Step-by-Step Coding Guide for O0350: Resident’s COVID-19 Vaccination is Up to Date

1. Review of Medical Records

Objective: Verify whether the resident's COVID-19 vaccination is current according to the CDC's latest guidelines.
Actions:

• Access the resident’s medical records, including vaccine administration logs, immunization history, and progress notes.
• Check if the resident has received the recommended COVID-19 vaccinations or boosters based on the most up-to-date CDC guidelines.

2. Understanding Definitions

O0350: Resident’s COVID-19 Vaccination is Up to Date: This item refers to whether the resident’s COVID-19 vaccination status aligns with the current CDC guidelines on COVID-19 vaccinations and boosters.

• Up to date: The resident has received the complete initial series of COVID-19 vaccines and any additional recommended booster doses.
• COVID-19 Vaccination: Includes both primary series and booster doses.
• Guidelines: Vaccination recommendations may change as new variants of COVID-19 emerge or new vaccine formulations are available.

3. Coding Instructions

Step-by-Step:

• Step 1: Determine if the resident has completed the initial series of COVID-19 vaccines (e.g., two doses of an mRNA vaccine or one dose of Johnson & Johnson).
• Step 2: Check if the resident has received any booster doses, if eligible, per CDC guidelines.
• Step 3: If the resident is up to date with their COVID-19 vaccinations, mark O0350 as “Yes”.
• Step 4: If the resident’s COVID-19 vaccination is not up to date or vaccination status cannot be determined, mark O0350 as “No”.

4. Coding Tips

• Follow CDC Guidelines: Ensure the resident’s vaccination status is assessed against the most recent CDC recommendations, which may include additional booster doses for specific age groups or immunocompromised individuals.
• Check Records Thoroughly: Review vaccination records both from the nursing facility and any external sources, such as physician offices or public health departments.

5. Documentation

Objective: Ensure that the resident’s vaccination records reflect the current status of their COVID-19 immunization and any necessary follow-up actions.
Actions:

• Document: Record any COVID-19 vaccinations or booster doses administered, including the dates and type of vaccine received.
• Include Booster Information: Specify if the resident has received any booster doses and whether additional doses are planned or required.

6. Common Errors to Avoid

• Misclassifying Status: Do not mark a resident as up to date unless their vaccination records fully comply with the latest CDC recommendations.
• Incomplete Documentation: Avoid coding the resident as up to date without confirming complete documentation of all required doses, including boosters.

7. Practical Application

• Example 1: A resident received two doses of an mRNA vaccine and a subsequent booster. Based on current CDC guidelines, their vaccination is considered up to date, and O0350 is marked as "Yes".
• Example 2: A resident completed their initial vaccine series but has not yet received a recommended booster. O0350 is marked as "No".
• Example 3: A resident received one dose of the Johnson & Johnson vaccine and no further boosters, but CDC now recommends an additional booster. O0350 is marked as "No".

Please note that the information provided in this guide for MDS 3.0 Item set O0350 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.