O0110B1a: Radiation - On Admission, Step-by-Step
Step-by-Step Coding Guide for O0110B1a: Radiation - On Admission
1. Review of Medical Records
Objective: Confirm whether the resident received radiation therapy on the day of admission.
Actions:
- Access the resident’s medical records, including hospital discharge summaries, treatment logs, and physician orders.
- Look for documentation indicating that the resident underwent radiation therapy within the first three days of admission to the SNF.
- Verify the type of radiation treatment provided (e.g., external beam radiation, brachytherapy).
2. Understanding Definitions
O0110B1a: Radiation - On Admission: This item captures whether the resident was receiving radiation therapy for cancer or other conditions during the first three days of admission to the skilled nursing facility.
- Radiation Therapy: A treatment that uses high-energy particles or waves, such as X-rays, to destroy or damage cancer cells. This includes external beam radiation or radiation implants (brachytherapy).
Illustration 1:
Scenario: A resident was admitted to the SNF following radiation therapy for prostate cancer. They continued radiation sessions in an outpatient facility.
Result: O0110B1a is coded "Yes" because radiation therapy occurred during the admission period.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the resident’s medical records to verify if radiation therapy was provided within the first three days after admission.
- Step 2: Confirm that the treatment was radiation therapy for cancer or other applicable conditions.
- Step 3: If radiation therapy was provided, check O0110B1a as "Yes".
- Step 4: If the resident did not receive radiation therapy during the admission period, mark "No" in O0110B1a.
Illustration 2:
Scenario: A resident had completed radiation therapy before their admission to the SNF and was not scheduled for additional sessions.
Result: O0110B1a is coded "No", as radiation therapy was not part of the resident’s treatment plan during admission.
4. Coding Tips
- Differentiate Radiation Types: Ensure the treatment documented is radiation therapy, not other forms of therapy.
- Use Accurate Documentation: Review hospital discharge records and confirm any radiation sessions planned or continued in the first three days of admission.
Illustration 3:
Scenario: A resident’s chart shows that they are receiving outpatient radiation therapy for breast cancer, with treatments continuing on the second day after SNF admission.
Tip: Ensure all outpatient therapy sessions are logged, and O0110B1a is coded correctly.
5. Documentation
Objective: Ensure that radiation therapy is properly documented and coded for residents receiving this treatment upon admission.
Actions:
- Record the date and time of radiation therapy sessions provided during admission.
- Include any specific information on the type of radiation therapy, such as external beam radiation or brachytherapy.
Illustration 4:
Scenario: A resident’s treatment notes show that external beam radiation was administered on the second day of their stay, following their transfer from a hospital.
Documentation: The treatment session should be recorded, and O0110B1a should be coded "Yes".
6. Common Errors to Avoid
- Confusing Therapy Types: Do not confuse radiation therapy with other cancer treatments like chemotherapy or immunotherapy. Only radiation should be coded under O0110B1a.
- Incomplete Records: Avoid coding this item without clear documentation of the radiation treatment.
Illustration 5:
Scenario: A resident’s chart mentions they are undergoing cancer treatment, but the specific type of therapy is not clearly indicated.
Error: Lack of clear documentation could lead to incorrect coding. Always confirm the type of therapy before coding.
7. Practical Application
- Example 1: A resident was admitted following external beam radiation therapy for lung cancer. Radiation was continued during their SNF stay. O0110B1a is coded "Yes".
- Example 2: A resident had completed all radiation therapy prior to their SNF admission and did not require additional treatments. O0110B1a is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set O0110B1a 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.
