Step-by-Step Coding Guide for Item Set: O0400C2, Physical Therapy: Concurrent Minutes

1. Review of Medical Records

Objective: Determine the total concurrent minutes of physical therapy services provided to the resident. Key Points:

• Carefully examine the resident's medical records, therapy notes, and treatment logs for documentation of concurrent physical therapy services.
• Concurrent therapy is defined as therapy provided to two residents at the same time when the residents are not performing the same or similar activities.
• Total the minutes of concurrent therapy sessions provided over the specified reporting period.

2. Understanding Definitions

Objective: Clarify what constitutes concurrent minutes for physical therapy services. Key Points:

• Concurrent Minutes: Time spent providing therapy to two residents simultaneously, where the activities may differ, under the supervision of a licensed physical therapist or physical therapist assistant.
• This setting allows for the efficient use of therapy resources while still focusing on individual resident goals.
• Differentiate concurrent therapy from group therapy, where therapy is provided to multiple residents performing the same or similar activities.

3. Coding Instructions

Objective: Accurately code the total concurrent minutes of therapy provided. Key Points:

• Enter the total number of concurrent minutes of physical therapy services provided to the resident during the reporting period.
• If no concurrent therapy services were provided, enter '0'.
• Ensure the coded minutes accurately reflect time spent in concurrent therapy settings.

4. Coding Tips

Objective: Ensure precision and completeness in coding therapy minutes. Key Points:

• Verify session notes to ensure that therapy was indeed provided in a concurrent setting.
• Document the roles of both professionals involved in the concurrent session to support the coding.
• Regularly update and review the coding as additional therapy sessions occur throughout the reporting period.

5. Documentation

Objective: Maintain comprehensive documentation for concurrent therapy services. Key Points:

• Clearly document each concurrent therapy session, including the date, duration, participants, and specific interventions or techniques used.
• Note the individualized goals and outcomes for each resident involved in the concurrent therapy session.
• Differentiate concurrent sessions from other types of therapy sessions in documentation for clarity and accurate reporting.

6. Common Errors to Avoid

Objective: Identify and correct frequent documentation and coding mistakes. Key Points:

• Avoid confusing concurrent therapy with group therapy in documentation and coding.
• Ensure all concurrent therapy minutes are documented and calculated correctly; missing or inaccurate documentation can lead to incorrect reporting.
• Be cautious of not documenting the individual resident goals and interventions during concurrent sessions, which is necessary for accurate and justified coding.

7. Practical Application

Objective: Apply coding and documentation knowledge through practical examples. Key Points:

• Scenario: Two residents receive physical therapy in a concurrent setting on Tuesday for 45 minutes. One works on balance exercises while the other works on upper body strength. Document the session's individual goals, calculate the total concurrent minutes (45 minutes for each resident), and code accordingly.
• Use hypothetical scenarios in staff training sessions to practice identifying, documenting, and coding concurrent therapy minutes, emphasizing the importance of detailed session notes and individualized treatment goals.
• Discuss case studies in team meetings, focusing on the documentation and coding of concurrent physical therapy services, exploring strategies for accurate and compliant reporting.

Please note that the information provided in this guide for MDS 3.0 Item set O0400C2 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.