O0110C4a. Treatment: Oxygen Therapy- High Concentration- On Adm

Step-by-Step Coding Guide for Item Set O0110C4a: Treatment: Oxygen Therapy - High Concentration - On Admission

1. Review of Medical Records

• Objective: Identify instances of high-concentration oxygen therapy initiated upon the resident's admission.
• Action Steps:
  • Conduct a thorough examination of the resident's medical records upon admission, focusing on physician's orders, nursing assessments, and respiratory therapy notes.
  • Look for documentation indicating the start of high-concentration oxygen therapy, including the prescribed concentration (typically above 40%), method of delivery, and clinical indications.

2. Understanding Definitions

• High-Concentration Oxygen Therapy: Refers to the administration of oxygen at concentrations significantly higher than room air (21% oxygen), usually greater than 40%, to treat acute hypoxemias and other specific medical conditions.
• On Admission: Refers to treatments initiated during the 7-day look-back period from the resident's admission date.

3. Coding Instructions

• Action Steps:
  • Code the item as present if high-concentration oxygen therapy was ordered and initiated within the 7-day look-back period from admission.
  • Include the specific details of the oxygen concentration and delivery method as prescribed.

4. Coding Tips

• Verify that the prescribed oxygen concentration meets the criteria for "high concentration" (typically >40%).
• Distinguish high-concentration oxygen therapy from other oxygen therapies by its purpose and prescribed concentration.

5. Documentation

• Essential Elements:
  • Clearly document the medical justification for high-concentration oxygen therapy, including specific conditions necessitating this level of treatment.
  • Record the exact oxygen concentration prescribed, the method of delivery (e.g., mask type), and duration of therapy.

6. Common Errors to Avoid

• Failing to differentiate between standard and high-concentration oxygen therapy in coding, leading to inaccuracies.
• Overlooking physician orders or respiratory therapy notes that specify the oxygen concentration, resulting in incorrect coding.

7. Practical Application

Example Scenario: Upon admission, a resident with severe pneumonia exhibits signs of significant hypoxemia. The attending physician prescribes oxygen therapy at 60% concentration via a non-rebreather mask. The nursing and respiratory therapy documentation clearly outline the start date, concentration, and method of delivery, aligning with the physician’s orders for high-concentration oxygen therapy.

Please note that the information provided in this guide for MDS 3.0 Item O0110C4a: Type of Record 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.