Step-by-Step Coding Guide for Item Set O0400C5: Physical Therapy: Start Date

1. Review of Medical Records

• Objective: To accurately determine the start date of physical therapy for the resident.
• Steps:
  1. Gather Records: Collect all relevant documentation, including physical therapy orders, therapy logs, progress notes, and physician referrals.
  2. Identify Start Date: Look for the first date physical therapy was provided as ordered.
  3. Verify Consistency: Cross-check the identified start date across different records to ensure consistency.

2. Understanding Definitions

• Physical Therapy: A treatment method aimed at restoring function, improving mobility, and reducing pain through exercises, manual therapy, and other modalities.
• Start Date: The actual date when the physical therapy services were first provided to the resident, as documented by the therapy provider.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set O0400C5 on the MDS form.
  2. Determine Start Date:
     • Review the therapy documentation to identify the exact date physical therapy commenced.
     • Ensure the date reflects the first day services were rendered, not the date the order was written or approved.
  3. Code the Item:
     • Response Format: Use the MM/DD/YYYY format to enter the start date.
     • Input the identified start date in the designated field for item set O0400C5.
  4. Complete Entry: Double-check the entered date for accuracy.

4. Coding Tips

• Accurate Date Identification: Ensure the date recorded is the actual start date of therapy services, not any preliminary assessments or consultations.
• Consistent Documentation: Verify that the start date is consistently recorded across all therapy records.
• Cross-Check Orders: Match the start date with the corresponding physician orders and therapy logs.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set O0400C5 indicating the start date of physical therapy.
  • Therapy Orders: Original orders for physical therapy services, specifying the start date.
  • Therapy Logs: Detailed logs documenting the dates and types of therapy services provided.
  • Progress Notes: Notes from the therapist indicating the start of therapy and subsequent sessions.
  • Physician Referrals: Documentation of referrals that include the start date for physical therapy.

6. Common Errors to Avoid

• Incorrect Date: Avoid recording the date of the therapy order or initial consultation instead of the actual start date.
• Inconsistent Records: Ensure all documents consistently reflect the same start date for physical therapy.
• Overlooking Documentation: Do not overlook any therapy logs or progress notes that confirm the start date.

7. Practical Application

• Example:
  • Resident Background: Ms. Jane Doe is scheduled to begin physical therapy to improve mobility after a hip fracture.
  • Review Process: Access Ms. Doe’s therapy orders, therapy logs, and progress notes.
  • Verification: Confirm the start date of therapy services by reviewing the logs and notes.
  • Coding Process:
    • Step 1: Locate item set O0400C5 on the MDS form.
    • Step 2: Identify the start date from the therapy logs (e.g., 04/15/2023).
    • Step 3: Enter the start date in the MM/DD/YYYY format in the field for item set O0400C5.
    • Step 4: Verify the entered date with the documentation.
  • Illustration:
    • Provide a sample MDS form showing item set O0400C5 with the correct start date entered.
    • Include an example of a therapy log entry documenting the start date of physical therapy.

Please note that the information provided in this guide for MDS 3.0 Item set O0400C5 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.