O0110G2c. Treatment: Non-Invasive Mechanic Ventilator-BiPAP-At Discharge
Step-by-Step Coding Guide for Item Set: O0110G2c, Treatment: Non-Invasive Mechanical Ventilator- BiPAP-At Discharge
1. Review of Medical Records
Objective: To determine if BiPAP therapy was used at the time of discharge. Key Points:
- Examine the resident's medical records closely for mentions of BiPAP use leading up to discharge.
- Look for documentation from respiratory therapists, pulmonologists, and nursing notes detailing BiPAP settings, duration, and compliance.
- Assess discharge planning notes to confirm the continuation of BiPAP therapy post-discharge.
2. Understanding Definitions
Objective: Clarify BiPAP therapy and its indication for residents. Key Points:
- BiPAP stands for Bilevel Positive Airway Pressure, providing two levels of pressure for easier breathing for residents with respiratory issues.
- Indicated for conditions like COPD, sleep apnea, and respiratory distress, especially where CO2 retention is a concern.
- Understand the criteria for discontinuing BiPAP therapy and what documentation is needed to indicate "At Discharge" usage.
3. Coding Instructions
Objective: Accurately code for BiPAP usage at the time of discharge. Key Points:
- Code '1' if BiPAP therapy was used at any time on the day of discharge.
- Include the rationale for BiPAP therapy in the resident's discharge summary.
- Detail the specific settings and any recommendations for ongoing care or adjustments needed post-discharge.
4. Coding Tips
Objective: Ensure clarity and accuracy in coding BiPAP at discharge. Key Points:
- Verify the exact discharge date and time to confirm BiPAP use falls within this timeframe.
- Collaborate with the respiratory therapy department for accurate details on therapy settings and continuation plans.
- Remember, the intent is to capture the resident's status and needs at discharge accurately.
5. Documentation
Objective: Maintain comprehensive records for BiPAP therapy up to discharge. Key Points:
- Document the decision-making process for continuing BiPAP therapy, including interdisciplinary team input and resident/family discussions.
- Keep a detailed account of therapy settings, adjustments made, and resident tolerance up to the point of discharge.
- Ensure the discharge plan includes clear instructions for BiPAP use, including equipment needed and follow-up care.
6. Common Errors to Avoid
Objective: Identify and prevent common coding mistakes. Key Points:
- Misinterpreting "At Discharge" to mean cessation of therapy rather than continuation.
- Failing to document or communicate BiPAP therapy continuation needs with the receiving facility or home care provider.
- Overlooking the importance of including BiPAP therapy details in the discharge summary.
7. Practical Application
Objective: Reinforce learning through practical examples. Key Points:
- Scenario: A resident with chronic sleep apnea used BiPAP nightly during their stay and was discharged with a recommendation for ongoing nighttime use. How is this documented and coded?
- Conduct coding exercises based on discharge summaries, focusing on identifying and coding BiPAP therapy correctly.
- Review case studies where BiPAP therapy at discharge impacted post-discharge care and discuss how these were coded and documented.
Please note that the information provided in this guide for MDS 3.0 Item O0110G2c: 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.
