Step-by-Step Coding Guide for O0425: Part A Therapies

1. Review of Medical Records

• Objective: Identify all instances where Medicare Part A covered therapy services were provided.
• Procedure: Examine therapy documentation, including treatment notes, therapy schedules, and billing records for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) within the MDS look-back period.

2. Understanding Definitions

• Part A Therapies: Therapeutic services covered under the Medicare Part A benefit plan, including PT, OT, and SLP.
• Look-Back Period: The specific time frame for which the MDS assessment accounts, typically the 7 days preceding the assessment's ARD (Assessment Reference Date).

3. Coding Instructions

For each therapy type (PT, OT, SLP):

• Total Minutes: Enter the total minutes of therapy provided under Medicare Part A for each therapy type during the look-back period.
• Days: Enter the number of days each therapy type was administered, regardless of duration.

4. Coding Tips

• Accurate Tracking: Ensure therapy minutes and days are accurately tracked in real-time to simplify MDS coding.
• Interdisciplinary Communication: Maintain open communication channels with therapy departments to capture all therapy sessions accurately.

5. Documentation

• Comprehensive Records: Keep detailed records of each therapy session, noting the date, duration, and type of therapy.
• Progress Notes: Document the resident's response to therapy, including progress or any adverse reactions, in their medical records.

6. Common Errors to Avoid

• Miscounting Therapy Days: Ensure that the number of days a therapy was administered is accurately counted, avoiding duplicates within the same day for the same therapy type.
• Incomplete Documentation: Avoid gaps in therapy documentation that could lead to underreporting of therapy minutes or days.

7. Practical Application

Example Scenario: A resident received PT on Monday (30 minutes), Wednesday (30 minutes), and Friday (30 minutes), OT on Tuesday (45 minutes) and Thursday (45 minutes), and SLP on Wednesday (30 minutes) and Saturday (30 minutes).

• PT Total Minutes: 90 minutes, PT Days: 3
• OT Total Minutes: 90 minutes, OT Days: 2
• SLP Total Minutes: 60 minutes, SLP Days: 2

The Step-by-Step Coding Guide for item O04255 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.