Step-by-Step Coding Guide for Item Set O0400B6: Occupational Therapy - End Date

1. Review of Medical Records

• Objective: Gather accurate information regarding the end date of the resident’s occupational therapy.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including therapy notes, discharge summaries, and previous assessments.
  2. Identify Therapy Documentation: Look for documented instances of occupational therapy sessions, focusing on the start and end dates.
  3. Confirm Details: Verify the consistency of the therapy end date through various sources within the medical records.

2. Understanding Definitions

• Occupational Therapy: A form of therapy that helps individuals develop, recover, or maintain the daily living and work skills they need to function independently.
• End Date: The final date on which the resident received occupational therapy services.

3. Coding Instructions

• Steps:
  1. Identify Relevant Dates: Confirm the exact end date of the resident’s occupational therapy sessions from the therapy notes and discharge summaries.
  2. Verify Documentation: Ensure the end date is clearly documented in the therapy records.
  3. Code Appropriately: Enter the end date of the occupational therapy sessions in item set O0400B6 using the format MM/DD/YYYY.

4. Coding Tips

• Accurate Identification: Ensure the end date is explicitly mentioned and confirmed by the therapy records.
• Consistent Terminology: Use consistent terminology when documenting and coding the end date of occupational therapy.
• Consult Therapists: If there is any uncertainty, consult with the occupational therapist for clarification.

5. Documentation

• Required:
  • Therapy Notes: Detailed notes from the occupational therapist documenting the duration and end date of therapy.
  • Discharge Summaries: Include information about the end date of therapy in the resident’s discharge summary.
  • Medical History: Ensure the resident’s medical history includes any relevant information about occupational therapy and its conclusion.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the end date of therapy through multiple records and consultations.
• Incomplete Documentation: Make sure all relevant therapy notes and discharge summaries are included.
• Assumptions: Do not assume the end date of therapy without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: John, a 75-year-old resident, completed his occupational therapy sessions.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, including therapy notes and discharge summaries that indicate the end date of his occupational therapy as 09/15/2023.
    2. Identify End Date: It is confirmed that John’s occupational therapy ended on 09/15/2023.
    3. Document and Code: The nurse documents the end date in John’s records and codes O0400B6 as "09/15/2023".
  • Outcome: John’s end date of occupational 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 O0400B6 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.