Step-by-Step Coding Guide for Item Set O0110A2a: Treatment - Chemotherapy IV - On Admission

1. Review of Medical Records

Begin by thoroughly reviewing the resident's medical records upon admission. Look for documentation that specifies the resident has been receiving intravenous (IV) chemotherapy treatment prior to admission. This includes physician orders, nursing notes, and any transfer documentation from a hospital or other facility.

2. Understanding Definitions

• Chemotherapy: The use of chemical agents to treat diseases, especially cancer.
• IV Chemotherapy: Chemotherapy that is administered directly into the vein, allowing it to move quickly into the bloodstream to reach and affect cancer cells throughout the body.

3. Coding Instructions

• Code 1 (Yes): If the resident received IV chemotherapy treatment in the 14 days prior to admission to the facility.
• Code 0 (No): If the resident did not receive IV chemotherapy in the 14 days before admission or if the chemotherapy was not administered intravenously.

4. Coding Tips

• Ensure accurate capture of the 14-day look-back period from the date of admission.
• Understand the route of administration; only IV chemotherapy qualifies for this item.
• Review transfer documents for mentions of recent chemotherapy treatments.

5. Documentation

Document the specific IV chemotherapy treatments received, including drug names, dosages, dates of administration, and the medical rationale for the treatment. This documentation should be easily accessible in the resident's medical record.

6. Common Errors to Avoid

• Failing to recognize IV chemotherapy if administered at another facility within the look-back period.
• Confusion between different routes of chemotherapy administration (e.g., oral, IV, intramuscular) and incorrectly coding non-IV treatments here.
• Overlooking physician notes or orders that indicate ongoing chemotherapy treatment plans that include IV administration.

7. Practical Application

Example: A resident was admitted to the facility on April 15th. They received an IV chemotherapy treatment for breast cancer on April 5th at a hospital. This should be coded as 1 (Yes) for O0110A2a since the IV chemotherapy treatment occurred within the 14 days prior to admission to the facility.

Please note that the information provided in this guide for MDS 3.0 Item set O0110A2a 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.