Step-by-Step Coding Guide for Item Set O0110C1a: Treatment - Oxygen Therapy (On Admission)

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s use of oxygen therapy upon admission.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, nursing notes, admission forms, and previous assessments.
  2. Identify Oxygen Therapy Documentation: Look for documented instances where the resident was prescribed and receiving oxygen therapy at the time of admission.
  3. Confirm Details: Verify the consistency of the oxygen therapy documentation through various sources within the medical records.

2. Understanding Definitions

• Oxygen Therapy: The administration of oxygen as a medical intervention, which can be delivered via nasal cannula, mask, or other delivery systems.
• On Admission: Refers to the time frame immediately upon the resident’s admission to the facility.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm that the resident was receiving oxygen therapy at the time of admission from the medical records.
  2. Verify Documentation: Ensure the oxygen therapy is clearly documented in the resident’s admission records and initial nursing assessments.
  3. Code Appropriately: Code O0110C1a as "1" if the resident was receiving oxygen therapy on admission, and "0" if they were not.

4. Coding Tips

• Accurate Identification: Ensure the oxygen therapy is explicitly mentioned and confirmed by the admission records or physician orders.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s oxygen therapy.
• Consult Healthcare Providers: If there is any uncertainty, consult with the attending physician or respiratory therapist for clarification.

5. Documentation

• Required:
  • Admission Forms: Ensure the resident’s admission forms clearly indicate the use of oxygen therapy.
  • Physician Orders: Include any physician orders or prescriptions for oxygen therapy.
  • Nursing Notes: Document the initial nursing assessment indicating the use of oxygen therapy at the time of admission.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s oxygen therapy through multiple records and consultation.
• Incomplete Documentation: Make sure all relevant admission forms, physician orders, and nursing notes are included.
• Assumptions: Do not assume the use of oxygen therapy without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: John, a 75-year-old resident, was admitted to the facility and was receiving oxygen therapy via nasal cannula.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, including admission forms, physician notes, and nursing assessments that indicate he was on oxygen therapy at the time of admission.
    2. Identify Therapy: It is confirmed that John was receiving oxygen therapy at the time of admission.
    3. Document and Code: The nurse documents the use of oxygen therapy in John’s records and codes O0110C1a as "1".
  • Outcome: John’s use of oxygen therapy on admission is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C1 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.