Step-by-Step Coding Guide for Item Set O0425B5: Occupational Therapy: Days

1. Review of Medical Records

• Conduct a comprehensive review of the resident's medical and therapy records.
• Identify all days within the 7-day look-back period when the resident received occupational therapy services.

2. Understanding Definitions

• Occupational Therapy Days: Refers to the number of distinct calendar days during the look-back period on which the resident received occupational therapy services, regardless of the therapy's duration on each day.

3. Coding Instructions

• Count and record the number of days the resident received any form of occupational therapy services during the 7-day look-back period.
• Include all days, even if therapy was provided for a short duration.

4. Coding Tips

• Ensure that each day occupational therapy services were provided is only counted once, regardless of multiple therapy sessions on the same day.
• Review therapy schedules and attendance records for accuracy.

5. Documentation

• Document the dates of therapy service delivery, including a brief description of the therapy provided on each day.
• Maintain detailed therapy logs that capture the nature and goals of each session.

6. Common Errors to Avoid

• Double counting days when multiple occupational therapy sessions occur on the same day.
• Overlooking occupational therapy services provided during weekends or holidays.
• Failing to account for days when occupational therapy assessment without treatment was provided.

7. Practical Application

• Example: A resident recovering from a stroke receives occupational therapy focused on activities of daily living (ADL) retraining on Monday, Wednesday, and Friday during the look-back period. Each day is counted individually, resulting in a total of 3 occupational therapy days.

Please note that the information provided in this guide for MDS 3.0 Item set O0425B5 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.