O0300B: If Pneumococcal Vaccination Not Received, State Reason, Step-by-Step
Step-by-Step Coding Guide for O0300B: "If Pneumococcal Vaccination Not Received, State Reason"
1. Review of Medical Records
Objective: Verify whether the resident has received the pneumococcal vaccination. If not, confirm the reason for it.
Actions:
- Access the resident’s medical records, including immunization records, vaccination logs, and physician orders.
- Determine if the resident has received the pneumococcal vaccine. If not, verify whether the absence of vaccination is documented with an appropriate reason.
2. Understanding Definitions
O0300B: If Pneumococcal Vaccine Not Received, State Reason: This item captures the reason a resident has not received the pneumococcal vaccination if it was not administered.
- Not Eligible: The resident has a medical contraindication, such as an allergy or a physician's order not to immunize.
- Offered and Declined: The resident or their legal guardian declined the vaccine after being informed of the risks and benefits.
- Not Offered: The vaccine was not offered to the resident or their legal guardian.
3. Coding Instructions
Step-by-Step:
- Step 1: Determine whether the resident is up to date with their pneumococcal vaccination (based on O0300A). If the resident is not up to date, proceed to O0300B.
- Step 2: Identify the reason the vaccine was not given by reviewing medical documentation or discussing it with the resident, family, or responsible party.
- Step 3: Use one of the following codes to document the reason the vaccine was not given:
- Code 1: Not eligible due to medical contraindications (e.g., life-threatening allergy, physician order).
- Code 2: Offered and declined by the resident or their legal guardian.
- Code 3: Not offered to the resident or their legal guardian.
- Step 4: If no reason is documented or available, ensure proper follow-up with the medical team to resolve or document the reason.
4. Coding Tips
- Clarify Vaccine Eligibility: Ensure that contraindications (like allergies) are clearly documented in the resident's file.
- Offer Documentation: If the vaccine was declined, make sure there is documentation that the resident or legal guardian was informed about the vaccine’s benefits and risks.
- Follow-Up on Missing Documentation: If the vaccine was not offered, check with the care team to understand why, and document this reason accurately.
5. Documentation
Objective: Ensure that the medical record clearly states why the pneumococcal vaccination was not administered.
Actions:
- Include specific notes regarding the contraindication, if any, or a documented conversation in which the vaccine was offered but declined.
- Document the plan for future vaccine offers if the resident’s eligibility status changes.
6. Common Errors to Avoid
- Failing to Document Reasons: Do not leave this item blank without clearly documenting the reason for non-vaccination.
- Misclassifying Contraindications: Ensure that the resident’s medical record supports any contraindication claimed as the reason for not receiving the vaccine.
- Omitting Offer: Ensure the vaccine is offered to all residents, and document if the offer was refused or missed.
7. Practical Application
- Example 1: A resident was not given the pneumococcal vaccine due to a severe allergic reaction to a prior dose. In this case, O0300B is coded 1 (Not eligible).
- Example 2: A resident was informed of the vaccine but chose to decline it. In this case, O0300B is coded 2 (Offered and declined).
- Example 3: A resident was admitted but was not offered the pneumococcal vaccine during their stay. O0300B is coded 3 (Not offered).
Please note that the information provided in this guide for MDS 3.0 Item set O0300B 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.
