Step-by-Step Coding Guide for Item Set O0425C5: Physical Therapy: Days

1. Review of Medical Records

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

2. Understanding Definitions

• Physical Therapy Days: Refers to the number of distinct calendar days during the look-back period on which the resident received any physical therapy services.

3. Coding Instructions

• Count and record the number of days the resident received physical therapy services during the 7-day look-back period.
• Each day should be counted once, even if multiple therapy sessions occurred on that day.

4. Coding Tips

• Ensure accurate differentiation between days physical therapy was provided and days without therapy, including weekends and holidays if therapy was provided.
• Precisely review therapy schedules and attendance records for accurate day counts.

5. Documentation

• Document the date and a brief description of the physical therapy provided on each day, including the duration and specific treatments or exercises performed.
• Maintain detailed therapy logs that capture the nature and goals of each session.

6. Common Errors to Avoid

• Double counting days when multiple physical therapy sessions occur on the same day.
• Overlooking physical therapy services provided during weekends or holidays.
• Failing to document therapy sessions adequately, leading to discrepancies in the number of therapy days reported.

7. Practical Application

• Example: A resident recovering from hip replacement surgery receives physical therapy focusing on mobility and strength training on Monday, Wednesday, and Friday during the look-back period. Each day is counted individually, resulting in a total of 3 physical therapy days.

Please note that the information provided in this guide for MDS 3.0 Item set O0425C5 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.