O0110C4a: Treatment: Oxygen Therapy - High-Concentration - On Adm, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110C4a: Treatment: Oxygen Therapy - High-Concentration - On Adm

1. Review of Medical Records

• Objective: Accurately document the initiation of high-concentration oxygen therapy upon admission.
• Steps:
  1. Gather Documentation: Collect admission records, physician orders, respiratory therapy notes, and initial nursing assessments.
  2. Identify Oxygen Therapy: Look for documentation indicating the initiation of high-concentration oxygen therapy on admission.
  3. Consult Healthcare Providers: Verify the initiation and details of the oxygen therapy with the respiratory therapist and attending physician.

2. Understanding Definitions

• High-Concentration Oxygen Therapy: Administration of oxygen at a high concentration (generally >40%) to treat or prevent hypoxia.
• On Adm: Indicates the treatment was started upon the resident’s admission to the facility.

3. Coding Instructions

• Steps:
  1. Review Documentation: Confirm the start of high-concentration oxygen therapy on admission.
  2. Select Appropriate Code: In the MDS, indicate the initiation of high-concentration oxygen therapy under item O0110C4a.
  3. Enter Details: Ensure accurate entry of all relevant details including date and type of therapy initiated.

4. Coding Tips

• Accurate Dates: Verify that the date of initiation matches the admission date.
• Clear Documentation: Ensure that the type and concentration of oxygen therapy are clearly documented.
• Consistency: Ensure consistency across all medical records regarding the initiation of oxygen therapy.

5. Documentation

• Required:
  • Physician Orders: Written orders specifying the need for high-concentration oxygen therapy.
  • Nursing Admission Notes: Notes detailing the initiation of therapy and resident's response.
  • Respiratory Therapy Records: Documentation of the setup and monitoring of oxygen therapy.
  • Care Plans: Include oxygen therapy as part of the resident’s individualized care plan.

6. Common Errors to Avoid

• Incorrect Dates: Ensure the start date of oxygen therapy is accurately documented as the admission date.
• Incomplete Records: Verify that all documentation is complete and includes necessary details about the therapy.
• Misclassification: Do not confuse high-concentration oxygen therapy with other types of oxygen treatments.

7. Practical Application

• Example:
  • Resident Profile: John Doe, a 70-year-old male with COPD, admitted with severe hypoxia.
  • Steps:
    1. Review Records: Collect admission records, physician orders, and respiratory therapy notes.
    2. Verify Therapy: Confirm that high-concentration oxygen therapy was initiated upon admission.
    3. Consult Providers: Speak with the respiratory therapist to verify details of the therapy.
    4. Enter Code: Document the initiation of high-concentration oxygen therapy under item O0110C4a in the MDS.
    5. Documentation: Ensure all records accurately reflect the initiation and type of oxygen therapy.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C4a 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.