Step-by-Step Coding Guide for Item Set O0110H2c: Treatment - IV Medications - Vasoactive Med - At Discharge

This guide provides a comprehensive overview for coding the use of Intravenous (IV) Medications, specifically Vasoactive Medications, at the time of discharge. The focus is on item set O0110H2c within medical records, crucial for ensuring accurate documentation and coding in patient care settings.

1. Review of Medical Records

• Objective: Identify any instances where vasoactive IV medications were administered at discharge.
• Process: Examine the patient's medical chart, focusing on physician orders, nursing notes, and medication administration records (MAR) around the time of discharge. Look for names of vasoactive drugs and any related documentation.

2. Understanding Definitions

• Vasoactive Medications: These are drugs that affect the tone, caliber, or diameter of blood vessels, thereby influencing blood pressure and blood flow. Common examples include dopamine, norepinephrine, and epinephrine.
• At Discharge: Refers to medications that the patient is receiving through an IV at the time they leave the care setting.

3. Coding Instructions

• When to Code: Only code the item if the patient was receiving vasoactive medications intravenously at the time of discharge.
• How to Code: Enter the appropriate code in item set O0110H2c to indicate the presence (code 1) or absence (code 0) of vasoactive IV medication at discharge.

4. Coding Tips

• Accuracy: Double-check medication names and administration times to ensure accuracy.
• Clarity: Ensure that the documentation clearly indicates the medication was administered intravenously and was ongoing at discharge.

5. Documentation

• Detail Required: Documentation should include the name of the medication, dosage, route of administration (IV), and the timing relative to discharge.
• Clarity and Completeness: Ensure clarity in the documentation so that anyone reviewing the record can understand that vasoactive medication was administered via IV at discharge.

6. Common Errors to Avoid

• Incorrect Timing: Confusing medications given during the stay with those administered at discharge.
• Omission: Failing to document the route of administration or the fact that the medication was ongoing at discharge.
• Inaccuracy: Incorrectly identifying medications as vasoactive when they are not.

7. Practical Application

• Example Scenario: A patient with septic shock was receiving norepinephrine via an IV infusion to maintain blood pressure. Upon discharge, the patient was transferred to another facility for continued care, still on the norepinephrine infusion. This should be documented and coded as receiving vasoactive IV medication at discharge.
• Illustration: For clarity, visual aids such as flowcharts demonstrating the decision-making process for coding can be helpful. An example would be a flowchart that starts with "Was the patient receiving IV medication at discharge?" leading to "Was the medication vasoactive?" and culminating in the appropriate coding action.

Please note that the information provided in this guide for MDS 3.0 Item set O0110H2c 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.