Understanding and Coding MDS 3.0 Item O0425A2: SLP and Audiology Services: Concurrent Minutes

Understanding and Coding MDS 3.0 Item O0425A2: SLP and Audiology Services: Concurrent Minutes

Introduction

Purpose:
Concurrent therapy in speech-language pathology (SLP) and audiology involves treating two residents simultaneously, with each resident working on different activities. MDS Item O0425A2, SLP and Audiology Services: Concurrent Minutes, is used to document the total minutes of concurrent therapy provided by SLP and audiology services during the assessment period. Accurate documentation of these therapy minutes is crucial for ensuring compliance with Medicare regulations and supporting proper reimbursement. This article provides detailed guidance on how to correctly code this item according to the latest MDS guidelines.

What is MDS Item O0425A2?

Explanation:
MDS Item O0425A2, SLP and Audiology Services: Concurrent Minutes, is part of Section O, which focuses on special treatments, procedures, and programs provided to the resident. This item captures the total number of minutes that the resident participated in concurrent therapy sessions provided by SLP and audiology services during the assessment 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 essential for tracking the resident’s therapy utilization and ensuring that therapy services are appropriately billed under Medicare Part A.

Guidelines for Coding O0425A2

Coding Instructions:
To correctly code Item O0425A2, follow these steps:

1. Identify Concurrent SLP and Audiology Sessions: Review the resident’s therapy records to identify the concurrent SLP and audiology sessions attended during the assessment period. Concurrent therapy involves two residents working on different activities simultaneously, under the supervision of a single therapist or therapy assistant.
2. Calculate the Total Minutes: Add up the total number of minutes the resident spent in concurrent SLP and audiology therapy sessions during the 7-day look-back period. Include only the time during which the resident was actively engaged in concurrent therapy.
3. Select the Appropriate Response:
   • Enter the total number of concurrent SLP and audiology therapy minutes provided during the assessment period.
   • If no concurrent therapy was provided, enter 0.
4. Enter the Response in Item O0425A2: Record the calculated total concurrent therapy minutes in Item O0425A2. Ensure that this information is consistent with the resident’s therapy records and that the care plan reflects the therapy services provided.

Example Scenario:
A resident participated in concurrent SLP sessions on two separate days during the 7-day look-back period, with each session lasting 40 minutes. The total concurrent therapy time was 80 minutes. The MDS Coordinator would enter 80 in Item O0425A2 to document the total concurrent therapy minutes. 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 thorough documentation of all concurrent SLP and audiology sessions, including the specific dates, duration, and activities performed. This documentation should support the coding of Item O0425A2 and provide a clear record for tracking the resident’s therapy utilization and Medicare billing.

Interdisciplinary Communication:
Ensure effective communication among the therapy team and other care staff to accurately track and document the minutes spent in concurrent SLP and audiology therapy. This helps ensure consistency in reporting and supports proper care planning.

Regular Audits:
Conduct regular audits of therapy documentation to ensure that all concurrent SLP and audiology therapy minutes are accurately recorded and that the total time is correctly reflected in Item O0425A2. This helps avoid discrepancies that could impact Medicare reimbursement.

Conclusion

Summary:
MDS Item O0425A2 is essential for documenting the total minutes of concurrent therapy provided by speech-language pathology and audiology services to residents in long-term care settings. By accurately coding this item and ensuring clear documentation, healthcare professionals can monitor therapy utilization, ensure compliance with Medicare regulations, and support proper reimbursement. Following the guidelines and best practices outlined in this article will help ensure that concurrent SLP and audiology services are properly managed and documented.

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 3-148] for detailed guidelines on documenting concurrent SLP and audiology therapy minutes and other special treatments.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item O0425A2: SLP and Audiology Services: 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.