O0110J2c: Hemodialysis - At Discharge, Step-by-Step
Step-by-Step Coding Guide for O0110J2c: Hemodialysis - At Discharge
1. Review of Medical Records
Objective: Verify whether the resident was receiving hemodialysis at the time of discharge.
Actions:
- Access the resident’s medical records, including treatment logs, physician orders, and discharge summaries.
- Confirm documentation indicating that the resident underwent hemodialysis during the last three days prior to discharge.
- Ensure the records specify hemodialysis, not peritoneal dialysis, as the two treatments are coded differently.
2. Understanding Definitions
O0110J2c: Hemodialysis - At Discharge: Hemodialysis involves filtering the resident’s blood through a machine to remove waste products and excess fluids. This code captures whether the resident was receiving hemodialysis in the last three days before discharge.
- Hemodialysis: The resident’s blood is filtered externally using a dialysis machine with special filters (dialyzers). The treatment is typically done in a dialysis center or hospital.
- Frequency: Often conducted three times a week.
- Procedure Duration: Each session usually lasts 3-5 hours.
Illustration 1:
Scenario: A resident with chronic kidney disease requires dialysis. During their stay in the nursing facility, they receive hemodialysis on Monday, Wednesday, and Friday at a local dialysis center. The resident is discharged on a Friday after their last dialysis session.
Result: O0110J2c is coded "Yes" because hemodialysis was received within the last three days prior to discharge.
3. Coding Instructions
Step-by-Step:
- Step 1: Review medical records for any hemodialysis treatment administered within the last three days before discharge.
- Step 2: Confirm that the treatment was hemodialysis, not peritoneal dialysis, and was performed using a dialysis machine at a center or hospital.
- Step 3: If the resident underwent hemodialysis, mark O0110J2c as "Yes".
- Step 4: If the resident did not receive hemodialysis, mark "No" in O0110J2c.
Illustration 2:
Scenario: A resident is discharged after receiving peritoneal dialysis, but no hemodialysis was provided. Peritoneal dialysis is managed at home, requiring different coding.
Result: O0110J2c is coded "No" because hemodialysis was not provided, even though dialysis treatment was in place.
4. Coding Tips
- Differentiate Dialysis Types: Ensure the resident received hemodialysis, not peritoneal dialysis.
- Hemodialysis: Performed using a machine at a dialysis center.
- Peritoneal Dialysis: Administered through the peritoneal cavity, often done at home or in the facility.
- Use Clear Documentation: The resident’s discharge summary must indicate hemodialysis sessions performed in the three days before discharge.
Illustration 3:
Scenario: A resident undergoes both hemodialysis (for long-term renal failure) and intravenous medication administration for an infection. It’s important not to confuse IV treatments with dialysis treatments, as both have separate coding requirements.
Tip: Always code dialysis separately from other treatments like IV fluids or medications.
5. Documentation
Objective: Ensure that hemodialysis is clearly documented as part of the resident’s treatment in the days leading up to discharge.
Actions:
- Record the dates and times of hemodialysis sessions, particularly those within the last three days.
- Include specific notes on the dialysis facility, transportation arrangements (if applicable), and any post-dialysis monitoring.
Illustration 4:
Scenario: The resident’s discharge summary shows that they received hemodialysis on Wednesday and Friday. The discharge took place on Friday after their last session. The summary details that the resident tolerated treatment well and was cleared for discharge afterward.
Documentation: The hemodialysis treatment is clearly logged, and O0110J2c is coded "Yes".
6. Common Errors to Avoid
- Misclassifying Dialysis Types: Don’t confuse peritoneal dialysis with hemodialysis.
- Peritoneal dialysis requires different coding under O0110J3.
- Incomplete Documentation: Ensure that treatment dates and times for the hemodialysis are documented, especially in the discharge period.
Illustration 5:
Scenario: A resident’s chart mentions they are a dialysis patient, but the documentation doesn’t specify whether hemodialysis or peritoneal dialysis was performed.
Error: This lack of clarity can lead to incorrect coding. Always confirm the dialysis type and frequency in the records.
7. Practical Application
- Example 1: A resident was receiving hemodialysis three times a week and had their last session the day before discharge. O0110J2c is coded "Yes".
- Example 2: A resident was receiving peritoneal dialysis at home, and no hemodialysis was administered in the facility. O0110J2c is coded "No".
- Example 3: A resident was scheduled for hemodialysis but did not attend their final session before discharge. O0110J2c is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set O0110J2c 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.
