Step-by-Step Coding Guide for Item Set O0110O1c: Treatment - IV Access at Discharge

Step-by-Step Coding Guide for Item Set O0110O1c: Treatment - IV Access at Discharge

1. Review of Medical Records

• Objective: Determine if the resident had IV access at the time of discharge.
• Process:
  • Discharge Summary: Review the discharge summary for documentation of IV access.
  • Nursing Notes: Check nursing notes for details about the IV access during the discharge period.
  • Physician Orders: Verify physician orders regarding the continuation or removal of IV access at discharge.
  • Medication Administration Records (MARs): Examine MARs for administration of medications through IV access close to the discharge date.

2. Understanding Definitions

• IV Access at Discharge: Refers to the presence of an IV line used for medication, fluids, or other treatments that is in place at the time the resident is discharged from the facility.

3. Coding Instructions

• Code O0110O1c:
  • 0: No, the resident did not have IV access at discharge.
  • 1: Yes, the resident had IV access at discharge.
• Example: If a resident had an IV line for antibiotics that was still in place at the time of discharge, code O0110O1c as '1'.

4. Coding Tips

• Clear Documentation: Ensure that the presence of IV access at discharge is clearly documented in multiple records.
• Interdisciplinary Communication: Confirm details with the discharge planning team, including nurses and physicians, to ensure accurate coding.

5. Documentation

• Required Documentation:
  • Discharge Summary: Note indicating the status of IV access at discharge.
  • Nursing Notes: Documentation detailing the IV access.
  • Physician Orders: Orders that specify continuation or removal of IV access.
  • MARs: Records showing medications administered via IV close to the discharge date.
• Example: "The discharge summary dated 05/10/2024 states that the resident was discharged with a peripheral IV line in place for antibiotic therapy."

6. Common Errors to Avoid

• Incorrect Timing: Ensure the IV access was in place at the exact time of discharge, not removed shortly before.
• Incomplete Records: Avoid coding without verifying through complete and consistent documentation.
• Misinterpretation: Do not code IV access if it was only planned but not actually present at discharge.

7. Practical Application

• Scenario: A resident is discharged with an IV line for continued home antibiotic therapy. The discharge summary, nursing notes, and physician orders confirm the presence of IV access at the time of discharge. Therefore, O0110O1c is coded as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set O0110O1c 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.