Step-by-Step Coding Guide for Item set O0425A1: SLP and Audiology Services: Individual Minutes

1. Review of medical records

• Begin by reviewing the resident’s comprehensive medical record to identify any prescribed speech-language pathology (SLP) or audiology services.
• Look for specific orders from healthcare providers, including the frequency and duration of individual sessions.

2. Understanding definitions

• Clarify what constitutes "individual minutes": This refers to the total number of minutes a resident receives one-on-one SLP or audiology services during the look-back period (usually 7 days).
• Note that group or concurrent sessions are not included in this item.

3. Coding Instructions

• Record the total number of individual minutes of SLP or audiology services provided during the look-back period.
• Enter the total minutes directly into the MDS item O0425A1.

4. Coding tips

• Ensure that only one-on-one sessions are recorded under this item.
• Double-check that no group therapy sessions are mistakenly included.

5. Documentation

• Document each session in the resident's medical record, including date, time, duration, and type of service provided.
• Ensure documentation is clear and detailed to support the coding and facilitate accurate billing.

6. Common errors to avoid

• Not differentiating between individual and group sessions.
• Failing to document all sessions accurately in the resident's medical record.

7. Practical application

• Example: A resident receives SLP services for 30 minutes on Monday, Wednesday, and Friday. Each session is individual. The coder should total these minutes (30+30+30) and enter 90 in O0425A1.

Please note that the information provided in this guide for MDS 3.0 Item set O0425A1 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.