Transfer OASIS
A transfer OASIS is the assessment time point completed when a home health patient is admitted to an inpatient facility for 24 hours or more for reasons other than diagnostic tests. It comes in two forms: transfer without agency discharge, when the agency expects the patient back, and transfer with discharge, when the agency ends care. It must be completed within 2 calendar days of the transfer or of learning about it.
Transfer with vs. without discharge
Reason for assessment 06 is a transfer where the patient remains on the agency's books, anticipating a resumption of care when they return home. Reason for assessment 07 is a transfer paired with agency discharge, used when the agency does not expect to resume care, for example a patient heading to long-term placement. The choice matters: an RFA 06 must be followed by a ROC or an eventual discharge action, while an RFA 07 closes the episode. Miscoding between the two creates dangling episodes, billing confusion, and OASIS sequencing errors in iQIES.
What qualifies as a transfer
The trigger is admission to an inpatient bed, such as a hospital, skilled nursing facility, inpatient rehabilitation facility, or long-term acute care hospital, for 24 hours or more for something other than diagnostic testing. Emergency department visits without inpatient admission and short observation stays do not qualify. The transfer OASIS is a data collection, not a visit: it can be completed from agency records and information from the facility or family, which is why the deadline runs 2 calendar days from the transfer or from when the agency learned of it.
Why transfers matter beyond compliance
Every transfer is also a hospitalization event, and acute care hospitalization is among the most heavily weighted results in home health: it feeds claims-based quality measures, star ratings, HHVBP performance, and referral source perception. Transfer patterns are the raw material for reducing avoidable hospitalizations, so agencies should review each one: Was there a missed early-warning sign? A medication issue? A gap between visits? Under PDGM, the inpatient stay can also change the admission source classification of the next 30-day payment period, and a transfer to another home health agency mid-period triggers a partial episode payment for the losing agency.
Keeping transfers clean operationally
Late detection is the main failure mode:
- Maintain a same-day alert process for patients who go to the ER or hospital
- Confirm inpatient admission status and admission date with the facility
- Complete the transfer OASIS within 2 calendar days of learning of the qualifying stay
- Choose RFA 06 vs. 07 deliberately and document the rationale
- Reconcile transfer, ROC, and discharge records so no episode is left open
Frequently asked questions
Does an observation stay require a transfer OASIS?
Not unless the patient is actually admitted as an inpatient for 24 hours or more for reasons other than diagnostic tests. ED visits and observation-only stays do not trigger a transfer OASIS, though they are worth tracking internally as near-miss hospitalization events.
Does a transfer OASIS require a home visit?
No. It is one of the OASIS time points that can be completed without an in-person patient encounter, using information from the facility, family, and agency records, within 2 calendar days of the transfer or of learning about it.
What happens after a transfer without discharge?
The episode stays open. When the patient returns home, the agency completes a resumption of care assessment within 2 calendar days of the return. If the patient never returns to service, the agency must still close the record with an appropriate discharge action.