Step-by-Step Coding Guide for Item Set O0425C4: Physical Therapy: Co-treatment Minutes

1. Review of Medical Records

• Begin with a comprehensive examination of the resident's medical and therapy records.
• Identify instances where the resident received physical therapy in a co-treatment setting during the 7-day look-back period, noting the duration of each session.

2. Understanding Definitions

• Co-treatment Minutes: Time spent receiving physical therapy services when two therapists, possibly from different disciplines, work with the resident simultaneously. It focuses on achieving more complex or interdisciplinary goals.

3. Coding Instructions

• Accurately record the total number of minutes the resident received physical therapy in a co-treatment setting within the 7-day look-back period.
• Sum the minutes from each session to provide a comprehensive total.

4. Coding Tips

• Verify that the therapy session qualifies as co-treatment, with clear interdisciplinary goals and simultaneous engagement from both therapists.
• Precisely track start and end times of each co-treatment session for an accurate count of minutes.

5. Documentation

• Document the date, duration, specific activities or treatments provided, and the disciplines involved in each co-treatment session.
• Record the therapeutic goals targeted during these sessions and any resident progress noted.

6. Common Errors to Avoid

• Confusing co-treatment therapy with concurrent therapy or group therapy sessions.
• Overlooking co-treatment sessions due to unclear documentation or misinterpretation of session goals.
• Failing to document the collaborative nature of the session, including contributions from both disciplines.

7. Practical Application

• Example: A resident recovering from a stroke receives a co-treatment session lasting 45 minutes focusing on upper body strength and fine motor skills. A physical therapist and an occupational therapist collaborate, utilizing a combination of exercises and functional tasks. This session is carefully documented, contributing to the total co-treatment minutes.

Please note that the information provided in this guide for MDS 3.0 Item set O0425C4 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.