Understanding and Coding MDS 3.0 Item O0110C4c: Treatment - Oxygen Therapy - High-Concentration - At Discharge

Understanding and Coding MDS 3.0 Item O0110C4c: Treatment - Oxygen Therapy - High-Concentration - At Discharge

Introduction

Purpose:
Oxygen therapy is a critical treatment for residents who require supplemental oxygen to maintain adequate blood oxygen levels. MDS Item O0110C4c, Treatment: Oxygen Therapy - High-Concentration - At Discharge, is used to document whether a resident was receiving high-concentration oxygen therapy at the time of discharge from a long-term care facility. Accurate documentation of this item is essential for ensuring continuity of care, compliance with clinical guidelines, and effective discharge planning. This article provides detailed guidance on how to correctly code this item according to the latest MDS 3.0 guidelines.

What is MDS Item O0110C4c?

Explanation:
MDS Item O0110C4c, Treatment: Oxygen Therapy - High-Concentration - At Discharge, is part of Section O, which focuses on special treatments, procedures, and programs provided to the resident. This item specifically captures whether the resident was receiving high-concentration oxygen therapy at the time of discharge. High-concentration oxygen therapy typically involves the administration of oxygen at concentrations higher than 40% to address severe hypoxemia or respiratory distress.

Documenting the use of high-concentration oxygen therapy at discharge is crucial to ensure that the resident’s ongoing respiratory care needs are communicated to the next care provider and that appropriate follow-up care is arranged.

Guidelines for Coding O0110C4c

Coding Instructions:
To correctly code Item O0110C4c, follow these steps:

1. Review the Resident’s Discharge Records:

   • Carefully review the resident’s medical records, particularly the discharge summary, to determine if high-concentration oxygen therapy was required at the time of discharge.

2. Determine the Appropriate Response:

   • Code “1” if the resident was receiving high-concentration oxygen therapy at the time of discharge.
   • Code “0” if the resident was not receiving high-concentration oxygen therapy at discharge.

3. Enter the Response in Item O0110C4c:

   • Record the appropriate code (1 or 0) based on the resident’s use of high-concentration oxygen therapy at discharge.
   • Ensure that this information is consistent with the resident’s discharge records and aligns with the facility’s documentation protocols.

Example Scenario:
A resident with severe chronic obstructive pulmonary disease (COPD) required high-concentration oxygen therapy during their stay at the facility. At the time of discharge, the resident continued to need this therapy, and arrangements were made for high-concentration oxygen to be provided at home. The MDS Coordinator would enter 1 in Item O0110C4c to indicate that high-concentration oxygen therapy was being provided at discharge. This ensures that the resident’s ongoing care needs are accurately documented and that appropriate follow-up care can be arranged.

Best Practices for Accurate Coding

Documentation:

• Maintain thorough records of all oxygen therapy provided during the resident’s stay, especially noting if high-concentration oxygen therapy was required at the time of discharge.
• Clearly document the resident’s condition, the flow rate of oxygen, and the duration of therapy, supporting accurate coding of Item O0110C4c.

Communication:

• Ensure effective communication among the healthcare team to accurately track and document the need for high-concentration oxygen therapy, particularly at the time of discharge.
• Communicate with the resident’s next care provider or home health agency to ensure they are aware of the ongoing need for high-concentration oxygen therapy and any necessary follow-up care.

Regular Audits:

• Conduct regular audits of discharge records to verify that all relevant information about oxygen therapy is accurately recorded in Item O0110C4c.
• Address any discrepancies promptly to ensure compliance with documentation requirements and to maintain the integrity of resident care records.

Conclusion

Summary:
MDS Item O0110C4c is essential for documenting whether a resident required high-concentration oxygen therapy at the time of discharge from a long-term care facility. Accurate coding of this item ensures that the resident’s ongoing respiratory care needs are fully documented and supports the coordination of follow-up care. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure that high-concentration oxygen therapy is appropriately managed and documented, thereby supporting quality care and accurate reporting.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-149] for detailed guidelines on documenting high-concentration oxygen therapy at discharge and other special treatments.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item O0110C4c: Treatment - Oxygen Therapy - High-Concentration - At Discharge was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.