Step-by-Step Coding Guide for Item Set O0110A2c: Treatment - Chemotherapy IV - At Discharge

1. Review of Medical Records

Begin the process by conducting a comprehensive review of the resident's medical records close to the discharge date. Look specifically for any evidence that the resident has been receiving intravenous (IV) chemotherapy treatments. This should include checking physician orders, nursing notes, and treatment administration records for mentions of chemotherapy, focusing on the 14 days leading up to discharge.

2. Understanding Definitions

• Chemotherapy: The use of drugs to stop or slow the growth of cancer cells, often by killing them or preventing their division.
• IV Chemotherapy: This method involves administering chemotherapy drugs directly into the bloodstream through a vein, making it a systemic treatment.

3. Coding Instructions

• Code 1 (Yes): If the resident received IV chemotherapy treatment at any point in the 14 days prior to discharge and the treatment is ongoing at the time of discharge.
• Code 0 (No): If the resident did not receive IV chemotherapy within the 14 days before discharge, or if the treatment was concluded before discharge.

4. Coding Tips

• Verify that the chemotherapy was administered via IV. Treatments given by other routes should not be coded in this item.
• Confirm the treatment timeline to ensure it falls within the specified 14-day look-back period from the discharge date.
• Pay special attention to the discharge plan to determine if IV chemotherapy treatment is ongoing post-discharge.

5. Documentation

In the resident's medical record, clearly document the specific IV chemotherapy drugs administered, dosages, dates of administration, and any side effects observed. Also, include a detailed discharge plan that outlines the continuation of IV chemotherapy treatment, if applicable.

6. Common Errors to Avoid

• Misidentifying the route of chemotherapy administration (i.e., coding non-IV treatments in this item).
• Overlooking documentation that indicates the continuation of IV chemotherapy treatment after discharge.
• Incorrectly coding completed treatments as ongoing at the time of discharge.

7. Practical Application

Example: A resident has been receiving a course of IV chemotherapy for lung cancer every three weeks. The most recent session occurred 10 days prior to discharge, and the oncologist has scheduled the next session for three weeks from the discharge date. This scenario should be coded as 1 (Yes) for O0110A2c, as the treatment is ongoing and falls within the 14-day look-back period.

Please note that the information provided in this guide for MDS 3.0 Item set O0110A2c  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.