Understanding and Coding MDS 3.0 Item O0400A2: Speech-Language Pathology/Audiology: Concurrent Minutes

Introduction

Purpose:
Concurrent therapy in speech-language pathology and audiology involves treating two residents simultaneously, with each resident working on different activities under the supervision of one therapist. MDS Item O0400A2, Speech-Language Pathology/Audiology: Concurrent Minutes, is used to document the total minutes of speech-language pathology or audiology provided in a concurrent therapy setting during the assessment period. Accurate documentation of these therapy minutes is crucial for ensuring compliance with Medicare regulations, supporting proper reimbursement, and facilitating effective care 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 O0400A2?

Explanation:
MDS Item O0400A2, Speech-Language Pathology/Audiology: Concurrent Minutes, is part of Section O, which focuses on special treatments, procedures, and programs provided to the resident. This item specifically captures the total number of minutes that the resident received speech-language pathology or audiology in a concurrent therapy setting during the 7-day look-back period. Concurrent therapy is defined as therapy provided to two residents simultaneously, with each resident performing different activities, under the supervision of one therapist or therapy assistant.

Documenting the total concurrent therapy minutes is crucial for tracking the resident’s therapy utilization, evaluating the effectiveness of the rehabilitation program, and ensuring that therapy services are appropriately billed under Medicare Part A.

Guidelines for Coding O0400A2

Coding Instructions:
To correctly code Item O0400A2, follow these steps:

1. Identify Concurrent Speech-Language Pathology/Audiology Sessions Provided:

   • Review the resident’s therapy records to identify all concurrent speech-language pathology or audiology sessions attended during the 7-day look-back period.
   • Concurrent therapy involves treating two residents simultaneously, with both residents working on different therapy activities.

2. Calculate the Total Minutes:

   • Add up the total number of minutes the resident spent in concurrent speech-language pathology or audiology sessions during the look-back period.
   • Include only the time during which the resident was actively engaged in concurrent therapy, under the supervision of a therapist or therapy assistant.

3. Select the Appropriate Response:

   • Enter the total number of concurrent speech-language pathology/audiology minutes provided during the assessment period.
   • If no concurrent therapy was provided, enter 0.

4. Enter the Response in Item O0400A2:

   • Record the calculated total minutes of concurrent speech-language pathology/audiology services in Item O0400A2.
   • Ensure that this information is consistent with the resident’s therapy records and that the care plan reflects the concurrent therapy services provided.

Example Scenario:
A resident participated in concurrent speech-language therapy sessions on three separate days during the 7-day look-back period. Each session lasted for 30 minutes, with the resident working on different activities from the other resident in the session. The total concurrent therapy time was 90 minutes. The MDS Coordinator would enter 90 in Item O0400A2 to document the total minutes of concurrent speech-language pathology/audiology services. This ensures accurate documentation of the resident’s therapy utilization and supports proper care planning and Medicare billing.

Best Practices for Accurate Coding

Documentation:

• Maintain detailed records of all concurrent speech-language pathology/audiology sessions, including the specific dates, duration, and activities conducted during each session.
• Ensure that documentation accurately reflects the resident’s participation in concurrent therapy to support the coding of Item O0400A2.

Interdisciplinary Communication:

• Foster effective communication among the therapy team, nursing staff, and other care providers to accurately track and document the total minutes of concurrent speech-language pathology/audiology services provided.
• Regularly update the care plan to reflect any changes in the resident’s concurrent therapy schedule or activities.

Regular Audits:

• Conduct periodic audits of therapy documentation to verify that all concurrent speech-language pathology/audiology minutes are accurately recorded and that the total time is correctly reflected in Item O0400A2.
• Address any discrepancies promptly to ensure compliance with Medicare reimbursement requirements and to maintain the integrity of resident care records.

Conclusion

Summary:
MDS Item O0400A2 is essential for documenting the total number of minutes of speech-language pathology or audiology provided in a concurrent therapy setting to residents in long-term care settings. Accurate coding of this item ensures that therapy utilization is effectively monitored, compliance with Medicare regulations is maintained, and proper reimbursement is secured. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure that concurrent speech-language pathology/audiology services are appropriately managed and documented, thereby enhancing the quality of care provided to residents.

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 3-148] for detailed guidelines on documenting the number of minutes of concurrent speech-language pathology/audiology services and other special treatments.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item O0400A2: Speech-Language Pathology/Audiology: Concurrent Minutes 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.