Step-by-Step Coding Guide for Item set O0110O1b: Treatment: IV Access - While a Resident

1. Review of Medical Records

• Objective: To confirm whether intravenous (IV) access was utilized while the resident was at the facility.
• Process:
  • Examine physician orders for any instructions regarding IV treatments including medications, fluids, or other therapies.
  • Review nursing documentation for records of IV administration, including start and end dates.
  • Check medication administration records (MAR) for entries related to IV treatments.

2. Understanding Definitions

• IV Access - While a Resident: Refers to the use of any intravenous lines for administration of fluids, medication, or nutritional substances during the resident's stay in the facility.

3. Coding Instructions

• Code O0110O1b:
  • 0: No IV access was utilized.
  • 1: IV access was utilized at any time during the stay.
• Example: If a resident received IV antibiotics for an infection during their stay, code O0110O1b as '1'.

4. Coding Tips

• Verify the exact days IV access was in use to ensure accurate coding, especially if the IV treatment spans over the assessment reference date.
• Consult with nursing staff if documentation is unclear or incomplete.

5. Documentation

• Required Documentation:
  • Physician’s orders specifying the IV treatment.
  • Nursing notes indicating the insertion and removal of the IV.
  • MAR entries showing the administration of treatments via IV.
• Ensure that the documentation clearly specifies the duration and purpose of the IV access.

6. Common Errors to Avoid

• Coding for IV access that was ordered but not actually initiated.
• Overlooking short-term IV access used during the look-back period.
• Failing to update coding when IV access is discontinued before the assessment cut-off.

7. Practical Application

• Scenario: A resident develops pneumonia and is ordered to receive IV antibiotics for a 7-day course. The IV is placed on the first day of treatment and removed upon completion. The nurse records each day’s antibiotic administration in the MAR. During MDS coding, the staff verifies these entries and codes O0110O1b as '1' to reflect the IV antibiotic treatment during the resident’s stay.

Please note that the information provided in this guide for MDS 3.0 Item set O0110O1b 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.