Step-by-Step Coding Guide for Item Set: O0110K1b, Treatment: Hospice- While a Resident

1. Review of Medical Records

Objective: Determine if hospice care was provided during the resident's stay. Key Points:

• Carefully review the resident's medical records for any documentation of hospice care enrollment, including physician orders, nursing notes, and hospice service logs.
• Look for hospice care agreements or contracts, interdisciplinary team meeting notes, and individual care plans related to hospice care.
• Note the date of enrollment in hospice care and any changes in the level of care or services provided during the resident's stay.

2. Understanding Definitions

Objective: Clarify what constitutes hospice care within a long-term care setting. Key Points:

• Hospice care focuses on palliative care, providing comfort, and supporting quality of life for residents with terminal illnesses.
• It involves a comprehensive approach, including pain and symptom management, psychological, social, and spiritual support, tailored to the resident's needs and preferences.
• Hospice care can be provided in various settings, including long-term care facilities, ensuring the resident's comfort and dignity.

3. Coding Instructions

Objective: Accurately code for hospice care provided while the individual is a resident. Key Points:

• Code '1' if the resident received hospice care at any time during their stay, excluding the day of admission and discharge.
• Ensure that coding reflects the actual provision of hospice care services, verified through detailed medical records.
• Document all periods of hospice care received during the resident's stay, regardless of the duration.

4. Coding Tips

Objective: Enhance accuracy and consistency in coding hospice care treatments. Key Points:

• Regularly update and review the resident’s medical records to ensure all instances of hospice care are captured.
• Collaborate with the hospice care team to clarify any ambiguities in documentation regarding the provision of care.
• Accurately capturing the initiation, continuation, or termination of hospice care is vital for resident care planning and resource allocation.

5. Documentation

Objective: Maintain comprehensive documentation for hospice care. Key Points:

• Document detailed information about the hospice care provided, including services, frequency, interdisciplinary team involvement, and changes in care plans.
• Include notes on the resident's response to hospice care and any adjustments made to address their needs and preferences.
• Ensure that documentation reflects communication with the resident and their family regarding care goals and expectations.

6. Common Errors to Avoid

Objective: Identify and rectify frequent documentation and coding errors. Key Points:

• Not coding hospice care because it is considered part of routine care for the resident.
• Overlooking documentation of hospice care services due to inadequate communication between care teams.
• Failing to update hospice care plans or document changes in the level of care or services provided.

7. Practical Application

Objective: Apply coding and documentation practices to real-world scenarios. Key Points:

• Scenario: A resident with terminal cancer enrolls in hospice care two weeks after admission to manage pain and receive supportive services. Document and code this scenario, emphasizing the importance of accurate care capture and interdisciplinary collaboration.
• Utilize hypothetical resident scenarios in staff training sessions to practice identifying and coding hospice care, focusing on the nuances of documenting palliative care services.
• Discuss various case studies in team meetings, focusing on the challenges and best practices in documenting and coding hospice care, emphasizing the impact on resident well-being and facility operations.

Please note that the information provided in this guide for MDS 3.0 Item set O0110K1b 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.