Step-by-Step Coding Guide for O0250. Influenza Vaccine

1. Review of Medical Records

• Begin by thoroughly reviewing the resident's medical records, focusing on physician orders, nursing notes, and pharmacy records.
• Look for documentation of influenza vaccination status, including any received vaccines during the specified timeframe (October 1 through March 31).

2. Understanding Definitions

• Influenza Vaccine: A vaccine administered to protect against the flu. It's recommended yearly, especially for older adults and individuals with certain health conditions.

3. Coding Instructions

• O0250A: Code whether the resident received the influenza vaccine in the facility for the current flu season. If yes, record the date in O0250C.
• O0250B: If not received in the facility, code whether the vaccine was received outside the facility during this flu season.
• O0250C: Enter the date the vaccine was given if received.
• O0250D: If not vaccinated, code the reason: not in the facility during flu season, offered and declined, not offered, or medical contraindication.

4. Coding Tips

• Ensure the flu season's dates align with the assessment period.
• Clarify with nursing staff or pharmacists if documentation is unclear or missing.
• For residents admitted after March 31 or during the summer, review previous records or consult family/significant others to determine vaccination status before admission.

5. Documentation

• Maintain clear records in the resident's file, including vaccination dates, refusal forms, or medical contraindication notes.
• Document any conversations with residents or family members regarding the influenza vaccine, including their consent or refusal.

6. Common Errors to Avoid

• Overlooking vaccine documentation if administered outside the typical October 1 – March 31 timeframe.
• Failing to accurately code the reason for not vaccinating when applicable.
• Misinterpreting resident refusal or medical contraindications.

7. Practical Application

• Example 1: A resident receives the influenza vaccine on November 15 in the facility. Coding: O0250A = 1, O0250C = 11/15.
• Example 2: A resident declined the vaccine due to personal preference. Coding: O0250A = 0, O0250D = 2 (offered and declined).
• Example 3: A new resident was vaccinated at a clinic before admission on October 20. Coding: O0250A = 0, O0250B = 1, O0250C = 10/20.

The Step-by-Step Coding Guide for item O0250 in MDS 3.0 Section O is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.