Step-by-Step Coding Guide for Item Set O0110C2c: Treatment: Oxygen Therapy - Continuous - At Discharge

1. Review of Medical Records

• Objective: Identify instances where continuous oxygen therapy is prescribed at the time of discharge.
• Action Steps:
  • Review the resident’s medical record, focusing on the discharge planning sections, physician orders, and respiratory therapy notes.
  • Look for explicit mentions of oxygen therapy, including the prescribed flow rate, duration, and type of oxygen delivery system to be used after discharge.

2. Understanding Definitions

• Continuous Oxygen Therapy: The administration of oxygen at a prescribed concentration for more than 14 hours daily, intended to treat or prevent hypoxemia.
• At Discharge: Indicates treatments or interventions that are to continue as the resident transitions from the facility to another setting or home.

3. Coding Instructions

• Action Steps:
  • Code the item as present if the resident is discharged with orders for continuous oxygen therapy.
  • Include only therapy prescribed for 14 hours or more per day in this coding.

4. Coding Tips

• Verification: Ensure that the discharge instructions clearly state the continuation of oxygen therapy, specifying it as continuous.
• Clarity: Confirm that the duration (continuous) and specifics of oxygen therapy are documented.

5. Documentation

• Essential Elements:
  • Document the rationale for continuous oxygen therapy, including the resident's underlying condition(s) necessitating its use.
  • Include detailed instructions for the oxygen therapy, specifying equipment, flow rate, and duration, ensuring clarity for the next care provider or setting.

6. Common Errors to Avoid

• Omission: Failing to code oxygen therapy as continuous when it meets the criteria based on discharge instructions.
• Assumption: Assuming continuation without clear documentation in the discharge orders or plans.

7. Practical Application

Example Scenario: A resident with severe COPD is being discharged to a home setting. The discharge summary includes a prescription for continuous oxygen therapy, specifying 2 liters per minute via a nasal cannula, to be administered 24 hours a day. The documentation includes instructions for the home health care provider to monitor the therapy and adjust as necessary, with clear guidelines for equipment use and maintenance.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C2c 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.