O0110D1c. Treatment: Suctioning- At Discharge, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110D1c: Treatment: Suctioning - At Discharge

1. Review of Medical Records

• Objective: Identify any plans for the continuation of suctioning treatments as part of the resident's discharge plan.
• Action Steps:
  • Thoroughly examine the resident's medical records focusing on sections related to discharge planning, physician orders, and any respiratory therapy documentation.
  • Identify entries that specify the continuation of suctioning post-discharge, noting the method of suctioning (oral, nasal, tracheal), equipment used, and the clinical indications for its continuation.

2. Understanding Definitions

• Suctioning: A medical procedure used to clear the airways of secretions or blockages through various methods, crucial for residents unable to clear their airways independently.
• At Discharge: Indicates interventions or treatments recommended for continuation as the resident transitions from the facility to another care setting or home care.

3. Coding Instructions

• Action Steps:
  • Code for suctioning if it is included in the discharge instructions, indicating a need for the treatment to continue beyond the facility's care.
  • Document the specific details of the suctioning treatment prescribed for after discharge, including frequency and method.

4. Coding Tips

• Ensure the discharge plan clearly outlines the continuation of suctioning, specifying the conditions under which it should be administered.
• Clarify any specific instructions regarding suctioning method and equipment to be used post-discharge.

5. Documentation

• Essential Elements:
  • Document the clinical justification for continuing suctioning treatment, including details on the resident's condition necessitating this care.
  • Provide comprehensive instructions for post-discharge care providers, detailing how to perform the suctioning, equipment needed, and signs indicating the need for suctioning.

6. Common Errors to Avoid

• Omission: Not documenting or coding for suctioning as part of the discharge plan when clinically indicated.
• Vagueness: Failing to provide detailed instructions for suctioning post-discharge, leading to potential care gaps.

7. Practical Application

Example Scenario: A resident with ALS requires intermittent oral suctioning to manage saliva pooling and prevent aspiration. As part of the discharge planning, the care team includes oral suctioning in the resident's home care instructions, specifying the use of a portable suction machine, the technique for suctioning, and the frequency based on the resident's current needs and signs of distress.

Please note that the information provided in this guide for MDS 3.0 Item set O0110D1c 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.