O0110E1c. Treatment: Tracheostomy care- At Discharge, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110E1c: Treatment: Tracheostomy Care - At Discharge

1. Review of Medical Records

• Objective: Identify plans for the continuation of tracheostomy care as part of the resident's discharge plan.
• Action Steps:
  • Review the resident's medical records closely, focusing on sections relevant to discharge planning, physician orders, and respiratory therapy documentation.
  • Look for documentation specifying the need for ongoing tracheostomy care post-discharge, including cleaning, changing tubes, and managing the stoma site.

2. Understanding Definitions

• Tracheostomy Care: The routine maintenance and care of a tracheostomy site and tube, including site cleaning, dressing changes, and ensuring tube patency.
• At Discharge: Refers to interventions or treatments recommended to continue as the resident transitions from the facility to another care setting or home care.

3. Coding Instructions

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

4. Coding Tips

• Ensure clarity in the discharge plan about the continuation of tracheostomy care, specifying the detailed regimen to be followed.
• Highlight any specific instructions or equipment needed for effective tracheostomy care to be continued post-discharge.

5. Documentation

• Essential Elements:
  • Document the clinical justification for continuing tracheostomy care, detailing the resident's condition that necessitates this ongoing care.
  • Provide comprehensive instructions for post-discharge care providers, including how to perform tracheostomy care, equipment needed, and signs indicating the need for medical attention.

6. Common Errors to Avoid

• Omission: Not documenting or coding for tracheostomy care as part of the discharge plan when clinically indicated.
• Vagueness: Providing insufficient details for tracheostomy care post-discharge, leading to potential care gaps.

7. Practical Application

Example Scenario: A resident with a long-term tracheostomy due to chronic respiratory failure is prepared for discharge to a skilled nursing facility. The discharge plan includes detailed tracheostomy care instructions, emphasizing daily cleaning of the stoma site, weekly tube changes, and signs of infection to monitor. The care team ensures that the receiving facility has access to the same tracheostomy supplies used during the resident's stay and arranges for a respiratory therapist to consult post-discharge.

Please note that the information provided in this guide for MDS 3.0 Item set O0110E1c  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.