O0425A2: SLP and Audiology Services: Concurrent Minutes, Step-by-Step
Step-by-Step Coding Guide for Item Set O0425A2: "SLP and Audiology Services: Concurrent Minutes"
1. Review of Medical Records
- Objective: Accurately record the concurrent minutes of Speech-Language Pathology (SLP) and Audiology Services provided during the resident's stay.
- Actions:
- Access the resident’s medical records, focusing on therapy logs and session notes for the entire SNF Part A stay.
- Review documentation specifically for instances where SLP or audiology services were provided concurrently, meaning two residents were treated simultaneously but engaged in different activities.
- Confirm the accuracy of the minutes documented by therapists and cross-check with session logs.
2. Understanding Definitions
- O0425A2: Concurrent Minutes for SLP and Audiology Services: This item captures the total number of minutes that SLP or audiology services were provided on a concurrent basis. Concurrent therapy refers to when two residents are treated by the same therapist at the same time, but they are not performing the same or similar activities, and the therapist is providing line-of-sight supervision.
- Concurrent Therapy: Defined as therapy provided to two residents simultaneously by one therapist, where both residents are not performing the same activities, and both must be in the therapist’s line of sight.
3. Coding Instructions
- Step-by-Step:
- Step 1: Identify all SLP and audiology sessions provided during the resident's stay that meet the criteria for concurrent therapy.
- Step 2: Calculate the total number of minutes of concurrent therapy provided by adding up all sessions where concurrent therapy was documented.
- Step 3: Enter the total concurrent minutes in the O0425A2 field on the MDS.
- Step 4: If no concurrent therapy was provided, enter "0".
4. Coding Tips
- Ensure Accuracy: Verify that the minutes counted as concurrent meet the specific criteria for concurrent therapy and are documented accordingly.
- Document Justification: Ensure the rationale for using concurrent therapy is documented in the resident’s care plan, and it aligns with therapy goals.
- Cross-Check Logs: Ensure that all recorded minutes are supported by therapy logs, and discrepancies are addressed before finalizing the MDS.
5. Documentation
- Objective: Maintain comprehensive and accurate documentation of all concurrent therapy sessions.
- Actions:
- Record the specific times and dates of all concurrent therapy sessions.
- Document the types of activities performed during these sessions to justify the concurrent therapy classification.
- Keep detailed logs of all SLP and audiology therapy minutes, ensuring they match the MDS entries.
6. Common Errors to Avoid
- Incorrect Classification: Do not classify therapy as concurrent unless it strictly meets the criteria defined for concurrent therapy.
- Incomplete Documentation: Failing to document the specifics of the therapy session can result in incorrect coding and potential compliance issues.
- Overlapping Minutes: Ensure that minutes are not double-counted, especially when different types of therapy modes are used in close succession.
7. Practical Application
- Example 1: During the resident's stay, they received SLP services in a concurrent therapy session where another resident was treated simultaneously. The session lasted 30 minutes. These 30 minutes are entered into O0425A2.
- Example 2: A resident received audiology services exclusively in individual sessions, with no concurrent therapy provided. The O0425A2 field is coded as "0".
Please note that the information provided in this guide for MDS 3.0 Item set O0425A2 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.
