Step-by-Step Coding Guide for Item Set O0110D1b: Treatment: Suctioning - While a Resident

1. Review of Medical Records

• Objective: To identify instances of suctioning administered during the resident's stay, excluding the admission period.
• Action Steps:
  • Conduct a thorough review of the resident's medical records, focusing on physician orders, nursing assessments, and respiratory therapy documentation post-admission.
  • Look for entries indicating the initiation or continuation of suctioning procedures, specifying the type (oral, nasal, tracheal), method, and clinical rationale.

2. Understanding Definitions

• Suctioning: A medical procedure used to clear the airways of secretions or blockages. It can be performed through various methods, including orally, nasally, or via tracheostomy, depending on the resident's needs.
• While a Resident: Refers to treatments initiated or continued after the initial 7-day look-back period following admission.

3. Coding Instructions

• Action Steps:
  • Code this item if suctioning was performed at any point during the resident's stay, beyond the admission look-back period.
  • Document the specifics regarding the suctioning method and frequency as observed or prescribed during the resident's stay.

4. Coding Tips

• Pay close attention to the date and context in which suctioning was initiated to ensure accurate coding as "While a Resident."
• Differentiate suctioning related to routine care from that addressing acute or ongoing medical conditions.

5. Documentation

• Essential Elements:
  • Document the clinical indications for suctioning, detailing the resident's condition that necessitates this intervention.
  • Include detailed notes on the suctioning method, equipment used, frequency, and the resident's response to the treatment.

6. Common Errors to Avoid

• Oversight: Failing to document or code suctioning procedures because they are considered routine or ongoing care.
• Inaccuracy: Misclassifying the type or method of suctioning, leading to potential confusion or misrepresentation of the care provided.

7. Practical Application

Example Scenario: A resident with a chronic tracheostomy requires regular tracheal suctioning to maintain airway patency. The care plan, updated a month after admission, specifies suctioning to be performed every 4 hours and as needed for increased secretions. Nursing documentation reflects adherence to this plan, with entries detailing each suctioning event, the technique used, and the resident's tolerance of the procedure.

Please note that the information provided in this guide for MDS 3.0 Item set O0110D1b 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.