Step-by-Step Coding Guide for Item Set O0425C1: Physical Therapy: Individual Minutes

1. Review of Medical Records

• Start with a comprehensive examination of the resident's medical and therapy records.
• Identify all instances where the resident received individual physical therapy services during the 7-day look-back period, noting the duration of each session.

2. Understanding Definitions

• Individual Minutes: Refers to the time, in minutes, a resident spends receiving physical therapy services on a one-to-one basis with a therapist.

3. Coding Instructions

• Accurately record the total number of minutes the resident received individual physical therapy services within the look-back period.
• Sum the minutes from each day to provide a total count.

4. Coding Tips

• Ensure that the minutes recorded are for individual therapy sessions only, excluding group or co-treatment sessions.
• Be precise in capturing the start and end times of each therapy session for an accurate minute count.

5. Documentation

• Document the date, start and end time, and specific activities or treatments provided in each individual therapy session.
• Include the therapeutic goals targeted during these sessions in the documentation.

6. Common Errors to Avoid

• Misclassifying group or co-treatment sessions as individual therapy.
• Inaccurately recording the duration of therapy sessions, either by overestimating or underestimating the time spent.
• Failing to document each individual therapy session, including those that may occur outside of the standard schedule.

7. Practical Application

• Example: A resident undergoing post-operative knee replacement rehabilitation receives individual physical therapy focused on mobility enhancement and pain management on Monday (30 minutes), Wednesday (30 minutes), and Friday (30 minutes). Each session is documented, with the total for O0425C1 being 90 minutes.

Please note that the information provided in this guide for MDS 3.0 Item set O0425C1 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.