H0100C. Appliances: ostomy, Step-by-Step

Step-by-Step Coding Guide for Item Set: H0100C. Appliances: Ostomy

1. Review of Medical Records

   • Begin with a comprehensive review of the resident's medical records, focusing on any documentation related to ostomy care and management. This includes surgical reports, physician orders, nursing assessments, and notes from wound care specialists or enterostomal therapists. Look for information on the type of ostomy, reason for ostomy, and any complications or special care requirements documented.

2. Understanding Definitions

   • Ostomy: A surgically created opening in the body for the discharge of body wastes. Common types include colostomy (colon), ileostomy (ileum), and urostomy (urinary diversion).
   • Appliances: Refers to devices used in conjunction with an ostomy to collect waste, such as ostomy bags or pouching systems.

3. Coding Instructions

   • Code 0: No - If the resident does not have an ostomy.
   • Code 1: Yes - If the resident has an ostomy and uses related appliances for waste collection.
   • Determine the presence of an ostomy by reviewing medical records and through physical assessment. Note the type of ostomy and any specific appliances used for waste management.

4. Coding Tips

   • Verify the type of ostomy and the appliance used directly with the resident, their caregiver, or the healthcare provider to ensure accurate coding.
   • Be aware of the different ostomy types and corresponding care needs, as care practices may vary significantly between them.

5. Documentation

   • Accurately document the coding decision in the MDS. In the resident's care plan and medical record, include detailed notes regarding the ostomy, such as type, location, appliance used, skin care regimen, and any changes in the ostomy's condition or the care routine.

6. Common Errors to Avoid

   • Confusing different types of ostomy and their care needs, leading to inaccurate coding or care planning.
   • Failing to update the MDS and care plans when changes occur in the resident's ostomy condition or care requirements.

7. Practical Application

   • Example: Mrs. Green has a colostomy resulting from colorectal cancer surgery. Her care involves the use of a two-piece ostomy pouching system, which is changed every 3 days or as needed. The nursing staff assesses the skin around the stoma for irritation or signs of infection daily. For H0100C, Mrs. Green would be coded as "1" for Yes, indicating she has an ostomy and uses an appliance. Her care plan includes detailed instructions for ostomy care, appliance changing, and skin assessment protocols.

The Step-by-Step Coding Guide for item H0100C in MDS 3.0 Section H is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.