Clarification on O0400D2 Respiratory Therapy
Respiratory Therapy is a therapy service, whereas administering a nebulizer—whether it is for an acute or a chronic condition— is medication administration.
Medication administration and incentive spirometry can be part of a respiratory therapy treatment plan; however, by themselves, they are not respiratory therapy.
Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services are provided by a respiratory therapist or a trained nurse who must have documented proficiency in their employee file before providing these treatments.
Coding respiratory therapy
To code respiratory therapy on the MDS, you will need a physician’s order for respiratory therapy. The order must identify what respiratory therapy treatments will be provided, how often they will be provided, and how long they will be provided.
There must be a respiratory assessment that identifies the resident’s respiratory status, and an active written treatment plan or a care plan that identifies the problem, a measurable goal of treatment, and the interventions that will be used.
The resident’s response to the respiratory therapy services must be monitored and periodically evaluated to ensure that the resident receives needed therapies and the current treatment plan is effective. The resident’s response to the respiratory therapy services must be evaluated by a respiratory therapist or trained respiratory nurse at least quarterly when completing an MDS and with changes in the resident’s condition.
The facility must track and document the number of minutes that respiratory therapy services were provided each day. A resident must receive at least 15 minutes of respiratory therapy for it to be considered a day of therapy.
This time includes resident assessment, treatment administration, monitoring, setup, and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without the supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS.
Radiation Coding Clarification
Use code O0110B1 Radiation if any type of radiation is administered intermittently or via radiation implant for cancer treatment. Section O, O0110A1, Chemotherapy, and O0110B1, Radiation, are both subitems categorized under “Cancer Treatments,” which provides additional context for the intended scope of this item. If radiation treatment is provided for any other reason like Osteoarthritis, Tendonitis, Bursitis, Plantar Fasciitis, O01110B1 Radiation cannot be coded.
GG0130 and GG0170 Supporting Documentation
Supporting documentation used to complete the MDS must be documented in the medical record during the three-day observation period. Case Mix Review staff is looking for Functional Abilities supporting documentation on all three shifts.
MDS coding must be consistent with the clinical assessments documented in the medical record and must be validated for accuracy by the staff completing the assessment. If there is no documentation to support the MDS coding during the look back period, a late entry note referencing the observation period will not be accepted.
When discrepancies between the medical record documentation and the MDS coding exist, a clarification note must be written to explain the rationale for the coding decision, how the information was obtained, and who provided it.
Clarification notes can be written after the Assessment Reference Date (ARD) but must be documented prior to the MDS completion date. A clarification note is not used for a lack of documentation in the observation period. Late entry clarification notes written after the MDS completion date will not be used to validate the MDS coding.
