Step-by-Step Coding Guide for O0110: Special Treatments, Procedures, and Programs

1. Review of Medical Records

• Objective: Identify all special treatments, procedures, and programs the resident has received.
• Procedure: Thoroughly review clinical notes, orders from healthcare providers, therapy session notes, and other relevant documentation in the resident's medical records for evidence of special treatments, procedures, or programs within the MDS assessment look-back period.

2. Understanding Definitions

• Special Treatments, Procedures, and Programs: Interventions that are beyond routine care, which may include but are not limited to IV medications, ventilator support, dialysis, chemotherapy, tracheostomy care, suctioning, respiratory therapy, wound care, and rehabilitation programs.
• Look-Back Period: The timeframe prior to the MDS assessment date for which the resident's care and treatments are reviewed. This typically covers the 7 days leading up to the assessment unless another period is specified.

3. Coding Instructions

• Item O0110 categorizes various treatments and programs. For each category:
  • Code '1' if YES: The procedure or treatment was provided during the look-back period.
  • Code '0' if NO: The procedure or treatment was not provided during the look-back period.
• Specific instructions for coding each category are provided in the MDS 3.0 RAI Manual.

4. Coding Tips

• Interdisciplinary Review: Consult with various members of the healthcare team to ensure all relevant treatments and programs are captured.
• Accuracy: Pay close attention to the start and end dates of treatments to accurately capture services provided within the look-back period.

5. Documentation

• Comprehensive Details: Clearly document the type, frequency, duration, and specific goals of each treatment or program.
• Interdisciplinary Notes: Include notes from all relevant disciplines involved in the resident's care plan, highlighting their contributions to the treatment or program.

6. Common Errors to Avoid

• Overlooking Treatments: Failing to include treatments that may not occur daily but were provided during the look-back period.
• Documentation Gaps: Insufficient detail about the treatments or programs that were administered, making it difficult to accurately code the MDS.

7. Practical Application

Example Scenario: A resident receives wound care for a pressure ulcer, respiratory therapy due to chronic obstructive pulmonary disease (COPD), and participates in a restorative walking program.

• Practical Coding: Code each relevant category under O0110 based on the provided services during the look-back period, ensuring that each intervention is accurately documented and supported by clinical notes.

The Step-by-Step Coding Guide for item O0110 in MDS 3.0 Section O is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that 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.