Step-by-Step Coding Guide for Item Set A0310G1: Interrupted Stay

1. Review of Medical Records

• Objective: Determine if the resident experienced an interrupted stay.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including admission and discharge notes, transfer records, and any previous assessments.
  2. Identify Documentation of Interrupted Stay: Look for documented instances where the resident was discharged from the facility and then readmitted within the interrupted stay window.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across different parts of the medical records.

2. Understanding Definitions

• Interrupted Stay: An interrupted stay occurs when a resident is discharged from the facility and then readmitted to the same facility within a specific time frame, generally within three consecutive calendar days.
• Key Points:
  • An interrupted stay impacts the assessment schedule and payment policy.
  • The time frame for an interrupted stay is crucial in determining how it affects the resident’s stay and assessment.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm the resident’s interrupted stay based on medical records and transfer/discharge/re-admission logs.
  2. Verify Documentation: Ensure the interrupted stay is clearly documented, including the dates of discharge and readmission.
  3. Code Appropriately: Enter the code for the interrupted stay in item set A0310G1:
     • 1: Yes, the resident experienced an interrupted stay.
     • 0: No, the resident did not experience an interrupted stay.

4. Coding Tips

• Accurate Identification: Ensure the interrupted stay is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the interrupted stay.
• Consult Records: Cross-check with other records and assessments to verify the interrupted stay status.

5. Documentation

• Required:
  • Admission and Discharge Notes: Include details of the resident’s discharge and readmission dates.
  • Transfer Records: Document instances where the resident was transferred to another facility or hospital and then readmitted.
  • Care Plans: Update care plans to reflect changes in the resident’s stay status and any adjustments in care required due to the interrupted stay.
  • Previous Assessments: Verify the resident’s stay status across previous assessments to ensure consistency.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the interrupted stay through multiple records and logs.
• Incomplete Documentation: Make sure all relevant documentation is included and accurately reflects the interrupted stay.
• Assumptions: Do not assume the interrupted stay status without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: John, an 85-year-old resident, was discharged to a hospital for acute care and readmitted to the same facility within two days.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, noting the discharge to the hospital and readmission to the facility within two days.
    2. Identify Interrupted Stay: It is confirmed that John experienced an interrupted stay.
    3. Document and Code: The nurse documents the interrupted stay details in John’s records and codes A0310G1 as "1".
  • Outcome: John’s interrupted stay is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set A0310G1 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.