Step-by-Step Coding Guide for Item Set: O0110J2c, Treatment: Dialysis- Hemodialysis- At Discharge

1. Review of Medical Records

Objective: Determine if hemodialysis treatment was administered at the time of discharge. Key Points:

• Review the resident's medical records closely around the discharge period for any documentation of hemodialysis treatment.
• Focus on physician orders, medication administration records (MARs), nursing notes, and dialysis treatment logs detailing hemodialysis sessions on the day of discharge.
• Document the specifics of the hemodialysis event, including the setting (in-facility or outpatient), frequency, duration, and any complications noted.

2. Understanding Definitions

Objective: Clarify what constitutes hemodialysis treatment at discharge. Key Points:

• Hemodialysis is a medical procedure where blood is filtered outside the body through a machine to remove waste products and excess fluid, primarily used for individuals with renal failure.
• This treatment can occur in various settings, including hospitals, dialysis centers, and, in some cases, long-term care facilities equipped with the necessary machinery.
• Understanding the procedure and scheduling of hemodialysis is crucial for accurate documentation and coding at discharge.

3. Coding Instructions

Objective: Accurately code for hemodialysis treatment administered at the time of discharge. Key Points:

• Code '1' if the resident underwent hemodialysis treatment on the day of discharge.
• Ensure the coding reflects the actual administration of hemodialysis treatment, verified through medical records, not just planned or ordered treatments.
• Document both in-facility and outpatient hemodialysis treatments administered on the day of discharge.

4. Coding Tips

Objective: Ensure precision in coding hemodialysis treatments at discharge. Key Points:

• Verify the discharge date against hemodialysis treatment records to ensure accurate coding.
• Collaborate with healthcare team members to clarify any ambiguities in documentation regarding hemodialysis treatment.
• For residents transferred for hemodialysis on the day of discharge, ensure proper communication and documentation from the dialysis center to accurately code the treatment.

5. Documentation

Objective: Maintain comprehensive documentation for hemodialysis treatment at discharge. Key Points:

• Document the details of hemodialysis treatment administered on the day of discharge, including type, duration, setting, and any observations or complications.
• Note any post-discharge instructions related to ongoing hemodialysis treatment, including scheduling, transportation arrangements, and follow-up care.
• Ensure the discharge summary includes a clear rationale for the hemodialysis treatment and outlines the plan for continuing care.

6. Common Errors to Avoid

Objective: Identify and mitigate frequent documentation and coding mistakes. Key Points:

• Overlooking hemodialysis treatments administered on the day of discharge due to incomplete documentation or miscommunication between care teams.
• Misinterpreting plans or orders for hemodialysis as actual administration, leading to incorrect coding if the treatment was not executed.
• Failing to document the transition of care or post-discharge hemodialysis plan, potentially impacting the resident's continuity of care.

7. Practical Application

Objective: Apply coding and documentation knowledge through practical examples. Key Points:

• Scenario: A resident with chronic kidney disease receives hemodialysis in an outpatient center on the morning of their discharge. Detail the process of documenting and coding this treatment, focusing on the importance of capturing all relevant details for continuity of care.
• Use hypothetical scenarios in staff training sessions to practice identifying and coding hemodialysis treatments at discharge, emphasizing the significance of accurate documentation.
• Discuss real-life case studies in staff meetings, focusing on the challenges and best practices in documenting and coding hemodialysis treatments at discharge and their impact on post-discharge care planning.

Please note that the information provided in this guide for MDS 3.0 Item O0110J2c: 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.