O0110A3c: Treatment: Chemotherapy - Oral - At Discharge, Step-by-Step

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

1. Review of Medical Records

• Objective: Gather accurate information about the resident’s chemotherapy treatment.
• Steps:
  1. Collect Information: Review the resident's medical records, including treatment plans, physician notes, and discharge summaries.
  2. Treatment History: Identify documented chemotherapy treatments, focusing on oral chemotherapy prescribed at discharge.
  3. Medication Records: Verify the specific medications and their administration routes.

2. Understanding Definitions

• Chemotherapy - Oral: Chemotherapy drugs administered orally, in pill or liquid form, rather than intravenously or by injection.
• At Discharge: Refers to the medications prescribed to the resident at the time of their discharge from the facility.

3. Coding Instructions

• Steps:
  1. Identify Treatment: Confirm that oral chemotherapy was prescribed at discharge.
  2. Check Documentation: Ensure the chemotherapy is documented in the discharge summary and treatment plan.
  3. Code Appropriately: Code O0110A3c for residents who are prescribed oral chemotherapy at discharge.

4. Coding Tips

• Verify Prescriptions: Double-check that the oral chemotherapy is listed in the discharge medications.
• Consistency: Ensure documentation across medical records matches the discharge summary.
• Clarify Details: If uncertain, consult with the prescribing physician or oncology team.

5. Documentation

• Required:
  • Discharge Summary: Include the specific oral chemotherapy drugs prescribed.
  • Physician Notes: Document physician notes and treatment plans.
  • Medication List: Ensure the discharge medication list includes the oral chemotherapy drugs.

6. Common Errors to Avoid

• Misdocumentation: Avoid coding if the chemotherapy was administered via another route.
• Inconsistent Records: Ensure all records consistently document the oral chemotherapy at discharge.
• Omitting Details: Do not omit any specific chemotherapy drugs from the discharge summary.

7. Practical Application

• Example:
  • Resident Profile: Jane, a 68-year-old resident, is undergoing treatment for cancer and is being discharged from the facility.
  • Steps:
    1. Review Records: The nurse reviews Jane’s treatment plan and discharge summary.
    2. Identify Treatment: Oral chemotherapy is listed in the discharge medications.
    3. Confirm Details: The nurse verifies with the physician that Jane’s oral chemotherapy is correctly documented.
    4. Document and Code: The nurse codes O0110A3c for Jane’s oral chemotherapy at discharge.
  • Outcome: Jane’s chemotherapy treatment is accurately coded and documented, ensuring proper follow-up and care planning.

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