Step-by-Step Coding Guide for Item Set O0110C3c: Treatment: Oxygen Therapy - Intermittent - At Discharge

1. Review of Medical Records

• Objective: To identify any orders for intermittent oxygen therapy as part of the resident's discharge plan.
• Action Steps:
  • Thoroughly review the resident's medical record, especially focusing on the sections related to discharge planning, physician orders, and respiratory therapy notes.
  • Identify any documentation that specifies intermittent oxygen therapy, noting the prescribed flow rate, duration, and method of oxygen delivery intended after discharge.

2. Understanding Definitions

• Intermittent Oxygen Therapy: Administration of oxygen at prescribed intervals rather than continuously, often used to alleviate short-term episodes of hypoxemia. This may be prescribed for use during certain activities or at specific times of the day.
• At Discharge: Treatments or interventions that are recommended to continue as the resident transitions from the facility to another setting or home care.

3. Coding Instructions

• Action Steps:
  • Code for intermittent oxygen therapy if the resident is discharged with instructions for oxygen use that do not qualify as continuous (less than 14 hours per day).
  • Record the specifics of the intermittent therapy, including the times of day and circumstances under which it should be used.

4. Coding Tips

• Detail-Oriented: Ensure the discharge instructions clearly detail the intermittent nature of the oxygen therapy, including specific usage instructions.
• Clarity Is Key: Confirm that the documentation precisely describes how the oxygen therapy is to be administered intermittently.

5. Documentation

• Essential Elements:
  • Document the medical justification for intermittent oxygen therapy, including specific conditions or activities that necessitate its use.
  • Provide clear instructions for the post-discharge care provider, detailing the oxygen flow rate, duration, and method of delivery.

6. Common Errors to Avoid

• Generalization: Avoid vague documentation that does not specify the oxygen therapy as intermittent.
• Overlooking Details: Missing to code oxygen therapy as "intermittent" when discharge instructions clearly specify non-continuous use.

7. Practical Application

Example Scenario: A resident recovering from a severe pneumonia episode is ready for discharge. The discharge plan includes intermittent oxygen therapy prescribed during sleep and physical activity, at a flow rate of 2 liters per minute via nasal cannula. Detailed instructions are provided for the home health provider, specifying the periods of use and emphasizing the need for monitoring and adjusting the therapy based on the resident's oxygen saturation levels and respiratory status.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C3c 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.