O0400B2: Occupational Therapy: Concurrent Minutes, Step-by-Step
Step-by-Step Coding Guide for Item Set O0400B2: Occupational Therapy: Concurrent Minutes
1. Review of Medical Records
- Objective: Gather accurate information about concurrent occupational therapy sessions.
- Steps:
- Collect Information: Review the resident’s medical records, therapy logs, and treatment plans.
- Therapy Documentation: Identify all instances of occupational therapy sessions attended by the resident.
- Session Details: Note the duration and type (concurrent therapy) of each session.
2. Understanding Definitions
- Concurrent Occupational Therapy: Therapy sessions where the therapist treats two residents at the same time, who are performing different activities.
- Concurrent Minutes: The total number of minutes a resident spends in concurrent occupational therapy sessions during the specified period.
3. Coding Instructions
- Steps:
- Identify Concurrent Sessions: Confirm which occupational therapy sessions were conducted concurrently.
- Calculate Total Minutes: Sum the minutes the resident spent in concurrent occupational therapy sessions over the 7-day look-back period.
- Code Appropriately: Enter the total number of concurrent therapy minutes in item O0400B2.
4. Coding Tips
- Accurate Timing: Ensure all concurrent therapy minutes are accurately recorded for each session.
- Consistent Documentation: Verify that therapy logs consistently document the concurrent nature of the sessions and their duration.
- Consult Therapists: If there is any uncertainty about the classification of therapy sessions, consult with the occupational therapists.
5. Documentation
- Required:
- Therapy Logs: Detailed logs of all therapy sessions, including the type (concurrent) and duration.
- Progress Notes: Notes from therapists documenting the resident’s participation and progress in concurrent therapy.
- Attendance Records: Records showing attendance in each concurrent therapy session.
6. Common Errors to Avoid
- Misclassification: Ensure only concurrent therapy minutes are included, not individual or group therapy minutes.
- Incomplete Logs: Ensure all sessions are logged with complete details about duration and type.
- Overestimation: Avoid estimating or rounding up minutes; use exact recorded times.
7. Practical Application
- Example:
- Resident Profile: John, an 80-year-old resident, participates in concurrent occupational therapy sessions.
- Steps:
- Review Records: The nurse reviews John’s therapy logs and progress notes.
- Identify Concurrent Sessions: It is confirmed that John attended concurrent therapy sessions totaling 120 minutes in the last 7 days.
- Calculate and Code: The nurse sums the concurrent therapy minutes and codes O0400B2 as 120 minutes.
- Outcome: John’s concurrent therapy participation is accurately documented and coded, ensuring proper reflection of his therapy regimen.
Please note that the information provided in this guide for MDS 3.0 Item set O0400B2 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.
