Step-by-Step Coding Guide for Item Set O0110B1a: Treatment: Oxygen Therapy - On Admission

1. Review of Medical Records

Objective: To identify and verify the resident's use of oxygen therapy during the 7-day look-back period. Key Points:

• Thoroughly review the resident’s medical chart, focusing on physician's orders, nursing notes, and respiratory therapy records.
• Look for documentation indicating the initiation of oxygen therapy, including the date started and any changes in the administration details (flow rate, delivery method).

2. Understanding Definitions

Objective: Clarify what constitutes oxygen therapy and when it is coded on admission. Key Points:

• Oxygen therapy involves administering oxygen at concentrations greater than ambient air (21%) to improve oxygenation.
• "On Admission" refers to oxygen therapy started within the 7-day look-back period from the date of the MDS assessment.

3. Coding Instructions

Objective: Accurate coding of O0110B1a based on CMS guidelines. Key Points:

• Code as "1" if oxygen therapy was initiated at any time during the 7-day look-back period.
• Include any form of oxygen delivery (nasal cannula, mask, etc.) prescribed by a healthcare professional.

4. Coding Tips

• Ensure the therapy was specifically ordered by a physician or authorized healthcare provider.
• Review for any temporary discontinuations but code based on initiation during the look-back period.

5. Documentation

Objective: Ensure comprehensive and precise documentation of oxygen therapy. Key Points:

• Document the specific reason for oxygen therapy, including underlying conditions (COPD, pneumonia, etc.).
• Record the delivery method, flow rate, and duration of therapy.

6. Common Errors to Avoid

• Failing to code oxygen therapy if it was started prior to but continued into the 7-day look-back period.
• Overlooking physician orders or notes indicating the medical necessity for oxygen therapy.

7. Practical Application

Example Scenario: A resident was admitted to the facility with chronic obstructive pulmonary disease (COPD) exacerbation and prescribed 2 liters per minute of oxygen via nasal cannula upon admission. The therapy was documented in the physician's orders and nursing notes, including the start date, which falls within the 7-day look-back period.

Please note that the information provided in this guide for MDS 3.0 Item O0110B1a: 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.