O0425A5. SLP and Audiology services: Days, Step-by-Step

Step-by-Step Coding Guide for Item Set O0425A5: SLP and Audiology Services - Days

1. Review of Medical Records

Objective: Accurately determine the days a resident received SLP (Speech-Language Pathology) and audiology services. Key Points:

• Thoroughly review the resident's therapy documentation within the 7-day look-back period to identify any SLP and audiology service sessions.
• Note each day that the resident participated in either individual, group, concurrent, or co-treatment SLP and audiology sessions.

2. Understanding Definitions

Objective: Clarify what constitutes a "day" of SLP and audiology services for coding purposes. Key Points:

• A "day" refers to any calendar day within the 7-day look-back period on which the resident received SLP and/or audiology services, regardless of the session's duration or format (individual, group, etc.).
• Days should be counted even if multiple types of sessions occur on the same day.

3. Coding Instructions

Objective: Provide detailed instructions on how to code the number of days a resident received SLP and audiology services. Key Points:

• Count each calendar day within the look-back period on which the resident participated in at least one session of SLP or audiology services.
• Ensure to include all types of service delivery methods (e.g., individual, group).

4. Coding Tips

Objective: Offer practical advice to ensure accurate coding. Key Points:

• Use a calendar to visually track the days on which therapy services were provided to avoid miscounts.
• Review not only therapy session notes but also daily nursing and activity logs for mentions of SLP and audiology services.

5. Documentation

Objective: Emphasize the importance of thorough and accurate documentation. Key Points:

• Ensure each session of SLP and audiology services is documented, including the date, type of service (individual, group, etc.), and goals addressed.
• Documentation should be clear and detailed to support the coding of therapy days accurately.

6. Common Errors to Avoid

Objective: Identify frequent mistakes in coding and how to prevent them. Key Points:

• Not counting a day when multiple therapy sessions occurred because they were assumed to be on the same day.
• Overlooking sessions due to inadequate review of interdisciplinary notes or misinterpretation of session types.

7. Practical Application

Objective: Apply coding guidelines through examples. Key Points:

• Example 1: Resident Q participates in an individual SLP session on Monday and a group audiology session on Wednesday. Coding: 2 days.
• Example 2: Resident R attends a co-treatment SLP and OT session on Tuesday and an individual audiology session on Thursday and Friday. Coding: 3 days.

Please note that the information provided in this guide for MDS 3.0 Item set O0425A5 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.