Step-by-Step Coding Guide for Item Set O0425A2: SLP and Audiology Services - Concurrent Minutes

1. Review of Medical Records

Objective: Accurately capture the minutes a resident spent receiving concurrent SLP (Speech-Language Pathology) and audiology services. Key Points:

• Scrutinize the resident's therapy documentation, especially focusing on notes indicating concurrent sessions within the 7-day look-back period.
• Identify sessions where the resident received therapy at the same time as one other resident but with individualized attention from the therapist.

2. Understanding Definitions

Objective: Define concurrent SLP and audiology services minutes for accurate coding. Key Points:

• Concurrent therapy minutes are those where services are provided to two residents simultaneously, with each working on their individual therapy goals.
• The residents do not necessarily need to be doing the same activities but must be in the same room or area under one therapist's supervision.

3. Coding Instructions

Objective: Detail the process for coding concurrent SLP and audiology services minutes correctly. Key Points:

• Total the minutes of SLP and audiology services provided concurrently to the resident across the 7-day look-back period.
• Ensure minutes coded reflect the time both residents participated in the concurrent session together.

4. Coding Tips

Objective: Offer guidance for accurate and consistent coding of concurrent therapy minutes. Key Points:

• Verify that sessions marked as concurrent meet the proper criteria (two residents, individualized goals, simultaneous service).
• Document start and end times carefully to ensure accurate minute calculation.

5. Documentation

Objective: Emphasize the critical role of thorough documentation in coding. Key Points:

• Each concurrent SLP and audiology session should be clearly documented, noting the therapy's concurrent nature, goals for each resident, and session duration.
• Include any relevant observations or progress made during the session that might impact future care planning.

6. Common Errors to Avoid

Objective: Highlight common pitfalls in coding concurrent therapy minutes. Key Points:

• Coding minutes as concurrent when the resident was actually in a group or individual session.
• Miscounting the total concurrent minutes by not aligning the session times of both residents accurately.

7. Practical Application

Objective: Provide practical examples to illustrate coding guidelines. Key Points:

• Example 1: Resident G and Resident H receive a 40-minute concurrent audiology session on Tuesday. Coding for both residents: 40 minutes each.
• Example 2: Resident I and Resident J participate in a 30-minute concurrent SLP session on Monday and Wednesday. Coding for both residents: 60 minutes each.

Please note that the information provided in this guide for MDS 3.0 Item set O0425A2 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.