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What You Need to Know About a Significant Change in Condition

Under PDGM, there will be more instances of Significant Change in Condition (SCIC) assessments than seen under the previous prospective payment system. These instances include RFA-5 Other Follow-Up assessment. A SCIC adjustment occurs when a patient experiences a major decline or improvement in condition (as defined by the agency) without qualifying for inpatient admission.

Asking the Right Questions

When it comes to a SCIC, the most important questions you can ask your team are:

  • Do they understand when this change is warranted?
  • Do you have policies that specify when a SCIC should be performed?

CMS revealed in an OASIS Q&A that if there is a diagnosis change between one 30-day claim and the next, there is no requirement for the home health organization to complete an RFA 5 Other Follow-Up assessment to ensure that diagnosis coding on the claim matches the OASIS assessment. So, an agency may change the diagnosis with physician documentation during the second 30-day billing period without performing a SCIC.

However, the Medicare Home Health Conditions of Participation rule 484.55(d) does require an RFA-5 when there has been a major improvement or decline in a patient’s condition that was not envisioned in the original plan of care. CMS expects agencies to have and follow specific policies that determine the criteria for when an Other Follow-Up assessment must be completed.

The CMS rule states that a demonstrated improvement or worsening of a patient’s condition, which changes and was not anticipated in the patient’s plan of care, would be considered a “major decline or improvement in the patient’s health status” that would warrant update and revision of the comprehensive assessment. The criteria for updating a comprehensive assessment include:

  • Documenting revisions within two days of the change
  • Updating the assessment completion date on the second 30-day claim if the assessment changes impact the case-mix group (functional score only)
  • If only the primary diagnosis changed, there is no need to complete an RFA-5 Other Follow-Up

Many agencies believe that performing a SCIC will increase payment for the second 30-day billing period, but that is not always the result. A 30-day billing period may increase or decrease in payment due to this update. However, each agency will be held to their own policies, making this the most important decision regarding this change that an agency can make.

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