Step-by-Step Coding Guide for Item Set O0110B1c: Treatment: Oxygen Therapy - At Discharge

1. Review of Medical Records

Objective: To identify any instances of oxygen therapy being administered at the time of discharge.

• Action: Examine the resident's medical records closely, focusing on the period leading up to discharge. Look for physician's orders, nursing notes, and respiratory therapy documentation indicating the administration of oxygen therapy.

2. Understanding Definitions

Objective: Clarify what constitutes oxygen therapy specifically at discharge.

• Key Points: Oxygen therapy involves the administration of oxygen at concentrations greater than that in ambient air to prevent or treat hypoxia. "At Discharge" refers to oxygen therapy being prescribed for the resident to continue post-discharge from the facility.

3. Coding Instructions

Objective: Accurately code for the administration of oxygen therapy at discharge.

• Action: Code oxygen therapy if it was administered during the discharge process or if it was prescribed for use immediately following discharge.

4. Coding Tips

• Verify the continuation of oxygen therapy post-discharge through prescriptions or physician's discharge orders.
• Ensure the method of oxygen delivery and flow rate are specified for accurate post-discharge care instructions.

5. Documentation

Objective: Ensure proper documentation of oxygen therapy at discharge.

• Key Points: Document the rationale for continued oxygen therapy, including underlying conditions necessitating its use, and the specific instructions for its use after discharge.

6. Common Errors to Avoid

• Failing to code for oxygen therapy at discharge if it is prescribed for use outside the facility.
• Overlooking physician's orders or discharge planning notes indicating the need for continued oxygen therapy.

7. Practical Application

Example Scenario: A resident with chronic obstructive pulmonary disease (COPD) is discharged from the facility to home care. The discharge plan includes a prescription for oxygen therapy at 2 L/min via nasal cannula to be continued at home. The discharge documentation should reflect this plan, including the necessity and specifics of the oxygen therapy, ensuring a seamless transition to home care.

Please note that the information provided in this guide for MDS 3.0 Item set O0110B1c  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.