Step-by-Step Coding Guide for Item Set O0425A4: SLP and Audiology Services - Co-treatment Minutes

1. Review of Medical Records

Objective: Identify and accurately record the minutes a resident has received co-treatment from SLP and audiology services. Key Points:

• Carefully review the resident's therapy documentation for mentions of co-treatment sessions within the 7-day look-back period.
• Document each session's duration that involved co-treatment, ensuring these sessions are distinctly identified from individual, group, or concurrent therapy sessions.

2. Understanding Definitions

Objective: Clarify what constitutes co-treatment minutes for SLP and audiology services. Key Points:

• Co-treatment involves two clinicians from different professional disciplines providing therapy to the same resident at the same time, working on different or similar goals.
• For SLP and audiology services, this could involve a speech-language pathologist and an audiologist simultaneously addressing complementary aspects of communication and hearing.

3. Coding Instructions

Objective: Accurately code the minutes of SLP and audiology co-treatment sessions. Key Points:

• Sum the total minutes the resident was engaged in co-treatment by SLP and audiology professionals during the 7-day look-back period.
• Only code minutes as co-treatment when two disciplines actively engage with the resident on therapeutic activities simultaneously.

4. Coding Tips

Objective: Tips for precise and consistent coding of co-treatment minutes. Key Points:

• Double-check the professional disciplines involved in each session to ensure they meet the criteria for co-treatment.
• Clarify and verify the session duration and the roles of each clinician to accurately code the minutes.

5. Documentation

Objective: Highlight the crucial role of detailed documentation for co-treatment sessions. Key Points:

• Clearly document the date, start and end times, participating clinicians and their disciplines, specific goals addressed, and the resident's response to co-treatment.
• Ensure documentation is comprehensive and signed by both clinicians involved in the co-treatment session.

6. Common Errors to Avoid

Objective: Address frequent mistakes in coding co-treatment minutes and strategies to avoid them. Key Points:

• Avoid incorrectly coding group or concurrent therapy minutes as co-treatment.
• Ensure not to overlook the documentation of co-treatment sessions due to miscommunication between disciplines.

7. Practical Application

Objective: Apply coding guidelines to practical scenarios. Key Points:

• Example 1: Resident O participates in a 30-minute co-treatment session with SLP focusing on language processing and audiology on auditory processing strategies. Coding: 30 minutes of co-treatment.
• Example 2: Resident P engages in a 45-minute session where the SLP works on expressive communication while the audiologist adjusts and trains on hearing aid usage. Coding: 45 minutes of co-treatment.

Please note that the information provided in this guide for MDS 3.0 Item set O0425A4 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.