Step-by-Step Coding Guide for Item Set O0425B2: Occupational Therapy - Concurrent Minutes

1. Review of Medical Records

Objective: Identify the minutes a resident spent in concurrent occupational therapy sessions. Key Points:

• Carefully examine the resident’s occupational therapy documentation within the 7-day look-back period, focusing on sessions marked as concurrent.
• Note each session's duration where the resident received therapy at the same time as one other resident, but with each working on their own individual goals.

2. Understanding Definitions

Objective: Define what constitutes concurrent minutes for occupational therapy. Key Points:

• Concurrent occupational therapy refers to sessions provided to two residents simultaneously by the same therapist or therapy assistant, where each resident is engaged in different activities tailored to their specific therapeutic goals.
• The key aspect of concurrent therapy is that it involves individualized treatment plans being executed in the same space, not group therapy activities.

3. Coding Instructions

Objective: Accurately code the minutes of concurrent occupational therapy sessions. Key Points:

• Aggregate the total minutes the resident was engaged in concurrent occupational therapy during the 7-day look-back period.
• Only include minutes from sessions where exactly two residents were treated simultaneously, and both were engaged in individualized therapeutic activities.

4. Coding Tips

Objective: Provide tips to ensure precise and consistent coding. Key Points:

• Verify that the documentation specifies the session as concurrent, noting the presence of another resident receiving therapy simultaneously.
• Clarify session notes to ensure each resident's individual goals were addressed during the concurrent session.

5. Documentation

Objective: Highlight the importance of thorough documentation for concurrent sessions. Key Points:

• Clearly document the start and end times of the concurrent session, the activities performed by each resident, and the therapeutic goals addressed.
• Ensure documentation reflects the concurrent nature of the session, including details of both residents' participation and progress.

6. Common Errors to Avoid

Objective: Identify and prevent common mistakes in coding concurrent therapy minutes. Key Points:

• Avoid confusing concurrent therapy minutes with group therapy or individual therapy minutes; ensure the session meets the specific criteria for concurrent therapy.
• Ensure accurate recording of the session's duration; do not overestimate the time by failing to document the start and end times accurately.

7. Practical Application

Objective: Demonstrate the application of these guidelines with examples. Key Points:

• Example 1: Resident U and Resident V both receive 30 minutes of concurrent occupational therapy on Monday, focusing on different fine motor skills. Coding for each resident: 30 concurrent minutes.
• Example 2: Resident W participates in a 45-minute concurrent session with Resident X on Wednesday, with Resident W focusing on self-feeding techniques while Resident X works on dressing skills. Coding for each resident: 45 concurrent minutes.

Please note that the information provided in this guide for MDS 3.0 Item set O0425B2 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.