Step-by-Step Coding Guide for Item Set O0110A3c: Treatment - Chemotherapy - Oral - At Discharge

1. Review of Medical Records

Start the coding process by meticulously reviewing the resident's medical records close to their discharge date. Focus on identifying documentation indicating that the resident was receiving or was prescribed oral chemotherapy treatment to continue post-discharge. This includes reviewing physician orders, nursing notes, pharmacy records, and discharge planning documents.

2. Understanding Definitions

• Chemotherapy: A treatment method that uses drugs to kill cancer cells or stop them from growing.
• Oral Chemotherapy: Chemotherapy that is taken by mouth in pill, capsule, or liquid form, as opposed to being administered intravenously or through other routes.

3. Coding Instructions

• Code 1 (Yes): If the resident was taking oral chemotherapy drugs in the 14 days prior to discharge, with the treatment intended to continue after leaving the facility.
• Code 0 (No): If the resident was not taking oral chemotherapy drugs in the 14 days before discharge or if the oral chemotherapy treatment was completed before discharge.

4. Coding Tips

• Ensure the chemotherapy is specifically oral. Intravenous or other non-oral forms of chemotherapy should not be coded here.
• Confirm the treatment is ongoing and intended to continue post-discharge.
• Accurately account for the 14-day look-back period leading up to the discharge date.

5. Documentation

In the resident's medical records and discharge summary, clearly document:

• The names of the oral chemotherapy medications
• Dosages
• Frequency and duration of the treatment
• Instructions for continued treatment after discharge
• Any relevant information from oncologists or treating physicians regarding the resident's cancer treatment plan.

6. Common Errors to Avoid

• Coding treatments that are not administered orally under this item.
• Missing documentation that oral chemotherapy is to continue post-discharge.
• Incorrectly coding completed treatments as ongoing at the time of discharge.

7. Practical Application

Example: A resident has been undergoing treatment for pancreatic cancer with an oral chemotherapy regimen started two months prior to discharge. The most recent prescription was filled 10 days before discharge, with clear instructions for the resident to continue taking the medication as prescribed, without interruption, post-discharge. This scenario should be coded as 1 (Yes) for O0110A3c, as the oral chemotherapy treatment is ongoing and intended to continue after the resident leaves the facility.

Please note that the information provided in this guide for MDS 3.0 Item O0110A3c: 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.