Step-by-Step Coding Guide for Item Set O0400C3: Physical Therapy: Group Minutes

1. Review of Medical Records

• Objective: To gather accurate information about the physical therapy group sessions.
• Steps:
  1. Collect Information: Review the resident's medical records, therapy logs, and treatment plans.
  2. Therapy Documentation: Identify all instances of physical therapy sessions attended by the resident.
  3. Session Details: Note the duration and type (group therapy) of each session.

2. Understanding Definitions

• Group Physical Therapy: Physical therapy sessions provided simultaneously to two to six residents who are performing similar activities, supervised by a therapist who is not providing one-on-one attention.
• Group Minutes: The total number of minutes a resident participates in group physical therapy sessions during the specified period.

3. Coding Instructions

• Steps:
  1. Identify Group Sessions: Confirm which physical therapy sessions were group sessions.
  2. Calculate Total Minutes: Sum the minutes the resident spent in group physical therapy sessions over the 7-day look-back period.
  3. Code Appropriately: Enter the total number of group therapy minutes in item O0400C3.

4. Coding Tips

• Accurate Timing: Ensure all group therapy minutes are accurately recorded for each session.
• Consistent Documentation: Verify that the therapy logs consistently document the group nature of the sessions and the duration.
• Consult Therapists: If there is any uncertainty about the classification of therapy sessions, consult with the physical therapists.

5. Documentation

• Required:
  • Therapy Logs: Detailed logs of all therapy sessions, including the type (group) and duration.
  • Progress Notes: Notes from therapists documenting the resident’s participation and progress in group therapy.
  • Attendance Records: Records showing attendance in each group therapy session.

6. Common Errors to Avoid

• Misclassification: Ensure only group therapy minutes are included, not individual or concurrent therapy minutes.
• Incomplete Logs: Ensure all sessions are logged with complete details about duration and type.
• Overestimation: Avoid estimating or rounding up minutes; use exact recorded times.

7. Practical Application

• Example:
  • Resident Profile: Emily, a 75-year-old resident, participates in group physical therapy sessions.
  • Steps:
    1. Review Records: The nurse reviews Emily’s therapy logs and progress notes.
    2. Identify Group Sessions: It is confirmed that Emily attended group therapy sessions totaling 150 minutes in the last 7 days.
    3. Calculate and Code: The nurse sums the group therapy minutes and codes O0400C3 as 150 minutes.
  • Outcome: Emily’s group therapy participation is accurately documented and coded, ensuring proper reflection of her therapy regimen.

Please note that the information provided in this guide for MDS 3.0 Item set O0400C3 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.