O0110A1b: Chemotherapy - While a Resident, Step-by-Step
Step-by-Step Coding Guide for O0110A1b: Chemotherapy - While a Resident
1. Review of Medical Records
Objective: Confirm whether the resident received chemotherapy during their stay in the facility.
Actions:
- Access the resident’s medical records, including physician orders, treatment logs, and care notes.
- Verify if chemotherapy was administered during the resident's time in the facility. This includes all routes of administration, such as IV, oral, or other methods like intrathecal or topical.
2. Understanding Definitions
O0110A1b: Chemotherapy - While a Resident: This item captures any chemotherapy administered for the treatment of cancer during the resident's stay in the nursing facility, regardless of the method of administration. The chemotherapy can be provided through various routes such as intravenous (IV), oral, intramuscular, intrathecal, topical, etc..
Illustration 1:
Scenario: A resident was admitted to the facility for cancer treatment. They received regular IV chemotherapy over the course of their stay to manage their condition.
Result: O0110A1b is coded "Yes" because chemotherapy was administered during the resident's stay.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the medical records for documentation of chemotherapy administered during the resident’s stay.
- Step 2: Identify the route of administration (IV, oral, or other methods such as intramuscular or topical).
- Step 3: If chemotherapy was provided for cancer treatment, check O0110A1b as "Yes".
- Step 4: If no chemotherapy was provided during the resident’s stay, mark "No".
Illustration 2:
Scenario: A resident was prescribed oral chemotherapy for cancer during their stay at the facility.
Result: O0110A1b is coded "Yes", as oral chemotherapy qualifies under this item.
4. Coding Tips
- Medication Review: Ensure that the chemotherapy was administered for cancer treatment, not for other purposes.
- Confirm the Route: Review the route of administration, as chemotherapy may be provided via multiple methods (IV, oral, intrathecal, etc.).
- Multiple Treatments: If the resident received chemotherapy via more than one route, record all forms of administration.
5. Documentation
Objective: Ensure clear and accurate documentation of chemotherapy treatments administered during the resident’s stay.
Actions:
- Record the specific chemotherapy agents used, their dosages, and the route of administration.
- Include any relevant notes on the frequency of treatments and any related side effects or monitoring requirements.
Illustration 3:
Scenario: A resident’s chart includes regular entries for IV chemotherapy administered every three days, with notes on dosage and any side effects experienced by the resident.
Documentation: Ensure this is clearly recorded, and O0110A1b is coded "Yes".
6. Common Errors to Avoid
- Misclassifying Medications: Ensure that only chemotherapy administered for cancer treatment is coded under O0110A1b. Do not include other medications that may have similar properties but are not used for cancer treatment.
- Incomplete Documentation: Avoid coding without complete and clear documentation of chemotherapy treatments.
Illustration 4:
Scenario: A resident's records mention the use of megestrol acetate, which is classified as an antineoplastic but is being used for appetite stimulation.
Error: Megestrol acetate should not be coded as chemotherapy in this case because it is not being used for cancer treatment.
7. Practical Application
- Example 1: A resident was administered IV chemotherapy three times a week during their stay for the treatment of lymphoma. O0110A1b is coded "Yes".
- Example 2: A resident was receiving oral hormonal therapy to prevent cancer recurrence, but no chemotherapy. O0110A1b is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set O0110A1b 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.
