Step-by-Step Coding Guide for Q0610: Referral

1. Review of Medical Records

• Objective: Thoroughly examine the resident's medical records to identify any instances where a referral (to any service or agency) was made or considered. This includes physician orders, social services notes, and interdisciplinary team meeting outcomes.
• Key Documents to Review: Assessments, care plans, and any documented communication with the resident and their family about potential referrals during the look-back period.

2. Understanding Definitions

• Referral: The process of directing or recommending a resident to a service, provider, or agency outside the current care setting that may offer additional care, support, or resources to meet the resident's needs.

3. Coding Instructions

For Q0610 (if applicable), code according to the instructions provided in the MDS 3.0 manual, which typically involve selecting the appropriate option that best describes the action taken regarding referrals during the assessment period.

4. Coding Tips

• Ensure clarity on what constitutes a referral within your facility and the MDS 3.0 framework.
• Familiarize yourself with all referral options listed in Q0610 to accurately reflect the resident's situation.

5. Documentation

• Document the rationale behind making or not making a referral, including the specific services or agencies considered and any resident or family preferences or refusals.
• Include outcomes of any referrals made (e.g., accepted, declined, pending).

6. Common Errors to Avoid

• Inadequate Documentation: Not providing enough detail on why a referral was or was not made, or failing to document discussions with the resident and family.
• Misinterpretation of Referral Outcomes: Incorrectly coding referrals as complete without confirmation from the receiving service or agency.
• Overlooking Referral Opportunities: Not considering or documenting potential referrals that could benefit the resident based on assessed needs.

7. Practical Application

• Example Scenario: A resident is identified as needing specialized wound care upon discharge. The care team discusses this with the resident and family, decides to refer to a local wound care clinic, and documents the decision and reasons in the resident's care plan.
  • Documentation Needed: Include details of the care team's assessment, the discussion with the resident and family, the decision to refer, and the referral outcome.
  • Coding: Select the code that accurately reflects the referral was made to a specialized service, based on options provided in Q0610.

The Step-by-Step Coding Guide for item Q0610 in MDS 3.0 Section Q is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.