Step-by-Step Coding Guide for Item Set O0110A10a: Treatment - Chemotherapy - Other - On Admission

1. Review of Medical Records

Initiate the process by conducting a thorough review of the resident's medical records upon admission. This includes physician orders, nursing notes, and any transfer documentation that provides evidence of chemotherapy treatments received other than oral or IV. Look for treatments such as intramuscular injections, subcutaneous injections, or topical applications that the resident was receiving before admission.

2. Understanding Definitions

• Chemotherapy: The use of drugs to treat cancer by killing or slowing the growth of cancer cells.
• Other Chemotherapy: Refers to chemotherapy administered by methods other than oral (by mouth) or intravenous (IV) routes, including but not limited to intramuscular (IM), subcutaneous (subq), topical applications, or any other non-oral and non-IV methods.

3. Coding Instructions

• Code 1 (Yes): If the resident was receiving chemotherapy treatments through other routes (not oral or IV) in the 14 days prior to admission.
• Code 0 (No): If the resident was not receiving any form of chemotherapy via other routes in the 14 days before admission.

4. Coding Tips

• Carefully determine the route of chemotherapy administration mentioned in the medical records to ensure accurate coding.
• Pay close attention to the 14-day look-back period to capture any chemotherapy treatment received prior to admission.
• Include all non-oral and non-IV chemotherapy treatments under this item.

5. Documentation

Ensure detailed documentation of the chemotherapy treatment in the resident's medical records, including the drug name, dosage, route of administration, frequency, duration of the treatment, and any side effects observed.

6. Common Errors to Avoid

• Incorrectly coding oral or IV chemotherapy treatments in this item.
• Overlooking chemotherapy treatments received through routes other than oral or IV.
• Missing the 14-day look-back period for chemotherapy treatments received before admission.

7. Practical Application

Example: A resident admitted on June 1st was receiving intramuscular injections of chemotherapy for prostate cancer until May 25th, as documented in the transfer records from another healthcare facility. Since this treatment falls within the 14-day look-back period and is not administered orally or IV, it should be coded as 1 (Yes) for O0110A10a.

Please note that the information provided in this guide for MDS 3.0 Item O0110A10a: Type of Record 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.