Step-by-Step Coding Guide for Item Set O0110C1b: Treatment: Oxygen Therapy - While a Resident

1. Review of Medical Records

The first step in coding for item O0110C1b involves a thorough review of the resident’s medical records. This includes:

• Physician’s Notes: Examine progress notes, history, and physical examination records.
• Nursing Notes: Check nursing notes for observations and documentation of oxygen therapy use.
• Respiratory Therapy Records: Review records from respiratory therapists detailing the oxygen therapy provided.
• Medication Administration Records (MAR): Verify records for oxygen therapy orders and administration details.
• Hospital Discharge Summaries: Look for any information related to oxygen therapy from recent hospital stays.

2. Understanding Definitions

Understanding the key definitions related to this item is crucial:

• Oxygen Therapy: Administration of oxygen to increase the concentration of oxygen in the blood. This can be delivered continuously or intermittently through devices like masks, nasal cannulas, or specialized systems.
• While a Resident: This refers to the period when the resident is staying in the facility and receiving care, not during hospital stays or other external settings.

3. Coding Instructions

Follow these steps for accurate coding:

1. Verify Oxygen Therapy: Confirm that the resident received oxygen therapy after admission/entry or reentry to the facility and within the last 14 days.
2. Determine Type of Delivery: Identify if the oxygen was delivered continuously or intermittently.
3. Document in Column b: Record the presence of oxygen therapy in Column b (While a Resident) of the O0110C1b section:
   • Code 1 (Yes): If the resident received oxygen therapy while a resident.
   • Code 0 (No): If the resident did not receive oxygen therapy while a resident.

4. Coding Tips

• Consistent Documentation: Ensure that documentation in the medical records supports the coding entry.
• Detailed Records: Provide detailed descriptions of the type and frequency of oxygen therapy, including the device used and the duration of therapy.
• Review Orders: Double-check physician orders and respiratory therapy records to confirm the presence and type of oxygen therapy.

5. Documentation

Accurate documentation is critical for compliance and effective care planning:

• Daily Records: Maintain thorough daily records of the resident’s use of oxygen therapy.
• Care Plans: Update care plans to reflect the use of oxygen therapy and any related interventions.
• Interdisciplinary Communication: Ensure all team members are informed of and document any use of oxygen therapy and its impact on the resident’s condition.

6. Common Errors to Avoid

• Inconsistent Documentation: Avoid discrepancies between the MDS data and other medical records.
• Missing Records: Ensure all instances of oxygen therapy are documented accurately.
• Incorrect Coding: Double-check coding entries for accuracy, especially the presence and type of oxygen therapy.

7. Practical Application

Use case studies and scenarios to apply your knowledge:

• Example 1: A resident with chronic obstructive pulmonary disease (COPD) receives continuous oxygen therapy via nasal cannula. The therapy is documented in the resident’s records.
  • Coding: O0110C1b would be coded 1 (Yes) for continuous oxygen therapy while a resident.
• Example 2: A resident with pneumonia receives intermittent oxygen therapy via a mask during flare-ups, documented in nursing and respiratory therapy notes.
  • Coding: O0110C1b would be coded 1 (Yes) for intermittent oxygen therapy while a resident.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C1b 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.