Step-by-Step Coding Guide for Item Set K0100B: Swallow Disorder - Holds Food in Mouth/Cheeks

Step-by-Step Coding Guide for Item Set K0100B: Swallow Disorder - Holds Food in Mouth/Cheeks

1. Review of Medical Records

• Objective: To determine if the resident holds food in their mouth or cheeks.
• Process:
  • Nursing Notes: Review daily nursing notes for observations of the resident holding food in their mouth or cheeks.
  • Speech Therapy Records: Check speech therapy evaluations and progress notes for documented instances of holding food in the mouth.
  • Direct Observations: Examine records from direct observations by caregivers or dining staff.
  • Resident Interviews: Include interviews with the resident or family members about difficulties experienced during meals.

2. Understanding Definitions

• Holds Food in Mouth/Cheeks: Refers to a condition where the resident retains food in their mouth or cheeks instead of swallowing it. This can indicate a problem with the swallowing process and may lead to potential risks such as choking or malnutrition.

3. Coding Instructions

• Code K0100B:
  • 0: No, the resident does not hold food in mouth/cheeks.
  • 1: Yes, the resident holds food in mouth/cheeks.
• Example: If a resident frequently holds food in their mouth during meals, and this behavior is documented in the nursing notes and speech therapy records, code K0100B as '1'.

4. Coding Tips

• Detailed Observation: Ensure that observations are consistent and recorded over multiple meals to confirm the behavior.
• Consistency Across Records: Verify that nursing notes, speech therapy records, and any other relevant documentation consistently report the behavior.

5. Documentation

• Required Documentation:
  • Nursing Notes: Detailed notes from nursing staff indicating instances of holding food.
  • Therapy Records: Speech therapy evaluations and progress notes highlighting the issue.
  • Observation Records: Direct observation records from caregivers or dining staff.
• Example: "During the week of 05/01/2024, nursing notes indicate that the resident held food in their mouth during at least three meals. Speech therapy progress notes dated 05/05/2024 also confirm this behavior."

6. Common Errors to Avoid

• Assuming Behavior: Do not assume the resident holds food in their mouth without documented evidence.
• Inconsistent Documentation: Ensure all relevant documentation is consistent in reporting the behavior.
• Overlooking Intermittent Behavior: Consider intermittent behaviors if they occur frequently enough to pose a risk.

7. Practical Application

• Scenario: A resident is observed by nursing staff holding food in their mouth during multiple meals over a week. Speech therapy notes from the same period confirm the behavior. This consistent documentation supports coding K0100B as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set K0100B 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.