Step-by-Step Coding Guide for N0300. Injections

1. Review of Medical Records

Start by thoroughly reviewing the resident's medical records to identify any instances of injections given during the 7-day look-back period. Pay close attention to physician orders, nursing notes, and medication administration records for documentation of any injections.

2. Understanding Definitions

• Injections: Include medications given by subcutaneous (SQ), intramuscular (IM), or intradermal routes. This does not include insulin injections, which are coded separately in item N0350.

3. Coding Instructions

• N0300: Injections
  • A: Record the number of days an injection was received during the last 7 days.
  • Code 0: If no injections were given.
  • Code 1-7: Depending on the number of days injections were received.

4. Coding Tips

• Ensure accuracy by cross-referencing the resident's medical record with the nursing staff's accounts.
• Remember, insulin injections are excluded from N0300 and should be documented in N0350.

5. Documentation

• Clearly document each instance of an injection in the resident's medical record, including the date, time, medication, dosage, and route of administration.
• Ensure all documentation is accurate, complete, and reflects the care provided to the resident.

6. Common Errors to Avoid

• Not differentiating between types of injections (e.g., including insulin injections in N0300).
• Failing to review the entire 7-day look-back period, which may lead to underreporting.
• Overlooking injections because they were administered by different healthcare providers.

7. Practical Application

• Example Scenario: A resident received a vitamin B12 injection (IM) on two separate days and a flu vaccine (SQ) on another day within the 7-day look-back period.
  • Coding: You would code N0300 as 3, reflecting injections received on three different days.

The Step-by-Step Coding Guide for item N0300 in MDS 3.0 Section N 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.