O0110G1b. Treatment: Non-Invasive Mechanic Ventilator- While a Res, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110G1b: Treatment: Non-Invasive Mechanical Ventilator - While a Resident

1. Review of Medical Records

• Objective: To identify the continuation or initiation of non-invasive mechanical ventilation during the resident's stay, excluding the admission period.
• Action Steps:
  • Conduct a thorough review of the resident's medical records, focusing on critical care notes, physician orders, and respiratory therapy documentation post-admission.
  • Look for entries detailing the use of non-invasive mechanical ventilation, including the type of device (CPAP, BiPAP), settings, duration, and clinical reasons for ventilation.

2. Understanding Definitions

• Non-Invasive Mechanical Ventilation: The use of breathing support administered through a mask or nasal prong instead of an invasive endotracheal or tracheostomy tube. It includes Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) devices.
• 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 non-invasive mechanical ventilation was provided at any point during the resident's stay, beyond the admission look-back period.
  • Document the duration and specifics of the mechanical ventilation as observed or prescribed during the resident's stay.

4. Coding Tips

• Ensure accurate differentiation between non-invasive mechanical ventilation provided upon admission and care provided as the resident's condition evolves.
• Review respiratory therapy records and care plans to verify that documented non-invasive mechanical ventilation aligns with the prescribed regimen.

5. Documentation

• Essential Elements:
  • Document the clinical justification for ongoing or initiated non-invasive mechanical ventilation, detailing any changes in the resident's condition that necessitate this level of support.
  • Record comprehensive notes on device settings (e.g., CPAP pressure, BiPAP inspiratory and expiratory pressures), changes made to the regimen, and any monitoring or weaning plans.

6. Common Errors to Avoid

• Omission of Details: Missing documentation of changes in device settings or reasons for continued ventilation, leading to gaps in care understanding.
• Misclassification: Confusing non-invasive with invasive ventilation due to unclear documentation.

7. Practical Application

Example Scenario: During their stay, a resident with congestive heart failure (CHF) experiences exacerbated nocturnal dyspnea and is prescribed BiPAP therapy at night to improve oxygenation and ease breathing. The care team documents the initiation of BiPAP therapy, including specific settings tailored to the resident's needs, and outlines a monitoring process to assess effectiveness and adjust therapy as needed.

Please note that the information provided in this guide for MDS 3.0 Item set O0110G1b  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.