O0110C3a: Treatment: Oxygen Therapy - Intermittent - On Adm, Step-by-Step
Step-by-Step Coding Guide for Item Set O0110C3a: Treatment: Oxygen Therapy - Intermittent - On Adm
1. Review of Medical Records
- Objective: Ensure comprehensive review and accurate documentation of intermittent oxygen therapy received by the resident on admission.
- Steps:
- Gather Information: Collect all relevant medical records, including physician orders, nursing notes, respiratory therapy notes, and care plans.
- Identify Oxygen Therapy: Look for documented evidence of intermittent oxygen therapy prescribed and administered at the time of admission.
- Confirm Details: Verify the specifics of the therapy, including frequency, duration, and settings used.
2. Understanding Definitions
- Intermittent Oxygen Therapy: Oxygen therapy provided at intervals, rather than continuously, to support the resident's respiratory function.
- On Adm (On Admission): Refers to the period when the resident is first admitted to the facility.
3. Coding Instructions
- Steps:
- Identify Relevant Documentation: Confirm through the medical records that intermittent oxygen therapy was ordered and administered on admission.
- Verify Documentation: Ensure that the documentation clearly supports the use of intermittent oxygen therapy, including frequency and duration.
- Code Appropriately: Enter the appropriate code for item set O0110C3a:
- 0: No, the resident did not receive intermittent oxygen therapy on admission.
- 1: Yes, the resident received intermittent oxygen therapy on admission.
4. Coding Tips
- Accurate Identification: Ensure that the intermittent oxygen therapy is correctly identified and supported by relevant documentation.
- Consistent Terminology: Use consistent terminology and phrasing when documenting and coding intermittent oxygen therapy.
- Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.
5. Documentation
- Required:
- Physician Orders: Orders specifying the need for intermittent oxygen therapy.
- Nursing Notes: Documentation of the administration of oxygen therapy, including frequency and settings.
- Respiratory Therapy Notes: Detailed notes from the respiratory therapist regarding the administration and response to oxygen therapy.
- Care Plans: Plans that include the use of intermittent oxygen therapy as part of the resident’s treatment.
6. Common Errors to Avoid
- Misclassification: Ensure accurate identification by verifying the therapy through multiple records and observations.
- Incomplete Documentation: Make sure all relevant physician orders, nursing notes, and respiratory therapy notes are included to support the documented therapy.
- Assumptions: Do not assume the therapy status without proper documentation and verification; always check multiple sources.
7. Practical Application
- Example:
- Resident Profile: Sarah, a resident with COPD, is admitted to the facility and is prescribed intermittent oxygen therapy.
- Steps:
- Review Records: The nurse reviews Sarah’s medical records, noting the physician orders for intermittent oxygen therapy and the nursing notes documenting its administration on admission.
- Identify Therapy: It is confirmed through the documentation that Sarah received intermittent oxygen therapy on admission.
- Document and Code: The nurse documents Sarah’s therapy in her records and codes O0110C3a as "1" (Yes, the resident received intermittent oxygen therapy on admission).
- Outcome: Sarah’s use of intermittent oxygen therapy is accurately documented and coded, ensuring proper follow-up and care planning.
Please note that the information provided in this guide for MDS 3.0 Item set O0110C3a 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.
