Step-by-Step Coding Guide for Item Set V0200A13A: CAA-Feeding Tubes: Triggered

1. Review of Medical Records

• Objective: To gather comprehensive information about the resident's need for a feeding tube.
• Steps:
  1. Collect Medical Records: Obtain all relevant medical records, including previous assessments, physician's orders, and dietary evaluations.
  2. Review Physician Orders: Check for any orders regarding the initiation, continuation, or discontinuation of feeding tube use.
  3. Examine Nutritional Assessments: Look at assessments from dietitians and nutritionists regarding the resident's nutritional status and the need for feeding tube support.

2. Understanding Definitions

• Feeding Tube: A medical device used to provide nutrition to individuals who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation.
• Triggered: A condition or status that prompts further evaluation or action based on predefined criteria within the MDS assessment.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set V0200A13A on the MDS form.
  2. Determine Trigger: Identify if the resident's condition meets the criteria for triggering the feeding tube care area assessment (CAA).
  3. Select the Appropriate Code:
     • Code 1: Triggered - if the resident has a feeding tube or there is an active order for a feeding tube.
     • Code 0: Not triggered - if the resident does not have a feeding tube and there is no active order for a feeding tube.
  4. Record the Code: Enter the appropriate code in the designated field on the MDS form.

4. Coding Tips

• Verify Orders: Ensure that any feeding tube orders are current and clearly documented in the medical records.
• Consistency: Check for consistency in documentation across all relevant medical records, assessments, and care plans.
• Detail: Include specific information about the type of feeding tube, duration of use, and any related medical conditions.

5. Documentation

• Required:
  • Medical Orders: Clear documentation of physician orders for the use of a feeding tube.
  • Assessment Notes: Detailed notes from assessments by dietitians, nutritionists, and other healthcare professionals involved in the resident's care.
  • Care Plan: Documentation in the care plan addressing the use of the feeding tube, including goals and interventions.

6. Common Errors to Avoid

• Incorrect Coding: Ensure the correct trigger code (1 for triggered, 0 for not triggered) is entered based on the resident's status.
• Incomplete Documentation: Avoid missing or incomplete documentation regarding the feeding tube use.
• Misinterpretation: Do not assume the presence of a feeding tube without explicit documentation and verification.

7. Practical Application

• Example: A resident’s medical records include a current order for a gastrostomy tube (G-tube) for nutritional support.
  • Coding: The MDS form should reflect a code of 1 under item set V0200A13A.
• Illustration:
  • Physician Order Entry: "G-tube placement for long-term nutritional support, initiated on 06/01/2023."
  • MDS Entry: The coder marks 1 for V0200A13A on the MDS form.

Please note that the information provided in this guide for MDS 3.0 Item set V0200A13A 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.