O0110D2c. Treatment: Suctioning- Scheduled- At Discharge, Step-by-Step
Step-by-Step Coding Guide for Item Set O0110D2c: Treatment: Suctioning - Scheduled - At Discharge
1. Review of Medical Records
- Objective: Identify plans for the continuation of scheduled suctioning treatments as part of the resident's discharge plan.
- Action Steps:
- Carefully review the resident's medical records, especially focusing on discharge planning sections, physician orders, and respiratory therapy documentation.
- Look for documentation that specifies the continuation of suctioning on a scheduled basis post-discharge, including the method (oral, nasal, tracheal), frequency, and clinical indications.
2. Understanding Definitions
- Suctioning: A procedure to clear the airways of secretions or blockages, performed through various methods.
- Scheduled Suctioning: Suctioning performed at regular, predetermined intervals, distinct from as-needed (PRN) suctioning.
- At Discharge: Refers to treatments or interventions 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 on a scheduled basis.
- Document the specifics of the suctioning treatment prescribed for post-discharge care, including frequency and method.
4. Coding Tips
- Ensure clarity in the discharge plan regarding the scheduled nature of the suctioning, including specific intervals at which the procedure should be performed.
- Clarify any special instructions or equipment needed for suctioning to be effectively continued post-discharge.
5. Documentation
- Essential Elements:
- Document the clinical justification for continuing scheduled suctioning treatment, detailing the resident's condition that necessitates this care.
- Provide comprehensive instructions for post-discharge care providers, detailing the suctioning schedule, method, equipment used, and any signs indicating the need for adjustment.
6. Common Errors to Avoid
- Omission: Not documenting or coding for suctioning as part of the discharge plan when clinically indicated.
- Lack of Specificity: Failing to provide detailed instructions for scheduled suctioning post-discharge, leading to potential care gaps.
7. Practical Application
Example Scenario: A resident with a tracheostomy requires regular tracheal suctioning to maintain airway patency. The discharge plan includes tracheal suctioning every 4 hours and as needed for increased secretions. Detailed instructions for the home health care provider include the type of suction catheter, suctioning technique, and monitoring for potential complications.
Please note that the information provided in this guide for MDS 3.0 Item O0110D2c: 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.
