Step-by-Step Coding Guide for Item Set O0425C3: Physical Therapy: Group Minutes

1. Review of Medical Records

• Start by thoroughly reviewing the resident's medical and therapy records.
• Identify all instances of group physical therapy sessions attended by the resident during the 7-day look-back period, noting the duration of each session.

2. Understanding Definitions

• Group Therapy: Refers to physical therapy services provided simultaneously to four or more residents, regardless of whether they are performing the same or different activities, under the supervision of a therapist or assistant.

3. Coding Instructions

• Accurately record the total minutes the resident participated in physical therapy group sessions within the 7-day look-back period.
• Aggregate the minutes from each group session to obtain the total.

4. Coding Tips

• Ensure differentiation between group therapy and other therapy modes (individual, concurrent, co-treatment).
• Precisely track the duration of each group therapy session for an accurate total minute count.

5. Documentation

• Document the date, duration, and specific activities or treatments provided in each group therapy session.
• Include the goals targeted during these sessions and any progress noted in the resident's record.

6. Common Errors to Avoid

• Misclassifying group therapy sessions as another type of therapy mode.
• Overlooking group therapy sessions provided on weekends or holidays.
• Inaccurately recording the duration of therapy sessions, leading to errors in the total minutes reported.

7. Practical Application

• Example: A resident attends two group physical therapy sessions focusing on joint mobility and strengthening exercises. The first session on Monday lasts 45 minutes, and the second session on Thursday lasts 30 minutes. The total for O0425C3 is 75 minutes.

Please note that the information provided in this guide for MDS 3.0 Item set O0425C3 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.