Step-by-Step Coding Guide for Item Set: O0110Z1c, Treatment: None of the Above- At Discharge

1. Review of Medical Records

Objective: Confirm that no specific treatments listed in the MDS item sets were provided at the time of discharge. Key Points:

• Carefully review the resident's medical records close to the discharge period to ensure that none of the treatments specified in other sections of the MDS (e.g., IV therapy, dialysis, ventilator use) were provided.
• Examine physician orders, nursing notes, and treatment logs to validate the absence of these treatments.
• Document your findings, clearly stating the absence of specific treatments typically captured in the MDS item sets at the time of discharge.

2. Understanding Definitions

Objective: Define "None of the Above" in the context of MDS coding at discharge. Key Points:

• "None of the Above" refers to situations where the resident did not receive any of the specific treatments listed in the MDS item sets at the time of discharge.
• This category ensures that the resident's care needs and interventions received at discharge are accurately represented when specific treatments are not applicable.
• Knowledge of the treatments covered by MDS item sets is crucial for correctly identifying when to use this coding option.

3. Coding Instructions

Objective: Accurately code for the absence of specific treatments at discharge. Key Points:

• Code '1' under "None of the Above" if, after a thorough review of medical records, it is confirmed that none of the treatments listed in the MDS item sets were provided at the time of discharge.
• Ensure that coding accurately reflects the resident's status and the care provided at discharge, as verified through medical records.
• Document this coding decision to offer clarity on the interventions received at discharge.

4. Coding Tips

Objective: Ensure precision and consistency when coding "None of the Above." Key Points:

• Review all relevant sections of the MDS item sets to confirm the absence of specified treatments before coding "None of the Above."
• Cross-reference medical records to ensure no treatments were overlooked or undocumented.
• Use this code judiciously, making sure it accurately reflects the resident's care rather than due to missing information or documentation.

5. Documentation

Objective: Maintain detailed documentation when coding "None of the Above." Key Points:

• Include a summary of the review process in the resident's medical records, indicating that no specific treatments listed in the MDS were provided at the time of discharge.
• Document any assessments or observations that support the absence of these treatments.
• Ensure the resident's care plan and discharge summary reflect the current care needs and interventions, aligning with the coding of "None of the Above."

6. Common Errors to Avoid

Objective: Identify and address typical documentation and coding mistakes. Key Points:

• Avoid prematurely selecting "None of the Above" without thorough review of the medical records and MDS item sets.
• Do not miss treatments provided during the stay or at discharge that might not be explicitly documented in nursing notes or physician orders.
• Ensure consultation with all relevant healthcare team members to confirm the absence of specific treatments, avoiding assumptions based on incomplete information.

7. Practical Application

Objective: Apply coding and documentation practices effectively. Key Points:

• Scenario: A resident is discharged home after a stay with no need for the specific treatments listed in the MDS item sets like IV therapy, dialysis, or respiratory support. Document and code this scenario, emphasizing the importance of a comprehensive review of the resident's medical records and treatments at discharge.
• Use hypothetical resident scenarios in staff training sessions to reinforce reviewing and coding for "None of the Above," focusing on the meticulous examination of medical records and MDS item sets.
• Discuss case studies in team meetings to illustrate the significance of accurate documentation and coding, particularly for residents who do not receive the specific treatments listed in the MDS at discharge.

Please note that the information provided in this guide for MDS 3.0 Item set O0110Z1c 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.