O0110A10a: Chemotherapy - Other - On Admission, Step-by-Step
Step-by-Step Coding Guide for O0110A10a: Chemotherapy - Other - On Admission
1. Review of Medical Records
Objective: Confirm whether the resident received chemotherapy treatments classified as "Other" during the first three days of admission.
Actions:
- Access the resident’s medical records, including hospital discharge summaries, treatment logs, and physician orders.
- Verify documentation of chemotherapy administered within the first three days of admission. Ensure that chemotherapy was administered by a route other than IV or oral, such as intramuscular, intraperitoneal, intrathecal, or topical.
2. Understanding Definitions
O0110A10a: Chemotherapy - Other: This item refers to chemotherapy that is administered through routes other than intravenous (IV) or oral methods. These may include:
- Intramuscular: Injection into the muscle.
- Intraperitoneal: Injection into the peritoneal cavity.
- Intrathecal: Injection into the space surrounding the spinal cord.
- Topical: Applied directly to the skin.
Illustration 1:
Scenario: A resident admitted with cancer begins intrathecal chemotherapy for central nervous system involvement. The chemotherapy was initiated within the first two days of their SNF admission.
Result: O0110A10a is coded "Yes" because intrathecal chemotherapy was administered during the first three days of admission.
3. Coding Instructions
Step-by-Step:
- Step 1: Review medical records to determine if chemotherapy was administered during the first three days after admission.
- Step 2: Ensure the chemotherapy was administered by a method other than oral or IV (e.g., intramuscular, intrathecal).
- Step 3: If chemotherapy was administered by an alternative method, check O0110A10a as "Yes".
- Step 4: If no such chemotherapy was administered, mark "No".
Illustration 2:
Scenario: A resident received oral chemotherapy for cancer upon admission but no other forms of chemotherapy.
Result: O0110A10a is coded "No" because oral chemotherapy is coded separately.
4. Coding Tips
- Accurate Categorization: Only code chemotherapy administered through non-IV and non-oral methods.
- Clear Documentation: Review physician orders and discharge summaries to confirm the route of administration.
5. Documentation
Objective: Ensure chemotherapy treatment is properly documented for residents receiving non-oral or non-IV chemotherapy on admission.
Actions:
- Record the method and route of administration (e.g., intrathecal, topical).
- Document any related notes about dosage and frequency during the first three days of admission.
Illustration 3:
Scenario: A resident received intramuscular chemotherapy immediately after admission. The treatment was documented with details on dosage and frequency.
Documentation: Ensure the treatment is properly recorded, and O0110A10a is coded "Yes".
6. Common Errors to Avoid
- Misclassifying Administration Routes: Do not code chemotherapy administered via IV or oral routes under O0110A10a.
- Incomplete Documentation: Avoid coding this item without clear documentation of the route of administration and treatment dates.
Illustration 4:
Scenario: A resident's chart indicates chemotherapy was administered, but the specific route (intramuscular or IV) is not clearly indicated.
Error: Lack of clarity can lead to incorrect coding. Confirm the route of administration before coding.
7. Practical Application
- Example 1: A resident was admitted with advanced cancer and began intraperitoneal chemotherapy on the second day of their stay. O0110A10a is coded "Yes".
- Example 2: A resident only received oral chemotherapy on admission. O0110A10a is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set O0110A10a 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.
