K0100. Swallowing Disorder

Step-by-Step Coding Guide for K0100: Swallowing Disorder

Introduction

Swallowing disorders can significantly impact a resident's health by increasing the risk for malnutrition, dehydration, and aspiration pneumonia. Accurate assessment and documentation are crucial for effective care planning and intervention.

Steps for Assessment

1. Resident Interview:

   • Ask the resident about difficulties with swallowing during the 7-day look-back period. Specifically inquire about the symptoms listed in K0100A through K0100D.

2. Observation:

   • Observe the resident during meals and other times when eating, drinking, or taking medications to identify signs of possible swallowing disorders.

3. Staff Interview:

   • Interview staff members from all shifts who have interacted with the resident. Ask if they have noticed any of the symptoms listed in K0100A through K0100D during the 7-day look-back period.

4. Medical Record Review:

   • Review the resident's medical records for notes from nursing staff, physicians, dieticians, and speech-language pathologists. Look for any documented dental problems that could affect swallowing.

Coding Instructions

• K0100A: Loss of liquids/solids from mouth when eating or drinking.
• K0100B: Holding food in mouth/cheeks or residual food in mouth after meals.
• K0100C: Coughing or choking during meals or when swallowing medications.
• K0100D: Complaints of difficulty or pain with swallowing.
• K0100Z: None of the above - If none of the symptoms were present during the look-back period.

Documentation Tips

• Document any observed or reported symptoms in the resident's medical record.
• Note any interventions that have been successfully implemented to manage the swallowing disorder.

Common Errors to Avoid

• Failing to observe the resident during meals or snacks.
• Not consulting with interdisciplinary team members who may have observed symptoms.

Practical Application

Ensure the care plan includes strategies to manage the swallowing disorder, such as diet modification, positioning techniques, or referral to a speech-language pathologist for further evaluation and management.

The Step-by-Step Coding Guide for item K0100 in MDS 3.0 Section K 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.