Step-by-Step Coding Guide for Item Set O0425C2: Physical Therapy: Concurrent Minutes

1. Review of Medical Records

• Begin with an in-depth review of the resident's medical and therapy records.
• Identify instances of physical therapy provided concurrently to the resident during the 7-day look-back period, noting each session's duration.

2. Understanding Definitions

• Concurrent Therapy: Physical therapy provided to two residents at the same time, regardless of whether the residents are performing the same or different activities, under the supervision of one therapist or assistant.

3. Coding Instructions

• Record the total minutes the resident received physical therapy in a concurrent setting within the 7-day look-back period.
• Each resident's time is counted separately, even though the therapy is provided simultaneously.

4. Coding Tips

• Ensure accurate differentiation between concurrent and group therapy sessions.
• Precisely record the start and end times of concurrent therapy sessions for an accurate count of minutes.

5. Documentation

• Document each concurrent therapy session's date, duration, participants, and specific activities or treatments provided.
• Record therapeutic goals targeted during these sessions and any progress noted.

6. Common Errors to Avoid

• Confusing concurrent therapy with group or co-treatment therapy.
• Overlooking the requirement that concurrent therapy involves only two residents at a time.
• Failing to document the concurrent nature of the session and the involvement of another resident.

7. Practical Application

• Example: Two residents each receive 30 minutes of concurrent physical therapy focusing on balance and gait training on Monday and Wednesday. Each session is documented for both, totaling 60 minutes of concurrent therapy for each resident across the look-back period.

Please note that the information provided in this guide for MDS 3.0 Item set O0425C2 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.