K0100C. Swallow disorder: cough/ choke with meals/meds, Step-by-Step

Step-by-Step Coding Guide for Item Set: K0100C. Swallowing Disorder: Cough/Choke with Meals/Meds

1. Review of Medical Records

   • Begin with a comprehensive examination of the resident's medical records, focusing on notes related to nutrition, medication administration, and observations from speech-language pathologists. Specifically, look for any documented instances of coughing or choking during meals or when taking medications. This might include notes in nursing logs, dietary assessments, and therapy evaluations.

2. Understanding Definitions

   • Swallowing Disorder: Challenges with any phase of swallowing, from accepting foods and liquids into the mouth to moving them to the stomach. These disorders can lead to difficulty safely consuming foods, liquids, and medications.
   • Cough/Choke with Meals/Meds: A symptom of a swallowing disorder where the resident experiences coughing or choking while eating, drinking, or taking medications, indicating potential aspiration or difficulty in safely swallowing.

3. Coding Instructions

   • Code 0: No - If the resident does not exhibit coughing or choking during meals or medication administration.
   • Code 1: Yes - If there is evidence or observation of the resident coughing or choking while eating, drinking, or taking medications.
   • Determine the presence of coughing or choking based on medical documentation and direct observations from the care team.

4. Coding Tips

   • Engage with staff who are directly involved in feeding or medication administration for firsthand observations of any coughing or choking incidents.
   • Consider the consistency of foods or types of medications that may trigger these responses, as detailed observations can inform safer dietary or medication modifications.

5. Documentation

   • Clearly document your coding decision in the MDS. Additionally, in the resident’s medical record and care plan, detail any incidents of coughing or choking noted during meals or medication administration, including the context and any immediate interventions or follow-up assessments conducted.

6. Common Errors to Avoid

   • Overlooking mild or infrequent episodes of coughing or choking that may still signify a risk for aspiration.
   • Not updating the resident's care plan or MDS coding to reflect changes in their condition or the effectiveness of interventions.

7. Practical Application

   • Example: Mrs. Patel, who has Parkinson’s disease, experiences episodes of coughing when drinking thin liquids and occasionally while taking her pill medications. A speech-language pathologist assesses her and recommends thickened liquids and altering medication administration techniques. These interventions are documented in her care plan. For K0100C, Mrs. Patel would be coded as "1" for Yes, indicating she coughs/chokes with meals/meds. The care plan and MDS are updated to reflect these observations, with detailed strategies for managing her swallowing difficulties to reduce the risk of aspiration.

The Step-by-Step Coding Guide for item K0100C in MDS 3.0 Section K is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.