Step-by-Step Coding Guide for Item Set O0110A3a: Treatment - Chemotherapy - Oral - On Admission

1. Review of Medical Records

Start by thoroughly reviewing the resident's medical records upon admission. Focus on identifying any documentation that indicates the resident was receiving oral chemotherapy treatment prior to admission. This includes physician orders, nursing notes, pharmacy records, and any transfer documentation from another facility or outpatient setting.

2. Understanding Definitions

• Chemotherapy: A type of cancer treatment that uses drugs to kill cancer cells or slow their growth. It can be administered through various routes, including orally.
• Oral Chemotherapy: Chemotherapy that is taken by mouth, in the form of pills, capsules, or liquids.

3. Coding Instructions

• Code 1 (Yes): If the resident was taking oral chemotherapy drugs in the 14 days prior to admission to the facility.
• Code 0 (No): If the resident was not taking oral chemotherapy drugs in the 14 days before admission.

4. Coding Tips

• Verify the route of administration. For this item, only oral chemotherapy treatments should be considered.
• Review the medication administration record (MAR) and physician orders carefully to confirm the drug name, dosage, and administration schedule.
• Consider the 14-day look-back period carefully to ensure accurate coding.

5. Documentation

Ensure the resident's medical record includes detailed documentation of the oral chemotherapy treatment, such as the name of the medication, dosage, frequency, and duration of the treatment. Include any relevant notes from the transferring facility or outpatient treatment center regarding the resident's chemotherapy regimen.

6. Common Errors to Avoid

• Failing to notice oral chemotherapy treatment if it was started just before admission and is not yet fully documented in the resident's medical records.
• Confusing oral chemotherapy with other forms of treatment, such as IV chemotherapy or other oral medications not used for cancer treatment.
• Overlooking physician notes or MAR entries that indicate the continuation or initiation of oral chemotherapy treatment close to the admission date.

7. Practical Application

Example: A resident was admitted to the facility on March 15th. The review of the transfer documents and physician orders from the outpatient cancer treatment center reveals that the resident began an oral chemotherapy regimen on March 5th, to be taken daily for the treatment of colon cancer. This scenario should be coded as 1 (Yes) for O0110A3a since the resident was taking oral chemotherapy drugs within the 14 days prior to admission.

Please note that the information provided in this guide for MDS 3.0 Item O0110A3a: 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.