Step-by-Step Coding Guide for Item Set O0110C4c: Treatment: Oxygen Therapy - High Concentration - At Discharge

1. Review of Medical Records

• Objective: To identify any instances where high-concentration oxygen therapy is prescribed as part of the resident's discharge plan.
• Action Steps:
  • Thoroughly review the resident's medical records, focusing on sections relevant to discharge planning, physician orders, and respiratory therapy documentation.
  • Identify documentation that specifies high-concentration oxygen therapy, noting prescribed oxygen concentration (typically above 40%), method of delivery, and clinical indications for its use at discharge.

2. Understanding Definitions

• High-Concentration Oxygen Therapy: The administration of oxygen at concentrations significantly above room air (21% oxygen), usually greater than 40%, to address specific medical conditions.
• At Discharge: Indicates treatments or interventions recommended for continuation as the resident transitions from the facility to another setting or home care.

3. Coding Instructions

• Action Steps:
  • Code this item if the resident is discharged with instructions for high-concentration oxygen therapy.
  • Document the specifics of the therapy, including the oxygen concentration and delivery method as prescribed for post-discharge care.

4. Coding Tips

• Ensure discharge instructions clearly detail the high-concentration nature of the oxygen therapy, including specific usage instructions.
• Distinguish between standard oxygen therapy and high-concentration oxygen therapy based on the prescribed concentration and intended use.

5. Documentation

• Essential Elements:
  • Document the medical justification for high-concentration oxygen therapy at discharge, including conditions necessitating its use.
  • Provide clear instructions for post-discharge care providers, detailing oxygen concentration, flow rate, and method of delivery.

6. Common Errors to Avoid

• Overlooking the distinction between standard and high-concentration oxygen therapy in discharge documentation.
• Failing to provide detailed post-discharge instructions that specify the therapy as high-concentration.

7. Practical Application

Example Scenario: A resident with chronic obstructive pulmonary disease (COPD) exacerbation is stabilized and prepared for discharge to home care. The discharge plan includes high-concentration oxygen therapy at 50% via a venturi mask to be used as needed, based on specific criteria outlined by the pulmonologist. Detailed instructions for the home health care provider include monitoring criteria, oxygen setup, and emergency procedures.

Please note that the information provided in this guide for MDS 3.0 Item set O0110C4c 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.