O0110D2a. Treatment: Suctioning- Scheduled- Adm, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110D2a: Treatment: Suctioning - Scheduled - On Admission

1. Review of Medical Records

• Objective: To identify instances where scheduled suctioning was initiated upon the resident's admission.
• Action Steps:
  • Carefully review the resident's medical records upon admission, focusing on physician orders, nursing assessments, and respiratory therapy documentation.
  • Look for entries specifying the initiation of scheduled suctioning, including the type (oral, nasal, tracheal), method, frequency, and clinical indications.

2. Understanding Definitions

• Suctioning: A procedure to clear the airways of secretions or blockages. It can be performed through various methods, including orally, nasally, or via tracheostomy.
• Scheduled Suctioning: Suctioning performed at regular, predetermined intervals, as opposed to as-needed (PRN) suctioning.
• 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 this item as present if suctioning was ordered to be performed on a scheduled basis within the 7-day look-back period from admission.
  • Include specifics about the suctioning schedule as prescribed, emphasizing the structured intervals at which the procedure is to be performed.

4. Coding Tips

• Ensure documentation from the admission clearly indicates the suctioning was to be done on a scheduled basis, differentiating it from PRN suctioning.
• Verify the scheduling details, including frequency and times, are clearly documented and align with the physician's orders.

5. Documentation

• Essential Elements:
  • Document the medical justification for scheduled suctioning, including conditions necessitating this approach over PRN suctioning.
  • Record detailed notes on the prescribed suctioning schedule, including method, frequency, equipment used, and any specific techniques or precautions to be followed.

6. Common Errors to Avoid

• Incomplete Documentation: Not providing enough detail on the suctioning schedule or omitting the rationale behind choosing a scheduled approach.
• Misclassification: Incorrectly coding scheduled suctioning as PRN or vice versa due to unclear documentation or misunderstanding of the orders.

7. Practical Application

Example Scenario: Upon admission, a resident with chronic obstructive pulmonary disease (COPD) and frequent pulmonary secretions is prescribed oral suctioning every 4 hours to maintain airway patency. The physician’s orders clearly state the suctioning schedule, which is duly noted in the nursing and respiratory therapy documentation, including the type of suction catheter to be used, suctioning technique, and monitoring for potential adverse effects.

Please note that the information provided in this guide for MDS 3.0 Item set O0110D2a  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.