O0110J3a: Dialysis - Peritoneal - On Admission, Step-by-Step
Step-by-Step Coding Guide for O0110J3a: Dialysis - Peritoneal - On Admission
1. Review of Medical Records
Objective: Confirm whether the resident was receiving peritoneal dialysis on the day of admission.
Actions:
- Access the resident’s medical records, including hospital discharge summaries, physician orders, and dialysis treatment logs.
- Review the medical documentation to ensure that peritoneal dialysis was in progress or required on the first three days of the resident’s admission to the SNF.
2. Understanding Definitions
O0110J3a: Peritoneal Dialysis - On Admission: This refers to peritoneal dialysis administered to remove waste products and excess fluids from the blood by using the peritoneal membrane as a filter. Dialysate fluid is introduced into the peritoneal cavity, where it absorbs waste products and is then drained from the body.
- Peritoneal Dialysis: A form of dialysis that uses the peritoneum as a filter, including continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD).
- CAPD (Continuous Ambulatory Peritoneal Dialysis): Performed manually several times a day.
- APD (Automated Peritoneal Dialysis): Uses a machine, usually performed overnight.
3. Coding Instructions
Step-by-Step:
- Step 1: Confirm if peritoneal dialysis was being performed on the resident on the first three days after admission to the SNF.
- Step 2: Verify if the resident was undergoing peritoneal dialysis treatments either manually (CAPD) or automatically (APD) during this period.
- Step 3: If peritoneal dialysis was administered or required on admission, mark O0110J3a as “Yes”.
- Step 4: If the resident was not receiving peritoneal dialysis at the time of admission, mark O0110J3a as “No”.
4. Coding Tips
- Accurate Documentation: Ensure the medical record clearly documents the use of peritoneal dialysis, including whether the resident is on CAPD or APD.
- Hospital Discharge Summaries: Review the discharge notes from the hospital to confirm if peritoneal dialysis was started before SNF admission and continued during the first three days of the resident’s SNF stay.
5. Documentation
Objective: Ensure that the resident’s peritoneal dialysis treatment is accurately documented and coded at admission.
Actions:
- Record the type of peritoneal dialysis (CAPD or APD) and its start date.
- Include physician orders or dialysis logs that confirm the administration of peritoneal dialysis on admission.
6. Common Errors to Avoid
- Confusing Peritoneal with Hemodialysis: Ensure that only peritoneal dialysis is coded under O0110J3a. Hemodialysis should be coded separately under O0110J2.
- Incomplete Documentation: Avoid coding without sufficient documentation of the type of dialysis and the administration date.
7. Practical Application
- Example 1: A resident was admitted with orders to continue CAPD four times a day. The peritoneal dialysis was performed during the first three days of admission. O0110J3a is coded “Yes”.
- Example 2: A resident was admitted for general rehabilitation but did not require dialysis on admission. O0110J3a is coded “No”.
- Example 3: A resident had been receiving peritoneal dialysis in the hospital but switched to hemodialysis upon admission to the SNF. O0110J3a is coded “No”, while O0110J2 is coded for hemodialysis.
Please note that the information provided in this guide for MDS 3.0 Item set O0110J3a 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.
