Step-by-Step Coding Guide for Item Set O0400C4: Physical Therapy: Number of Days

1. Review of Medical Records

• Objective: Ensure accurate coding by thoroughly reviewing the resident’s medical records.
• Steps:
  1. Collect Documentation: Gather all relevant records, including physical therapy notes, treatment logs, and progress reports.
  2. Identify Therapy Sessions: Look for documented physical therapy sessions, including the date and type of therapy provided.
  3. Verify Consistency: Ensure that the number of days of physical therapy documented in the treatment logs matches the notes and progress reports.

2. Understanding Definitions

• Physical Therapy (PT): A form of treatment involving exercises and other physical activities to improve movement, strength, and function, often provided by a licensed physical therapist.
• Number of Days: Refers to the total count of calendar days on which physical therapy was administered to the resident during the assessment period.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set O0400C4 on the MDS form.
  2. Determine Number of Days:
     • Review the treatment logs and physical therapy notes to count the total number of days physical therapy was provided.
     • Ensure the count is within the designated assessment period.
  3. Code the Item:
     • Response Format: Enter the number of days (e.g., 00-07).
     • Input the exact number of calendar days on which physical therapy was provided to the resident during the assessment period.
  4. Complete Entry: Ensure the correct number is recorded in the designated field for item set O0400C4.

4. Coding Tips

• Accuracy: Double-check the therapy logs and progress notes to ensure the number of days is accurate.
• Assessment Period: Only include days within the specified assessment period.
• Calendar Days: Count each calendar day physical therapy was provided, not the number of therapy sessions.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set O0400C4 indicating the number of days physical therapy was provided.
  • Physical Therapy Logs: Detailed logs documenting each day physical therapy was administered, including the type and duration of therapy.
  • Progress Notes: Notes from the physical therapist documenting the resident’s progress and any changes in the therapy plan.

6. Common Errors to Avoid

• Incorrect Count: Ensure that the number of days reflects calendar days and not therapy sessions.
• Outside Assessment Period: Do not include therapy days outside the designated assessment period.
• Incomplete Documentation: Make sure all therapy days are documented in the therapy logs and progress notes.

7. Practical Application

• Example:
  • Resident Background: Mr. John Smith received physical therapy three times a week during the assessment period.
  • Review Process: Access Mr. Smith’s physical therapy logs and progress notes.
  • Verification: Confirm the therapy was provided on Monday, Wednesday, and Friday for a total of four weeks.
  • Coding Process:
    • Step 1: Locate item set O0400C4 on the MDS form.
    • Step 2: Verify and count the number of calendar days physical therapy was provided (e.g., 12 days).
    • Step 3: Enter "12" in the field for item set O0400C4.
    • Step 4: Ensure all records and documentation are complete and consistent.
  • Illustration:
    • Provide a sample MDS form showing item set O0400C4 with the number "12" entered.
    • Include an example of the resident’s physical therapy log, documenting the dates and types of therapy provided.

Please note that the information provided in this guide for MDS 3.0 Item set O0400C4 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.