patient’s body mass index (BMI) using the patient’s height and weight.

Time Points Item(s) Completed

Start of Care

Resumption of Care

Response-Specific Instructions

Whenever possible, a current height and weight should be obtained by the agency as part of the SOC/ROC assessment. • M1060.A Height o Measure height in accordance with the agency’s policies and procedures. o Measure and record the patient’s height to the nearest whole inch. o Use mathematical rounding (i.e., if height measurement is X.5 inches or greater, round height upward to the nearest whole inch. If height measurement number is X.1 to X.4 inches, round down to the nearest whole inch). For example, a height of 62.5 inches would be rounded to 63 inches, and a height of 62.4 inches would be rounded to 62 inches. o Only enter a height that has been directly measured by agency staff. Do not enter a height that is self-reported or derived from documentation from another provider setting. • M1060.B Weight o Weight should be measured in accordance with the agency’s policies and procedures. o Measure and record the patient’s weight in pounds. o Use mathematical rounding (e.g., if weight is X.5 pounds [lbs.] or more, round weight upward to the nearest whole pound. If weight is X.1 to X.4 lbs., round down to the nearest whole pound). For example, a weight of 152.5 lbs. would be rounded to 153 lbs. and a weight of 152.4 lbs. would be rounded to 152 lbs.

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Section K: Swallowing/Nutritional Status

o If agency staff weighs the patient multiple times during the assessment period, use the first weight. o Only enter a weight that has been directly measured by agency staff. Do not enter a weight that is self-reported or derived from documentation from another provider setting.

Coding Instructions

• Dash is a valid response to this item if: o the patient falls outside the following height and/or weight parameters  Height parameters <50 inches or >80 inches  Weight parameters <65 lbs. or > 440lbs o If a patient’s height/weight cannot be measured during the assessment timeframe, and no agencyobtained height/weight from a documented visit conducted within the previous 30-day window is available o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Coding Tips

• When reporting height for a patient with bilateral lower extremity amputation, measure and record the patient’s current height (i.e., height after bilateral amputation). • If a patient cannot be weighed, for example, because of extreme pain, immobility, or risk of pathological fractures, the use of a dash (–) is appropriate. • When there is an unsuccessful attempt to measure a patient’s height or weight, at SOC/ROC, an agencyobtained height or weight from a documented home health visit conducted within the previous 30-day window may be used to complete this item.

K0520: Nutritional Approaches

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Item Intent

The intent of this item is to identify if any nutritional approaches listed are used by the patient.

Item Rationale

• Nutritional approaches such as mechanically altered food or those that rely on alternative methods (e.g., parenteral/IV or feeding tubes) can diminish an individual’s sense of dignity and self-worth as well as diminish pleasure from eating. • The patient’s clinical condition may potentially benefit from the various nutritional approaches included here.

5 Academy of Nutrition and Dietetics. (2019). Academy of Nutrition and Dietetics definition of terms list. Retrieved from https://www.eatrightpro.org/-/media/eatrightpro-files/practice/scope-standards-of-practice/20190910-academy-definition-of-termslist.pdf?la=en&hash=1DB6495E0B94CB5FA3E7443B1E8436A32E50B8B8

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Chapter 2 Chapter 3 Time Points Item(s) Completed

Start of Care

Resumption of Care

Discharge from agency

Response-Specific Instructions for SOC/ROC

• Consult the patient, family, or caregiver and/or review the clinical record or other available documentation to determine if any of the listed nutritional approaches apply during the time period under consideration for the SOC/ROC assessment.

Coding Instructions for SOC/ROC

• Check all that apply during the time period under consideration for the SOC/ROC assessment. If none apply, check K0520Z, None of the above. • Dash is a valid response for this item. o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

Response Specific Instructions for Discharge

• Consult the patient, family, or caretaker and/or review the clinical record or other available documentation to determine if any of the listed nutritional approaches were received in the last 7 days (Column 1) and during the time period under consideration for the discharge assessment (Column 2).

Coding Instructions for Discharge

• Check all nutritional approaches that were received in the last 7 days (Column 1) and during the time period under consideration for the discharge assessment (Column 2). If none apply, check K0520Z, None of the above. • Dash is a valid response for this item. o Dash indicates “no information.” CMS expects dash use to be a rare occurrence.

General Coding Tip

• If a patient will receive one of the listed nutritional approaches as a result of this SOC/ROC assessment (for example, IV hydration will be started at this visit or a specified subsequent visit; the physician is contacted for an enteral order, etc.), mark the applicable nutritional approach.

Coding Tips for K0520A, Parenteral/IV feeding

• Parenteral/IV feeding includes parenteral or IV fluids provided for nutrition or hydration. Includes additional fluid intake specifically addressing a documented nutrition or hydration need. Excludes fluids provided solely to maintain access and patency. o The following items may be included:  IV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered continuously or intermittently.  Hypodermoclysis and subcutaneous ports in hydration therapy.  IV fluids can be coded in K0520A if needed to prevent dehydration if the additional fluid

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Section K: Swallowing/Nutritional Status

intake is specifically needed for nutrition and hydration. o The following items are NOT to be coded in K0520A:  IV medications—Code these when appropriate in O0110H, IV Medications.  IV fluids used to reconstitute and/or dilute medications for IV administration.  IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay.  IV fluids administered to flush the IV line.  Parenteral/IV fluids administered in conjunction with chemotherapy or dialysis.

Coding Tips for K0520B, Feeding tube

• Code only feeding tubes used to deliver nutritive substances and/or hydration during the time period under consideration.

Coding Tips for K0520D, Therapeutic Diet

• Enteral feeding formulas: o Should not be coded as a mechanically altered diet. o Should only be coded as K0520D, Therapeutic Diet when the enteral formula is altered to manage problematic health conditions, e.g. enteral formulas specific to diabetes. • A nutritional supplement given as part of the treatment for a disease or clinical condition manifesting an altered nutrition status, does not constitute a therapeutic diet, but may be part of a therapeutic diet.

Therefore, supplements (whether taken with, in-between, or instead of meals) are only coded in K0520D,

Therapeutic Diet when they are being taken as part of a therapeutic diet to manage problematic health conditions (e.g. supplement for protein-calorie malnutrition). o Food elimination diets related to food allergies (e.g. peanut allergy) can be coded as a therapeutic diet.

Examples for SOC/ROC: K0520A, Parenteral/IV feeding

1. A patient is admitted with orders for an antibiotic in 100 cc of normal saline via IV for symptoms of a urinary tract infection (UTI), fever, abnormal lab results (e.g., new pyuria, microscopic hematuria, urine culture with growth >105 colony forming units of a urinary pathogen), and documented inadequate fluid intake (i.e., output of fluids far exceeds fluid intake) with signs and symptoms of dehydration. The plan of care is updated to include a hydration intervention to ensure adequate hydration. Documentation shows IV fluids are being administered as part of the already identified need for additional hydration. Coding: K0520A would be checked. The IV medication would be coded at IV Medications item (O0110H). Rationale: The patient received 100 cc of IV fluid and there is supporting documentation that reflected an identified need for additional fluid intake for hydration. 2. A patient is admitted and receiving an antibiotic in 100 cc of normal saline via IV. They have a UTI, no fever, and documented adequate fluid intake. The patient is placed on an oral hydration plan to maintain adequate hydration. Coding: K0520A would NOT be checked. The IV medication would be coded at IV Medications item (O0110H).

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Rationale: The patient received IV fluids but it is not reported in K0520A because documentation indicated that fluid intake was adequate. Oral hydration is not included in K0520.

Examples for Discharge

1. The patient will be discharged today. They were receiving rehabilitation services for a stroke. The patient has longstanding Celiac disease and therefore was placed on a gluten free diet. Because of their recent stroke, they also have documented dysphagia requiring a mechanical soft diet and honey-thick liquids to prevent aspiration and will be discharged on this same diet. Coding: K0520C4 and K0520C5 as well as K0520D4 and K0520D5 would be checked. Rationale: The patient requires both a mechanically altered diet (i.e., mechanical soft diet and honeythick liquids) and a therapeutic diet (i.e., gluten free) for Celiac disease and they were administered in the last seven days as well as during the time period under consideration for the discharge assessment and are expected to continue after discharge. 2. Prior to their SOC/ROC with home health, the patient had been on a chopped diet due to facial trauma. They will be discharged today after rehabilitation services for multiple fractures after a car accident. The patient has been on a regular diet during their entire home health stay and has not required any parenteral or enteral nutrition.

Coding: K0520Z4 and K0520Z5 would be checked. Rationale: The patient had a regular diet their entire home health stay and did not require any nutritional modifications.

M1870: Feeding or Eating

Item Intent

Identifies the patient’s ability to feed themself, including the process of eating, chewing, and swallowing food. The intent of the item is to identify the patient’s ability, not necessarily actual performance. “Willingness” and “adherence” are not the focus of this item.

Time Points Item(s) Completed

Start of Care

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Resumption of Care Discharge from agency

Response-Specific Instructions

• Observation/demonstration is the preferred method to complete this item. Other sources of information include but are not limited to patient/caregiver interview, physical assessment, nutritional assessment, physician orders, plan of care, referral information, and review of past history. When coding this item, the assessing clinician may consider available input from other agency staff who have had direct patient contact. • Code this item based on the assistance needed by the patient to feed themself once the food is placed in front of them. Assistance means human assistance by verbal cueing/reminders, supervision, and/or standby or hands-on assistance. • Consider what the patient is able to do on the day of the assessment. If ability varies over time, enter the response describing the patient’s ability more than 50% of the time period under consideration. • Do not consider preparation of food, or transport of food to the table when coding this item. • “Meal set up”, (Response 1, option a), refers to activities such as mashing a potato, cutting up meat/vegetables when served, pouring milk on cereal, opening a milk carton, adding sugar to coffee or tea, arranging the food on the plate for ease of access, etc. - all of which are special adaptions of the meal for the patient.

Coding Instructions

• Code 5, Unable to take in nutrients orally or by tube feeding, if all nutrition is received intravenously (such as TPN) or for patients who are receiving only intravenous hydration. • Dash is not a valid response for this item.

Coding Tips

• If a patient is being weaned from tube feeding, code 3 or 4 will continue to apply until the patient no longer uses the tube for nutrition, at which time, code 0, 1, or 2. This is true, even if the tube remains in place, unused for a period of time.

OASIS-E Guidance Manual Effective 1/1/2023 Centers for Medicare & Medicaid Services