O0110O1a: Treatment - IV Access - On Admission, Step-by-Step
Step-by-Step Coding Guide for Item Set O0110O1a: Treatment - IV Access - On Admission
Step-by-Step Coding Guide for Item Set O0110O1a: Treatment - IV Access - On Admission
1. Review of Medical Records
- Objective: To determine if the resident had IV access upon admission.
- Process:
- Admission Records: Review the resident’s admission documentation for any mention of IV access being established upon admission.
- Physician Orders: Examine orders given at the time of admission to check for IV access directives.
- Nursing Notes: Look at nursing admission assessments and notes for documentation of IV access.
- Hospital Transfer Records: If the resident was transferred from a hospital, review the discharge summary and transfer notes for IV access details.
2. Understanding Definitions
- IV Access on Admission: Refers to the resident having an intravenous (IV) line in place when they are admitted to the facility. This can include peripheral IV lines, central lines, or peripherally inserted central catheters (PICCs).
3. Coding Instructions
- Code O0110O1a:
- 0: No, the resident did not have IV access on admission.
- 1: Yes, the resident had IV access on admission.
- Example: If a resident was admitted to the facility from a hospital with a peripheral IV line already in place, code O0110O1a as '1'.
4. Coding Tips
- Verification: Ensure that the documentation clearly states that the IV access was present at the time of admission.
- Consistent Documentation: Cross-check various records to ensure consistency in documentation regarding IV access.
5. Documentation
- Required Documentation:
- Admission Forms: Include details of IV access recorded during the admission process.
- Physician Orders: Document orders indicating the need for IV access upon admission.
- Nursing Admission Notes: Notes confirming the presence of IV access during the initial nursing assessment.
- Hospital Transfer Summary: If applicable, records indicating the resident was transferred with IV access in place.
- Example: "On 05/10/2024, the resident was admitted with a peripheral IV line in place as documented in the hospital transfer summary and confirmed by the nursing admission assessment."
6. Common Errors to Avoid
- Assuming Presence: Do not assume IV access was present without explicit documentation.
- Incomplete Documentation: Ensure all relevant records mention the presence of IV access to avoid discrepancies.
- Overlooking Transfers: Always review transfer records from hospitals or other facilities to verify IV access status.
7. Practical Application
- Scenario: A resident is admitted from a hospital with an existing central line for IV antibiotics. The nursing admission notes, physician orders, and hospital discharge summary all confirm the presence of the IV access. Based on this documentation, O0110O1a is coded as '1'.
Please note that the information provided in this guide for MDS 3.0 Item set O0110O1a 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.
