O0110H1c. Treatment: IV Medications- At Discharge, Step-by-Step
Step-by-Step Coding Guide for Item Set: O0110H1c, Treatment: IV Medications- At Discharge
1. Review of Medical Records
Objective: Determine the use of IV medications at the time of discharge. Key Points:
- Conduct a thorough review of the resident’s medical records close to the discharge date, focusing on medication administration records (MARs), physician orders, and nursing notes related to IV medications.
- Document any IV medication administered on the day of discharge, noting the medication name, dosage, frequency, and purpose.
- Pay attention to any physician notes or discharge planning documents that mention the continuation of IV medication post-discharge.
2. Understanding Definitions
Objective: Clarify what constitutes IV medications for coding purposes. Key Points:
- IV medications refer to drugs administered directly into the bloodstream through an intravenous line for immediate effect or ongoing treatment.
- This includes antibiotics, antivirals, hydration therapies, pain management medications, and others administered intravenously.
- Understanding IV medication administration's implications on resident care and discharge planning is essential for accurate documentation.
3. Coding Instructions
Objective: Accurately code for IV medication use at the time of discharge. Key Points:
- If IV medications were administered on the day of discharge, code '1' for this item.
- Ensure that coding reflects actual medication administration, not just physician's orders or plans for post-discharge care.
- Include all IV medications administered, regardless of the duration or frequency.
4. Coding Tips
Objective: Ensure accuracy and consistency in coding IV medications at discharge. Key Points:
- Verify the discharge date and medication administration records to confirm IV medication use on that day.
- Clarify any uncertainties with the nursing staff, pharmacy, or prescribing physician to ensure accurate coding.
- Be mindful of IV medications that may have been started on the day of discharge for continuation in an outpatient setting.
5. Documentation
Objective: Maintain comprehensive documentation for IV medication administration at discharge. Key Points:
- Document the name, dosage, route, and timing of IV medications administered on the day of discharge.
- Include notes on the reason for IV medication administration and any related care instructions for post-discharge.
- Ensure the discharge summary clearly outlines the plan for ongoing IV medication therapy, if applicable, including any follow-up appointments or home health care instructions.
6. Common Errors to Avoid
Objective: Identify and prevent typical mistakes in documentation and coding. Key Points:
- Failing to code IV medications administered on the day of discharge due to oversight or incomplete MARs.
- Misinterpreting physician orders for IV medications as actual administration, leading to inaccurate coding.
- Overlooking documentation related to the continuation or cessation of IV medications post-discharge.
7. Practical Application
Objective: Reinforce coding practices with real-world scenarios. Key Points:
- Scenario: A resident receiving IV antibiotic therapy for a bacterial infection is discharged with orders to continue the medication at home. Detail how this information is coded and documented, focusing on the discharge process and communication with home health services.
- Use training sessions to engage staff in identifying and coding IV medications at discharge through role-playing exercises or case studies.
- Discuss different scenarios in team meetings, such as residents transitioning to oral medications at discharge or those needing ongoing IV therapy, and how these are documented and coded.
Please note that the information provided in this guide for MDS 3.0 Item set O0110H1c 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.
