Step-by-Step Coding Guide for Item Set O0110C1c: Treatment: Oxygen Therapy - At Discharge

1. Review of Medical Records

• Objective: Collect comprehensive information to determine if the resident received oxygen therapy at discharge.
• Steps:
  1. Gather Records: Obtain discharge summaries, physician notes, respiratory therapy notes, and treatment plans.
  2. Identify Treatments: Look specifically for mentions of oxygen therapy in the treatment documentation.
  3. Confirm Treatment: Verify that oxygen therapy was indeed administered to the resident at the time of discharge.

2. Understanding Definitions

• Oxygen Therapy: Administration of oxygen as a medical intervention to treat or prevent hypoxia.
• At Discharge: Refers to the treatments the resident was receiving at the time they were discharged from the facility.

3. Coding Instructions

• Steps:
  1. Confirm Treatment: Verify that the resident received oxygen therapy at discharge.
  2. Locate the Correct Item: Ensure you are coding under O0110C1c, which specifically refers to oxygen therapy at discharge.
  3. Document the Information: Accurately enter the information into the MDS form, indicating "yes" if oxygen therapy was administered and "no" if it was not.

4. Coding Tips

• Accurate Timing: Ensure that the documentation clearly shows oxygen therapy was provided at the time of discharge, not before or after.
• Detailed Documentation: The discharge summary should explicitly mention oxygen therapy to avoid any ambiguity.
• Consult with Respiratory Therapists: If there are any doubts, consult with the respiratory therapy team for confirmation.

5. Documentation

• Required:
  • Discharge Summary: Must include a clear mention of oxygen therapy being administered at discharge.
  • Physician Orders: Should reflect the prescription of oxygen therapy at the time of discharge.
  • Respiratory Notes: Any notes from respiratory therapists indicating the provision of oxygen therapy at discharge.

6. Common Errors to Avoid

• Incorrect Timing: Coding for oxygen therapy provided before or after discharge rather than at discharge.
• Lack of Documentation: Missing or ambiguous documentation can lead to incorrect coding.
• Assumptions: Do not assume therapy was provided without explicit documentation.

7. Practical Application

• Example:
  • Resident Profile: Mary, a resident with chronic obstructive pulmonary disease (COPD), is discharged from the facility.
  • Steps:
    1. Review Records: The staff reviews Mary’s discharge summary, which mentions she was provided with oxygen therapy at discharge.
    2. Confirm Treatment: The summary and physician orders both confirm oxygen therapy at discharge.
    3. Document and Code: The staff accurately codes "yes" for item set O0110C1c, indicating Mary received oxygen therapy at discharge.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C1c 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.