Step-by-Step Coding Guide for Item Set O0110A10c: Treatment - Chemotherapy - Other - At Discharge

1. Review of Medical Records

Begin with an exhaustive review of the resident's medical records as the discharge date approaches. Specifically, look for documentation indicating the resident has been receiving chemotherapy treatments by methods other than oral or IV routes. This can include treatments administered via intramuscular (IM), subcutaneous (subq), topical applications, or any other routes documented in the treatment plans, physician orders, nursing notes, and pharmacy records.

2. Understanding Definitions

• Chemotherapy: A treatment method using drugs to kill or slow the growth of cancer cells.
• Other Chemotherapy: Refers to chemotherapy administered through routes other than oral or intravenous (IV), including intramuscular (IM), subcutaneous (subq), topical, or any method not categorized under standard oral or IV chemotherapy.

3. Coding Instructions

• Code 1 (Yes): If the resident was receiving chemotherapy treatments via routes other than oral or IV in the 14 days prior to discharge, and the treatment is expected to continue post-discharge.
• Code 0 (No): If the resident was not receiving chemotherapy by other methods in the 14 days before discharge, or if the treatment concluded before discharge.

4. Coding Tips

• Confirm the chemotherapy administration route to ensure it falls under the "other" category for accurate coding.
• Understand the 14-day look-back period leading up to discharge to correctly identify any qualifying treatments.
• Focus on the continuation of treatment post-discharge for correct coding under this item.

5. Documentation

In the resident’s medical record, document in detail the type of chemotherapy received, including drug names, dosages, routes of administration, administration frequency, and any noted side effects. Make sure the discharge plan clearly outlines the continuation of the specified chemotherapy treatment if applicable.

6. Common Errors to Avoid

• Misclassifying oral or IV chemotherapy treatments as "other" chemotherapy.
• Failing to note the continuation of chemotherapy treatment after discharge.
• Overlooking treatments administered through non-standard routes within the 14-day look-back period.

7. Practical Application

Example: A resident scheduled for discharge on July 15th received a topical chemotherapy cream for skin cancer treatment on July 5th. The treatment plan documented in the medical records indicates the application of the cream should continue daily for a total of 30 days. This scenario should be coded as 1 (Yes) for O0110A10c, as the treatment falls within the "other" category, occurs within the 14-day look-back period, and is expected to continue post-discharge.

Please note that the information provided in this guide for MDS 3.0 Item O0110A10c: 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.