O0110O4c: IV Access - Central - At Discharge, Step-by-Step

Step-by-Step Coding Guide for O0110O4c: IV Access - Central - At Discharge

1. Review of Medical Records

Objective: Verify whether the resident had central IV access at the time of discharge.
Actions:

• Access the resident’s medical records, including treatment notes, physician orders, and discharge summaries.
• Check for documentation confirming the presence of central IV access during the last three days at the facility.
• Confirm if the resident had a central line, such as a PICC line, tunneled port, or other centrally located IV devices.

2. Understanding Definitions

O0110O4c: IV Access - Central - At Discharge: This refers to central intravenous access used for medication administration, fluids, or other treatments during the last three days of the resident’s stay prior to discharge.

• Central IV Access: Refers to catheters such as PICC lines or tunneled ports, inserted into a central vein to administer medications, fluids, or blood products.
• PICC Line (Peripherally Inserted Central Catheter): A long catheter inserted through a peripheral vein, typically in the arm, and advanced to a large central vein near the heart.
• Tunneled Port: A catheter that is surgically placed under the skin and inserted into a large central vein, commonly used for long-term treatments.

3. Coding Instructions

Step-by-Step:

• Step 1: Review the medical records to determine if the resident had central IV access during the last three days of their stay.
• Step 2: Ensure that the IV access was central (e.g., PICC line, tunneled port) and not peripheral or midline.
• Step 3: If the resident had central IV access, check O0110O4c to indicate "Yes".
• Step 4: If the resident did not have central IV access at discharge, mark "No" in O0110O4c.

4. Coding Tips

• Central vs. Peripheral: Be sure to differentiate between central IV access and other types of access (e.g., peripheral or midline). Only central access (e.g., PICC, tunneled ports) should be coded in O0110O4c.
• Review Discharge Summary: The discharge summary should indicate if the central IV line was removed before discharge or remained in place, which is crucial for accurate coding.

5. Documentation

Objective: Ensure the resident's central IV access is clearly documented and appropriately coded in the discharge assessment.
Actions:

• Include specific details about the type of IV access (e.g., PICC line, tunneled port), including the date of placement and confirmation that it remained in place at discharge.
• If the IV access was removed before discharge, document the date and reason for removal.

6. Common Errors to Avoid

• Confusing Central and Peripheral Access: Ensure only central access is coded in O0110O4c. Peripheral lines or midlines should not be coded in this section.
• Incomplete Documentation: Avoid coding central IV access at discharge without corresponding documentation in the medical records.

7. Practical Application

• Example 1: A resident had a PICC line inserted during their stay for long-term IV antibiotic treatment, and the line remained in place at discharge. O0110O4c is coded “Yes”.
• Example 2: A resident had a peripheral IV line, but no central access during the last three days of their stay. O0110O4c is coded “No”.
• Example 3: A resident with a central port had it removed two days before discharge. O0110O4c is coded “No”, as the central access was not in place at the time of discharge.

Please note that the information provided in this guide for MDS 3.0 Item set O0110O4c 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.