Step-by-Step Coding Guide for Item Set O0110C2a: Treatment: Oxygen Therapy - Continuous - On Admission

1. Review of Medical Records

Start with a thorough review of the resident's medical records upon admission to identify any instances where oxygen therapy was initiated. Look for physician orders, nursing notes, and respiratory therapy records that specify the use of oxygen therapy, its flow rate, method of delivery, and the indication for its use.

2. Understanding Definitions

Oxygen therapy refers to the administration of oxygen at concentrations greater than that found in room air to treat or prevent hypoxemia. Continuous oxygen therapy is defined as oxygen delivered for 14 hours or more per day .

3. Coding Instructions

For O0110C2a, code continuous oxygen therapy if it was delivered for 14 hours or more per day during the 7-day look-back period from the date of admission. This includes oxygen administered via any method (mask, cannula, etc.) to relieve hypoxia .

4. Coding Tips

• Ensure that the documentation specifies "continuous" as per the CMS definition (14 hours or more per day).
• Verify that oxygen therapy was indeed initiated during the look-back period specifically for the admission assessment.

5. Documentation

Document the start date of oxygen therapy, including details such as the concentration of oxygen delivered, the method of delivery (e.g., nasal cannula or mask), and the specific hours per day the therapy was provided. Indicate the clinical justification for the therapy in the resident's medical record.

6. Common Errors to Avoid

• Failing to code oxygen therapy as "continuous" when it meets the 14 hours or more per day criterion.
• Overlooking or incorrectly documenting the start time and duration of oxygen therapy, leading to inaccurate coding.

7. Practical Application

Example: A resident with chronic obstructive pulmonary disease (COPD) exacerbation is admitted to the facility and prescribed oxygen therapy at a flow rate of 2 liters per minute via nasal cannula. The therapy is to be administered continuously, 24 hours a day. The medical record clearly documents the physician's order for continuous oxygen therapy starting on the day of admission, including the flow rate and method of delivery, to manage the resident's hypoxemia.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C2a 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.