Step-by-Step Coding Guide for O0300: Pneumococcal Vaccine

1. Review of Medical Records

• Objective: Confirm the resident’s pneumococcal vaccination status.
• Process: Review the resident's medical chart for documentation of pneumococcal vaccination, including dates of administration and vaccine types (e.g., PCV13 or PPSV23).

2. Understanding Definitions

• Pneumococcal Vaccine: A vaccine given to protect against pneumococcal disease caused by the bacterium Streptococcus pneumoniae. Two types are commonly used: PCV13 (pneumococcal conjugate vaccine) and PPSV23 (pneumococcal polysaccharide vaccine).

3. Coding Instructions

• Code 0 (Not received): If the resident has not received the pneumococcal vaccine prior to or during the current stay.
• Code 1 (Received): If the resident received the pneumococcal vaccine before or during the current stay.
• Code 9 (Unknown): If it is unknown whether the resident received the vaccine.

4. Coding Tips

• Vaccination Records: Ensure accurate and up-to-date vaccination records are maintained in the resident's medical chart.
• Recent Admissions: Pay close attention to recent admissions, verifying vaccination status with previous providers if necessary.

5. Documentation

• Vaccination Date: Record the date(s) of pneumococcal vaccination clearly in the resident's medical records.
• Vaccine Type: Specify which pneumococcal vaccine was administered (PCV13 or PPSV23).

6. Common Errors to Avoid

• Assuming Vaccination Without Documentation: Do not code a resident as vaccinated without proper documentation.
• Coding “Unknown” Prematurely: Exhaust all resources to verify vaccination status before coding as unknown.

7. Practical Application

Example Scenario: A resident admitted to the facility has a documented history of receiving the PPSV23 vaccine three years prior to admission. There’s no record of PCV13 vaccination.

• Application: Code as 1 (Received) and ensure the resident’s medical records accurately reflect the PPSV23 vaccination, including the date of administration.

The Step-by-Step Coding Guide for item O0300 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. Please note that 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.