O0110J2a: Hemodialysis - On Admission, Step-by-Step
Step-by-Step Coding Guide for O0110J2a: Hemodialysis - On Admission
1. Review of Medical Records
Objective: Confirm whether the resident was receiving hemodialysis on the day of admission.
Actions:
- Access the resident’s medical records, including hospital discharge summaries, dialysis center reports, and physician orders.
- Verify documentation confirming that the resident was receiving hemodialysis within the first three days of the nursing facility admission.
- Check for details on the frequency and type of dialysis treatment, confirming it was hemodialysis rather than peritoneal dialysis.
2. Understanding Definitions
O0110J2a: Hemodialysis - On Admission: Hemodialysis is a treatment where the resident’s blood is filtered through a dialysis machine to remove waste products and excess fluids. This code captures whether the resident was actively receiving hemodialysis within the first three days after admission to the facility.
- Hemodialysis: Involves filtering the resident’s blood using a dialysis machine with specialized filters (dialyzers). This process is generally performed at a dialysis center or hospital.
Illustration 1:
Scenario: A resident was transferred to the SNF following a hospital stay for renal failure. Hemodialysis is performed three times a week, with the resident undergoing treatment on the day of admission and during the first two days of their SNF stay.
Result: O0110J2a is coded "Yes" because hemodialysis was administered during the first three days of admission.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the resident’s medical records to determine if hemodialysis was administered within the first three days after admission.
- Step 2: Verify that the treatment documented was hemodialysis (not peritoneal dialysis).
- Step 3: If hemodialysis was provided, mark O0110J2a as "Yes".
- Step 4: If the resident was not receiving hemodialysis within the first three days of admission, mark "No".
Illustration 2:
Scenario: A resident arrives at the facility and begins receiving peritoneal dialysis at home. No hemodialysis was provided during the admission period.
Result: O0110J2a is coded "No", as the resident did not receive hemodialysis.
4. Coding Tips
- Distinguish Between Dialysis Types: Ensure the documentation specifies hemodialysis, not peritoneal dialysis, as these are coded differently (peritoneal dialysis is coded under O0110J3a).
- Review Hospital Discharge Records: Check the hospital discharge records to ensure that hemodialysis was part of the treatment plan at the time of admission.
5. Documentation
Objective: Ensure accurate and thorough documentation of hemodialysis treatments during the admission period.
Actions:
- Record the type of dialysis (hemodialysis) and the dates of the sessions.
- Include any orders for dialysis treatment continuation in the facility, particularly if dialysis was provided on the day of admission.
Illustration 3:
Scenario: The resident’s discharge summary from the hospital notes that they require hemodialysis three times a week, with the last session completed on the day of their SNF admission.
Documentation: Ensure the discharge summary and treatment plan specify the dates of dialysis treatment, and that O0110J2a is coded "Yes".
6. Common Errors to Avoid
- Confusing Dialysis Types: Be cautious not to confuse hemodialysis with peritoneal dialysis. Only hemodialysis should be coded under O0110J2a.
- Incomplete Documentation: Ensure there is clear documentation indicating the specific dialysis treatment provided during the first three days after admission.
Illustration 4:
Scenario: A resident’s chart notes that dialysis was required, but does not specify whether it was hemodialysis or peritoneal dialysis.
Error: Lack of clarity can lead to incorrect coding. Confirm the dialysis type with the care team or discharge records before coding.
7. Practical Application
- Example 1: A resident was admitted with a diagnosis of end-stage renal disease and began receiving hemodialysis immediately upon arrival. O0110J2a is coded "Yes".
- Example 2: A resident was admitted for other reasons and did not receive hemodialysis until several days after admission. O0110J2a is coded "No".
- Example 3: A resident received peritoneal dialysis on admission but no hemodialysis was provided. O0110J2a is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set O0110J2a 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.
