Step-by-Step Coding Guide for O0420: Distinct Calendar Days of Therapy

1. Review of Medical Records

• Objective: Collect data on therapy sessions provided to the resident, including physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP).
• Process: Examine therapy session logs, clinical notes, and billing records to identify the days on which each therapy type was administered within the MDS assessment look-back period.

2. Understanding Definitions

• Distinct Calendar Days of Therapy: Refers to the individual days within the assessment look-back period when the resident received one or more sessions of a specific type of therapy (PT, OT, SLP), regardless of the session's length or frequency on that day.
• Look-Back Period: Typically, the 7 days immediately preceding the ARD (Assessment Reference Date).

3. Coding Instructions

• Count the number of distinct calendar days each therapy type was provided. Each day a therapy service is provided counts as one distinct day, even if multiple sessions occurred on that day.
• Record the total number of distinct calendar days for PT, OT, and SLP separately.

4. Coding Tips

• Daily Tracking: Maintain accurate daily logs of therapy services to simplify the coding process.
• Clarify Multiple Sessions: Understand that multiple therapy sessions of the same type on a single day count as one distinct calendar day.
• Consult Therapy Providers: Regularly communicate with therapy staff to verify the accuracy of recorded therapy days.

5. Documentation

• Session Details: Document the date, type, and duration of each therapy session, along with the resident's response to therapy.
• Therapy Logs: Keep consolidated logs that clearly show the dates therapy services were provided to ease the coding process.

6. Common Errors to Avoid

• Overlooking Sessions: Ensure no therapy sessions are missed due to inadequate tracking or communication errors.
• Double Counting: Avoid counting the same type of therapy more than once on the same day when calculating distinct calendar days.
• Misinterpreting Look-Back Period: Carefully review the specific look-back period to ensure accurate coding.

7. Practical Application

Scenario: A resident received PT on Monday, Wednesday, and Friday; OT on Tuesday and Thursday; and SLP on Wednesday and Saturday within the look-back period.

• Practical Coding: According to the data, PT was provided on 3 distinct calendar days, OT on 2 distinct calendar days, and SLP on 2 distinct calendar days.

The Step-by-Step Coding Guide for item O0420 in MDS 3.0 Section O is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.