O0110E1b. Treatment: Tracheostomy care- While a Resident, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110E1b: Treatment: Tracheostomy Care - While a Resident

1. Review of Medical Records

• Objective: To identify instances of tracheostomy care provided during the resident's stay beyond the admission period.
• Action Steps:
  • Conduct a detailed examination of the resident's medical records, focusing on physician orders, nursing assessments, and respiratory therapy documentation after admission.
  • Look for entries that detail tracheostomy care, including cleaning, changing tracheostomy tubes, managing the stoma site, and any related procedures.

2. Understanding Definitions

• Tracheostomy Care: Involves the maintenance and care of a tracheostomy site and tube, including cleaning the site, changing dressings, and ensuring the tube remains free of blockages.
• While a Resident: Refers to treatments or interventions provided after the initial 7-day look-back period from the resident's admission.

3. Coding Instructions

• Action Steps:
  • Code this item as present if tracheostomy care was provided at any point during the resident's stay, excluding the admission look-back period.
  • Document the frequency and specifics of the tracheostomy care provided, including any changes in care procedures or products used.

4. Coding Tips

• Ensure accurate differentiation between tracheostomy care initiated upon admission and care provided continuously or as the resident's needs evolve.
• Review care plans and updates to verify that documented tracheostomy care aligns with the prescribed regimen and reflects any adjustments made based on the resident's condition.

5. Documentation

• Essential Elements:
  • Document the rationale for ongoing tracheostomy care, detailing any specific resident conditions that necessitate continued intervention.
  • Include comprehensive notes on the tracheostomy care regimen, highlighting method, frequency, equipment used, and staff observations regarding the stoma site's condition.

6. Common Errors to Avoid

• Overlooking Documentation: Missing documentation of routine tracheostomy care, assuming it's understood or unchanged from initial orders.
• Inaccuracies: Failing to update the resident's medical record with changes in tracheostomy care procedures or frequency, leading to discrepancies.

7. Practical Application

Example Scenario: A resident with a permanent tracheostomy due to severe neck trauma requires routine tracheostomy care. The care team performs daily site cleanings, dressing changes, and tube inspections. Over time, the frequency of dressing changes increases due to seasonal allergy-related increased secretions. Detailed documentation in the nursing notes reflects this adjustment, including the rationale and the resident's response to the change.

Please note that the information provided in this guide for MDS 3.0 Item set O0110E1b 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.