O0110G1c: Treatment: Non-Invasive Mechanical Ventilator - At Discharge, Step-by-Step

Step-by-Step Coding Guide for Item set O0110G1c: Treatment: Non-Invasive Mechanical Ventilator - At Discharge

1. Review of Medical Records

• Objective: To determine if a non-invasive mechanical ventilator was used at the time of the resident's discharge.
• Process:
  • Examine the resident's care plan and physician's orders for any mention of non-invasive ventilator support.
  • Review nursing documentation and respiratory therapy records to confirm usage details, specifically close to discharge dates.
  • Check discharge summaries to verify the continuation of non-invasive ventilatory support post-discharge.

2. Understanding Definitions

• Non-Invasive Mechanical Ventilator: A device that supports breathing without the need for intubation, typically using masks or similar interfaces to deliver ventilatory support.

3. Coding Instructions

• Code O0110G1c:
  • 0: Non-invasive mechanical ventilator not used at discharge.
  • 1: Non-invasive mechanical ventilator used at discharge.
• Example: If a resident with COPD exacerbation was using a BiPAP machine up to and including the day of discharge, code O0110G1c as '1'.

4. Coding Tips

• Confirm the type of ventilatory support (ensure it is non-invasive).
• Note the specific times of use, especially if the ventilator support ceased before discharge but within the look-back period.

5. Documentation

• Required Documentation:
  • Detailed physician’s orders specifying the use of a non-invasive ventilator.
  • Respiratory therapy notes detailing the settings and duration of use.
  • Discharge instructions that confirm the continuation of non-invasive ventilation if applicable.
• Documentation should explicitly state the usage of non-invasive ventilation to support accurate coding.

6. Common Errors to Avoid

• Misclassifying invasive ventilation (e.g., intubation) as non-invasive.
• Coding for discontinued non-invasive ventilation that was not in use at the time of discharge.
• Overlooking or misinterpreting the dates and times that correlate with the actual use of the ventilator.

7. Practical Application

• Scenario: A resident was admitted with acute respiratory failure and placed on a CPAP machine to assist with breathing. Throughout the stay, adjustments were made based on the resident's recovery progress. On the day of discharge, the resident was still using the CPAP machine. This information was detailed in the discharge summary to ensure continuity of care at home. The MDS coordinator reviews this information and codes O0110G1c as '1', reflecting the use of non-invasive mechanical ventilation at discharge.

Please note that the information provided in this guide for MDS 3.0 Item set O0110G1 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.