Step-by-Step Coding Guide for Item Set O0110A1c: Treatment - Chemotherapy - At Discharge

This guide focuses on the proper coding and documentation of chemotherapy treatment at the time of discharge as recorded in the MDS 3.0 item set O0110A1c.

1. Review of Medical Records

Begin by thoroughly examining the resident's medical records, focusing on physician orders, nursing notes, and treatment administration records. Look for documentation related to chemotherapy treatments, including type, dosage, frequency, and any specific instructions given at the time of discharge.

2. Understanding Definitions

Chemotherapy refers to the use of chemical substances to treat disease, particularly cancer. In the context of MDS coding, it includes treatments administered at the facility and those prescribed for continuation after discharge.

3. Coding Instructions

• Code 1 (Yes) if the resident received chemotherapy treatment during the last 14 days of their stay and the treatment is continuing at the time of discharge.
• Code 0 (No) if the resident did not receive chemotherapy treatment during this period, or if the treatment was completed before discharge.

4. Coding Tips

• Ensure the treatment falls within the 14-day look-back period and is ongoing at discharge.
• Verify chemotherapy orders are current and include detailed instructions for continued treatment post-discharge.
• Distinguish between active treatment and maintenance or follow-up care related to chemotherapy.

5. Documentation

Document the type of chemotherapy, dosages, administration method, and frequency in the resident’s medical record. Include physician orders for continued treatment post-discharge and any special instructions or precautions.

6. Common Errors to Avoid

• Overlooking chemotherapy treatments that fall within the 14-day look-back period but are not documented as continuing at discharge.
• Failing to update the MDS to reflect changes in chemotherapy orders or treatment plans at the time of discharge.

7. Practical Application

Example: A resident has been receiving chemotherapy intravenously every two weeks for lung cancer. The last treatment was 10 days before discharge, and the physician has ordered the treatment to continue on schedule after discharge. This scenario should be coded as 1 (Yes) for O0110A1c.

Please note that the information provided in this guide for MDS 3.0 Item O0110A1c: 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.