Step-by-Step Coding Guide for Item Set O0400A6: Speech-language/Audiology: End Date

1. Review of Medical Records

• Carefully review the resident's therapy records to determine the dates of service for any speech-language pathology or audiology services received.
• Confirm the end date of the most recent therapy session from the therapy logs, billing records, or therapist's notes.

2. Understanding Definitions

• End Date: This refers to the last date on which the resident received speech-language pathology or audiology services during the assessment period.

3. Coding Instructions

• Record the end date in the format MM/DD/YYYY.
• If the therapy is ongoing without a scheduled end date at the time of assessment, leave this item blank.

4. Coding Tips

• Ensure accuracy by cross-verifying the end date with multiple sources within the medical records, such as therapy schedules and billing documents.
• Consider therapy sessions that may occur after the initial review of records and update the end date accordingly.

5. Documentation

• Document the end date in the resident’s healthcare file, including the source of this information.
• Keep a record of any communication with therapists or other healthcare providers that confirms the last date of service.

6. Common Errors to Avoid

• Recording an incorrect date due to misunderstandings about the definition of "end date," which should reflect the last day the service was provided, not when it was billed or noted.
• Failing to update the MDS if therapy resumes or extends beyond the previously recorded end date.

7. Practical Application

• Example: Mrs. Jane Smith, a resident, was receiving speech therapy to address swallowing difficulties following a stroke. Her therapy sessions began on 01/05/2024 and were initially scheduled to end on 01/19/2024. However, upon reviewing the therapy logs and consulting with her speech therapist, it is noted that her therapy was extended due to slower-than-expected progress, with the new end date being 01/25/2024. For the MDS item O0400A6, the end date should be recorded as 01/25/2024.

Please note that the information provided in this guide for MDS 3.0 Item set O0400A6 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, understand and apply 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.