Step-by-Step Coding Guide for Item Set O0110B1b: Treatment: Oxygen Therapy - While a Resident

1. Review of Medical Records

Objective: Identify instances of oxygen therapy initiation or continuation while the resident is at the facility.

• Action: Examine medical records for physician's orders, nursing notes, and respiratory therapy documentation indicating oxygen therapy usage.

2. Understanding Definitions

Objective: Clarify what constitutes oxygen therapy within the resident's stay.

• Key Points: Oxygen therapy is the administration of oxygen at concentrations greater than what is found in ambient air to treat or prevent hypoxia.

3. Coding Instructions

Objective: Accurately reflect the resident's use of oxygen therapy.

• Action: Code oxygen therapy if administered at any point during the resident's stay after the initial admission, based on documented medical need.

4. Coding Tips

• Recommendation: Pay close attention to the duration and frequency of oxygen therapy to accurately code its continuous or intermittent use.

5. Documentation

Objective: Ensure comprehensive documentation of oxygen therapy.

• Key Points: Record the initiation, modification, and discontinuation dates of oxygen therapy, including flow rates and delivery methods.

6. Common Errors to Avoid

• Advisory: Do not overlook coding oxygen therapy if it was temporarily discontinued and then resumed during the resident's stay.

7. Practical Application

Example Scenario: A resident with chronic heart failure experiences worsening symptoms and is prescribed oxygen therapy at a flow rate of 2 L/min via nasal cannula two weeks after admission. This therapy is carefully documented in their medical records, including the rationale and specific orders from the healthcare provider.

Please note that the information provided in this guide for MDS 3.0 Item set O0110B1b 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.