Step-by-Step Coding Guide for Item Set O0400A3: Speech-Language/Audiology - Group Minutes

1. Review of Medical Records

• Objective: Gather accurate information regarding the time the resident spent in group speech-language or audiology therapy sessions.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including therapy logs, progress notes, and session schedules.
  2. Identify Group Therapy Sessions: Look for documented instances of group speech-language or audiology therapy sessions attended by the resident.
  3. Confirm Details: Verify the duration and frequency of these group therapy sessions through various sources within the medical records.

2. Understanding Definitions

• Group Speech-Language/Audiology Therapy: Therapy sessions where a therapist treats two to six residents simultaneously who are performing similar activities.
• Group Minutes: The total number of minutes a resident participated in group speech-language or audiology therapy sessions during the assessment period.

3. Coding Instructions

• Steps:
  1. Calculate Total Group Minutes: Sum the total minutes the resident participated in group speech-language or audiology therapy sessions during the assessment period.
  2. Verify Documentation: Ensure the group therapy minutes are accurately documented in the therapy logs and progress notes.
  3. Code Appropriately: Enter the total number of group therapy minutes in item set O0400A3.

4. Coding Tips

• Accurate Calculation: Double-check the recorded minutes to ensure the total is accurate.
• Consistent Terminology: Use consistent terminology when documenting and coding group therapy minutes.
• Consult Therapists: If there is any uncertainty, consult with the speech-language pathologists or audiologists for clarification on session durations and activities.

5. Documentation

• Required:
  • Therapy Logs: Detailed logs documenting the duration of each group speech-language or audiology therapy session attended by the resident.
  • Progress Notes: Include notes from therapists detailing the resident’s participation and progress in group therapy.
  • Session Schedules: Document the schedule of group therapy sessions to cross-reference with the resident’s attendance.

6. Common Errors to Avoid

• Misclassification: Ensure that only group therapy minutes (not individual or concurrent therapy) are included.
• Incomplete Documentation: Make sure all relevant details about the group therapy sessions are thoroughly documented.
• Assumptions: Do not assume the duration of sessions without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Jane, a 70-year-old resident, participated in group speech-language therapy sessions three times a week.
  • Steps:
    1. Review Records: The nurse reviews Jane’s therapy logs, which document the duration of each group therapy session.
    2. Calculate Total Minutes: It is confirmed that Jane attended group therapy sessions for 30 minutes each time, totaling 90 minutes for the week.
    3. Document and Code: The nurse documents the total group therapy minutes in Jane’s records and codes O0400A3 as "90".
  • Outcome: Jane’s participation in group speech-language therapy is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set O0400A3 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.