M1033 – Risk for Hospitalization is an OASIS-E item presented as a checklist of clinical and behavioral risk factors associated with an increased likelihood of hospitalization during the home health episode of care. Clinicians are instructed to review each risk factor and select all responses that apply to the patient.
Why M1033 is Important
M1033 is not just a checklist—it directly impacts clinical risk identification, care planning, and payment under PDGM.
- It contributes to the Functional Impairment Level used in PDGM case-mix adjustment.
- Higher risk indicators can influence case-mix weight and reimbursement levels.
- It also supports Value-Based Purchasing (HHVBP) by feeding into hospitalization and outcome-related measures.
In short, accurate M1033 responses helps ensure:
- Appropriate reimbursement
- Better risk adjustment
- More accurate quality reporting
- Stronger care planning to prevent avoidable hospitalizations
The Challenge
Clinicians often find M1033 challenging because it requires reviewing multiple look-back periods while pulling information from different sources such as hospital records, prior visits, and patient or caregiver reports. Some items also require clinical judgment, such as changes in mental status or difficulty following instructions. Since SOC and ROC assessments already require thorough documentation, this adds another layer of complexity to the process.
Here’s a quick review and guide to each M1033 item and how to determine whether each one applies:
Response 1: History of Falls
(2 or more falls — or any fall with injury — within the past 12 months)
Effective January 1, 2026, a fall is defined as an unintentional change in position resulting in the patient coming to rest on the ground, floor, or a lower surface such as a bed, chair, or bedside mat.
Falls may be:
- Witnessed
- Reported by the patient or another person
- Identified when the patient is found on the floor or ground
Key updates:
- Intercepted falls are considered falls
- Falls caused by an overwhelming external force are also counted
During therapeutic or balance-training activities:
- If a major injury occurs from a fall or intercepted fall, it is counted for M1033
- If no major injury occurs during the intervention, it is not counted for Response 1
Response 2: Unintentional Weight Loss
(10 pounds or more within the past 12 months)
Focus on unintentional weight loss, even if the patient is unaware of the change. Information may come from:
- Patient report
- Family or caregiver report
- Physician documentation
- Clinical records
Response 3: Multiple Hospitalizations
(2 or more hospitalizations within the past 6 months)
Hospitalization refers to admission to an inpatient acute care bed for 24 hours or more, excluding admissions for diagnostic testing only.
Do not include:
- Inpatient rehabilitation hospitals or rehab units
- Inpatient psychiatric hospitals
- Long-term care hospitals (LTCHs)
Response 4: Multiple Emergency Department Visits
(2 or more ED visits within the past 6 months)
Count only visits to a hospital emergency department during the 6-month look-back period.
Do not include:
- Urgent care visits
- Walk-in clinics
Response 5: Decline in Mental, Emotional, or Behavioral Status
(Within the past 3 months)
Select this response when the patient has experienced a significant mental, emotional, or behavioral decline that may affect their ability to remain safely at home or increase hospitalization risk.
The decline may be:
- Temporary or permanent
- Reported by the patient, caregiver, or physician
- Observed by the clinician
Note: Physician consultation may or may not have occurred.
Response 6: Difficulty Following Medical Instructions
(Within the past 3 months)
Select this response when there is reported or observed difficulty following medical instructions such as medications, diet, exercise, or treatment plans.
Examples include:
- Medication noncompliance
- Missed appointments
- Failure to follow dietary or therapy recommendations
- Failure to follow treatment instructions
Response 7: Currently Taking 5 or More Medications
Include all medications and medically necessary substances currently being taken, including:
- Prescription medications
- Over-the-counter (OTC) medications
- Vitamins and supplements
- Herbal or homeopathic products
- Medications given by any route (oral, topical, inhaled, injectable, etc.)
- Total parenteral nutrition (TPN)
- Oxygen therapy
Response 8: Currently Reports Exhaustion
Exhaustion may be physical or mental and should be based on the patient’s self-report or expressed experience.
Response 9: Other Risks Not Listed in Responses 1–8
Select this response when other clinically significant factors may increase hospitalization risk but are not specifically included in Responses 1–8.
Examples may include:
- Terminal illness
- Unsafe living conditions
- Poor caregiver support
- Decreased strength, balance, or sit-to-stand ability
- Other clinically relevant safety concerns
Final Takeaway
M1033 is a high-impact OASIS item that connects clinical assessment with PDGM reimbursement and hospitalization risk identification. While it can be challenging due to multiple considerations and clinical judgment requirements, clinicians’ strong understanding of the guidelines—supported by thorough QA review—helps ensure accurate documentation.
Ultimately, accurate M1033 responses support one of home health’s primary goals: preventing avoidable hospitalizations while ensuring appropriate care planning and resource allocation.
