Step-by-Step Coding Guide for Item Set O0110O2c: Treatment: IV Access - Peripheral - At Discharge

1. Review of Medical Records

• Objective: Accurately determine and document the use of peripheral IV access at discharge for a resident.
• Steps:
  1. Collect Information: Gather comprehensive medical records, including physician notes, nursing notes, treatment records, and discharge summaries.
  2. Identify Documentation of Peripheral IV Access: Look for documented instances of peripheral IV access at the time of discharge.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Peripheral IV Access: Involves the insertion of a needle or catheter into a peripheral vein for the administration of fluids, medications, or nutrients.
• At Discharge: Refers to the status of the resident’s treatment at the time they are discharged from the facility or care setting.
• Key Points:
  • Peripheral IV Access: Typically used for short-term treatments and involves veins in the arms, hands, feet, or legs.
  • Documentation: Ensure that the peripheral IV access was active at the time of discharge.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the presence of peripheral IV access at the time of discharge.
  2. Verify Documentation: Ensure that the documentation clearly notes the use of peripheral IV access at discharge, including any physician orders and nursing notes.
  3. Code Appropriately: Enter the appropriate code for item set O0110O2c:
     • 0: No, the resident did not have peripheral IV access at discharge.
     • 1: Yes, the resident had peripheral IV access at discharge.

4. Coding Tips

• Accurate Identification: Ensure the presence of peripheral IV access at discharge is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the use of peripheral IV access.
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the order and use of peripheral IV access at discharge.
  • Nursing Notes: Detailed notes from nursing staff documenting the maintenance and status of the peripheral IV access.
  • Treatment Records: Records indicating the use and management of peripheral IV access.
  • Discharge Summaries: Summaries that include the status of peripheral IV access at the time of discharge.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the use of peripheral IV access through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, nursing notes, and treatment records are included to support the documented use.
• Assumptions: Do not assume the presence of peripheral IV access without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Mary, an 80-year-old resident, was discharged with peripheral IV access for the administration of antibiotics.
  • Steps:
    1. Review Records: The nurse reviews Mary’s medical records, noting the physician’s order for peripheral IV access and the discharge summary confirming its use at discharge.
    2. Identify IV Access: It is confirmed through the documentation that Mary had peripheral IV access at the time of discharge.
    3. Document and Code: The nurse documents the peripheral IV access in Mary’s records and codes O0110O2c as "1".
  • Outcome: Mary’s use of peripheral IV access at discharge is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set O0110O2c 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.