O0110J1b. Treatment: Dialysis- While a Res, Step-by-Step

Step-by-Step Coding Guide for Item Set: O0110J1b, Treatment: Dialysis- While a Resident

1. Review of Medical Records

Objective: Identify dialysis treatment administered during the resident's stay. Key Points:

• Conduct a comprehensive review of the resident's medical records for documentation of dialysis treatment, including nursing notes, physician orders, and treatment logs.
• Focus on identifying the type of dialysis (hemodialysis or peritoneal dialysis), frequency, and any adjustments in treatment based on the resident's health status.
• Document each instance of dialysis treatment, noting dates, times, and any complications or interventions required.

2. Understanding Definitions

Objective: Define dialysis treatment in the context of a long-term care resident. Key Points:

• Dialysis is a medical procedure that replaces the function of the kidneys by removing waste products and excess fluid from the blood when the kidneys are no longer able to perform this function effectively.
• Hemodialysis involves circulating the blood outside of the body through an external filter, while peritoneal dialysis involves the infusion of a dialysis solution into the abdominal cavity.
• Understanding both types of dialysis is crucial for accurate documentation, as the care needs and scheduling for each can vary significantly.

3. Coding Instructions

Objective: Accurately code for ongoing dialysis treatment during the resident's stay. Key Points:

• Code '1' if the resident underwent dialysis treatment at any time during their stay, excluding the day of admission and discharge.
• Ensure that coding accurately reflects all instances of dialysis treatment, as verified through detailed medical records.
• Include information about both hemodialysis and peritoneal dialysis treatments, as applicable.

4. Coding Tips

Objective: Enhance accuracy and consistency in coding dialysis treatments. Key Points:

• Regularly update and review the resident’s medical records to ensure all instances of dialysis treatment are captured.
• Collaborate with the dialysis team, including nurses and technicians, to clarify any ambiguities in documentation.
• For residents undergoing hemodialysis at an external facility, ensure that transportation logs and external treatment records are reviewed and included in coding.

5. Documentation

Objective: Maintain thorough and accessible records for dialysis treatment. Key Points:

• Document detailed information about each dialysis session, including type, date, time, duration, and any observations or complications.
• Note the resident's response to treatment and any adjustments made by healthcare providers to address complications or improve outcomes.
• Ensure that dialysis schedules and any changes to treatment plans are clearly documented in the resident's care plan.

6. Common Errors to Avoid

Objective: Identify and prevent typical documentation and coding mistakes. Key Points:

• Omitting dialysis treatments from coding because they occur off-site or are considered routine for the resident.
• Inaccurate documentation of dialysis type or frequency, leading to errors in coding and potential gaps in care.
• Failing to document the coordination of care and communication between the long-term care facility and external dialysis providers.

7. Practical Application

Objective: Apply coding and documentation practices to real-world scenarios. Key Points:

• Scenario: A resident with chronic kidney disease requires peritoneal dialysis three times a week. During their stay, the resident experiences peritonitis requiring adjustments to their dialysis regimen. Document and code this scenario, highlighting the importance of detailed treatment records and responsive care planning.
• Use hypothetical resident cases in staff training sessions to practice coding for dialysis treatment, focusing on recognizing and documenting different types of dialysis.
• Review case studies in team meetings to discuss challenges and best practices in documenting and coding dialysis treatments, emphasizing the impact on resident care and facility operations.

Please note that the information provided in this guide for MDS 3.0 Item set O0110J1b  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.