Understanding and Coding MDS 3.0 Item O0110K1B: Treatment - Hospice (While a Resident)

Understanding and Coding MDS 3.0 Item O0110K1B: Treatment - Hospice (While a Resident)

Introduction

Purpose:
Hospice care is a compassionate approach to care that focuses on the quality of life for residents with serious, life-limiting illnesses. MDS Item O0110K1B, Treatment: Hospice (While a Resident), is used to document whether a resident received hospice services during their stay in a long-term care facility. Accurate documentation of this item is essential for ensuring that residents receive the appropriate end-of-life care, complying with regulatory requirements, and maintaining comprehensive care records. This article provides detailed guidance on how to correctly code this item according to the latest MDS 3.0 guidelines.

What is MDS Item O0110K1B?

Explanation:
MDS Item O0110K1B, Treatment: Hospice (While a Resident), is part of Section O, which focuses on special treatments, procedures, and programs provided to the resident. This item specifically captures whether the resident was receiving hospice care services while residing in the facility.

Hospice care is designed to provide comfort and support to residents in the final stages of a terminal illness. It includes physical, emotional, and spiritual care, typically provided by an interdisciplinary team of healthcare professionals. Documenting hospice care while the resident is in the facility ensures that all aspects of their care are accurately recorded and that appropriate support is provided.

Guidelines for Coding O0110K1B

Coding Instructions:
To correctly code Item O0110K1B, follow these steps:

1. Review the Resident’s Medical Records:

   • Carefully review the resident’s medical records to determine if they were receiving hospice care services at any time during their stay in the facility.

2. Determine the Appropriate Response:

   • Code “1” if the resident was receiving hospice care services while residing in the facility.
   • Code “0” if the resident did not receive hospice care during their stay.

3. Enter the Response in Item O0110K1B:

   • Record the appropriate code (1 or 0) based on the resident’s hospice care status during their stay.
   • Ensure that this information is consistent with the resident’s medical records and aligns with the facility’s documentation protocols.

Example Scenario:
A resident with terminal cancer was receiving hospice care services, including pain management and emotional support, during their stay at the facility. The MDS Coordinator would enter 1 in Item O0110K1B to indicate that hospice care was provided while the resident was in the facility. This ensures that the resident’s care is accurately documented and that all aspects of their end-of-life care are recorded.

Best Practices for Accurate Coding

Documentation:

• Maintain detailed records of all hospice services provided to the resident, including the initiation and continuation of hospice care.
• Ensure that documentation clearly reflects whether hospice care services were provided during the resident’s stay, supporting accurate coding of Item O0110K1B.

Communication:

• Foster effective communication among the healthcare team, hospice providers, and the resident’s family to ensure that all aspects of hospice care are accurately documented.
• Regularly update care plans to reflect any changes in the resident’s hospice care status and ensure that all team members are informed.

Regular Audits:

• Conduct regular audits of medical records to verify that all relevant information about hospice care is accurately recorded in Item O0110K1B.
• Address any discrepancies promptly to ensure compliance with documentation requirements and to maintain the integrity of resident care records.

Conclusion

Summary:
MDS Item O0110K1B is essential for documenting whether a resident received hospice care services during their stay in a long-term care facility. Accurate coding of this item ensures that the resident’s end-of-life care is fully documented and supports the implementation of appropriate care plans. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure that hospice care statuses are appropriately managed and documented, thereby supporting compassionate care and accurate reporting.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-149] for detailed guidelines on documenting hospice care while a resident and other special treatments.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item O0110K1B: Treatment - Hospice (While a Resident) was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.