O0110G2c. Treatment: Non-Invasive Mechanic Ventilator-BiPAP-At Discharge, Step-by-Step
Step-by-Step Coding Guide for Item Set: O0110G2c, Treatment: Non-Invasive Mechanical Ventilator-BiPAP-At Discharge
1. Review of Medical Records
Objective: Determine if BiPAP therapy was utilized at the time of discharge. Key Points:
- Thoroughly review the resident's medical records leading up to discharge for mentions of BiPAP therapy, focusing on respiratory therapist notes, physician orders, and nursing documentation.
- Pay attention to the resident's response to BiPAP therapy and any changes made to settings or frequency of use.
- Document any physician orders for continuing BiPAP therapy after discharge, indicating the therapy's necessity for the resident's well-being.
2. Understanding Definitions
Objective: Gain a clear understanding of BiPAP therapy and its application. Key Points:
- BiPAP, or Bilevel Positive Airway Pressure, offers two levels of air pressure: one for inhalation and a lower one for exhalation, aiding in respiratory conditions where CO2 retention is a concern.
- It is typically used for residents with sleep apnea, chronic obstructive pulmonary disease (COPD), or other conditions affecting normal breathing patterns.
- Understanding when and why BiPAP therapy is prescribed will aid in accurate documentation and coding.
3. Coding Instructions
Objective: Correctly code for BiPAP use at the time of discharge. Key Points:
- If BiPAP was used on the day of discharge, code '1' for this item.
- Record the purpose of BiPAP therapy and note if the resident will continue to need this therapy post-discharge.
- Include the final settings used for the resident's BiPAP therapy to provide a complete picture of the care provided.
4. Coding Tips
Objective: Ensure accurate and consistent coding for BiPAP therapy at discharge. Key Points:
- Confirm the discharge date and BiPAP usage on that day to ensure accurate coding.
- Collaborate with the care team, including respiratory therapists, to confirm details of BiPAP therapy.
- Accurately capturing BiPAP use at discharge is crucial for continuity of care and proper handoff to home or another facility.
5. Documentation
Objective: Maintain detailed records of BiPAP therapy up to and including discharge. Key Points:
- Document the rationale for continuing BiPAP therapy post-discharge, including anticipated benefits and goals.
- Include detailed instructions for BiPAP use in the discharge summary, ensuring that the receiving caregiver or facility has clear guidance.
- Record any resident and family education provided about BiPAP therapy to support adherence and understanding.
6. Common Errors to Avoid
Objective: Identify common pitfalls in coding and documentation. Key Points:
- Failing to note BiPAP use on the day of discharge, leading to inaccurate coding.
- Overlooking the documentation of BiPAP settings and rationale for continued use post-discharge.
- Assuming BiPAP therapy is discontinued at discharge without confirming with the care team or physician orders.
7. Practical Application
Objective: Apply coding knowledge through real-life scenarios. Key Points:
- Scenario: A resident with COPD has been on BiPAP therapy during their stay. On the day of discharge, BiPAP is used until the resident leaves the facility. The discharge plan includes continued BiPAP use at home. How would this be documented and coded?
- Discuss this scenario in team meetings, focusing on the importance of accurate coding and documentation for seamless care transition.
- Use case studies to practice coding for BiPAP use at discharge, highlighting different scenarios where BiPAP therapy may be indicated.
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.
