Step-by-Step Coding Guide for O0400: Therapies

1. Review of Medical Records

• Objective: Gather detailed information on all therapy services provided to the resident, including physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), respiratory therapy (RT), and psychological therapy.
• Process: Examine therapy documentation, including treatment plans, session notes, therapy schedules, and billing records, for the look-back period specified by the MDS assessment.

2. Understanding Definitions

• Therapies: Services aimed at rehabilitation or maintenance of functional status, including PT, OT, SLP, RT, and psychological therapy.
• Look-Back Period: The specific timeframe before the MDS assessment's ARD (Assessment Reference Date) during which therapy services are reviewed.

3. Coding Instructions

• PT, OT, SLP: Code the total minutes and the number of days these therapies were provided during the look-back period.
• RT, Psychological Therapy: Indicate whether these services were provided, without specifying minutes or days.

4. Coding Tips

• Accurate Tracking: Use detailed logs or software to track therapy services accurately throughout the look-back period.
• Clarify Service Types: Distinguish between maintenance and rehabilitative therapy goals, as this may affect coding.
• Interdisciplinary Communication: Regularly consult with therapy staff to ensure comprehensive documentation.

5. Documentation

• Detailed Records: Maintain precise records of therapy sessions, including the date, duration, type of therapy, and specific interventions.
• Progress Notes: Document the resident's response to therapy, noting any progress towards goals or adjustments needed in the care plan.

6. Common Errors to Avoid

• Miscounting Therapy Days: Ensure that the number of days therapy was administered is accurate, considering sessions across all therapy types.
• Inaccurate Minutes: Verify the total minutes of therapy provided, especially when sessions occur multiple times in a day.
• Overlooking Therapies: Include all relevant therapy types in the documentation, not just PT, OT, and SLP.

7. Practical Application

Example Scenario: A resident received PT for 30 minutes on Monday, Wednesday, and Friday; OT for 45 minutes on Tuesday and Thursday; and SLP for 30 minutes on Wednesday and Saturday during the look-back period.

• Coding: For PT, code 90 minutes and 3 days. For OT, code 90 minutes and 2 days. For SLP, code 60 minutes and 2 days. If RT or psychological therapy was provided, indicate their provision as appropriate.

The Step-by-Step Coding Guide for item O0400 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.