O0425A1. SLP and audiology services: Individual Minutes, Step-by-Step

Step-by-Step Coding Guide for Item Set O0425A1: SLP and Audiology Services - Individual Minutes

1. Review of Medical Records

Objective: To determine the exact minutes the resident received individual SLP (Speech-Language Pathology) and audiology services. Key Points:

• Examine therapy documentation, including SLP and audiology session notes, for the 7-day look-back period.
• Note each session's start and end time to calculate the total individual minutes spent in therapy.

2. Understanding Definitions

Objective: Clarify what constitutes individual SLP and audiology services minutes. Key Points:

• Individual minutes refer to one-on-one sessions between the therapist and the resident.
• Services must be directly related to the resident's SLP and audiology care plan to be countable.

3. Coding Instructions

Objective: Outline the process for accurately coding individual SLP and audiology services minutes. Key Points:

• Add up the total minutes of individual SLP and audiology services provided within the 7-day look-back period.
• Ensure that only direct one-on-one therapy time is included, excluding any group sessions or non-therapy interactions.

4. Coding Tips

Objective: Provide tips for consistent and accurate coding. Key Points:

• Double-check session durations against scheduled therapy times and actual therapy provided.
• Consider therapy sessions that may not occur in a traditional setting, such as bedside visits for audiology assessments.

5. Documentation

Objective: Highlight the importance of detailed documentation. Key Points:

• Each individual SLP and audiology session should be clearly documented, including therapy goals, duration, and outcomes.
• Documentation should reflect the therapy's relevance to the resident's specific treatment goals.

6. Common Errors to Avoid

Objective: Identify and avoid common coding errors. Key Points:

• Including minutes from group therapy sessions in the individual minutes count.
• Failing to update the resident's medical records with accurate session times, leading to potential underreporting or overreporting.

7. Practical Application

Objective: Demonstrate how to apply coding guidelines with examples. Key Points:

• Example 1: Resident E receives a 30-minute individual SLP session on Monday, Wednesday, and Friday. Coding: 90 minutes.
• Example 2: Resident F undergoes a 20-minute audiology assessment on Tuesday and two 15-minute individual SLP sessions on Thursday and Saturday. Coding: 50 minutes.

Please note that the information provided in this guide for MDS 3.0 Item set O0425A1 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.