Step-by-Step Coding Guide for Item Set O0500B: Range of Motion (Active): Number of Days

1. Review of Medical Records

• Begin with a thorough review of the resident's medical and therapy records.
• Identify all instances when the resident participated in active range of motion (ROM) exercises during the 7-day look-back period, noting the dates of these sessions.

2. Understanding Definitions

• Active Range of Motion (ROM) Exercises: Activities where the resident uses their own muscle strength to move a joint through the full range of movement, aiming to improve or maintain flexibility and muscle strength.

3. Coding Instructions

• Record the number of distinct calendar days during the look-back period on which the resident engaged in active ROM exercises.
• Count each day the exercises were performed, regardless of the number of sessions or joints exercised on that day.

4. Coding Tips

• Clearly differentiate between active and passive ROM exercises; for O0500B, only active ROM exercises should be counted.
• Double-check therapy schedules, nursing notes, and activity logs to ensure all days with active ROM exercises are accurately captured.

5. Documentation

• Document each active ROM exercise session, including the date, specific exercises performed, joints involved, and the duration of each session.
• Note observations regarding the resident's participation, response to exercises, and any changes observed in flexibility or muscle strength.

6. Common Errors to Avoid

• Confusing active ROM exercises with passive ROM exercises, leading to inaccurate coding.
• Overlooking active ROM exercises performed independently by the resident or as part of a group activity.
• Failing to document each day active ROM exercises are performed, resulting in underreporting.

7. Practical Application

• Example: A resident recovering from shoulder surgery engages in active ROM exercises targeting shoulder mobility on Tuesday, Thursday, and Saturday. Each session focuses on exercises such as arm raises and shoulder rotations, documented thoroughly, resulting in a total of 3 days reported for O0500B.

Please note that the information provided in this guide for MDS 3.0 Item set O0500B 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.