MDS Alert

Chemotherapy only appears once on the MDS, but coding it may be complicated.

Coding chemotherapy correctly may seem daunting. Ostensibly, chemotherapy uses drugs, but do you code it as a drug? Most forms of chemotherapy would not be administered in a skilled nursing facility (SNF), so how and where would a nurse assessment coordinator (NAC) document whether the resident received the treatment?

With chemotherapy being such a specialized treatment (and usually administered outside of regular nursing staff), the guidance for assessment for subitem O0100A (Special Treatments, Procedures, and Programs, Chemotherapy) makes a lot of sense. NACs are instructed to look at the clinical record to determine whether the resident received any chemotherapy treatments.

Follow These Steps for Assessment

“Review the resident’s medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days,” the RAI Manual says.

This guidance means you probably have to look outside of your own facility’s notes. You’ll need the specifics — the name of the drug, the dates and times administered, the progress notes — but if the treatment occurs within the look-back period, you should code the chemotherapy in Section O (Special Treatments, Procedures, and Programs), regardless of where the resident receives the treatment.

“Chemo should be coded if received in the 14-day look-back regardless of where the resident received the chemo while she/he wasa resident,” says Carol Maher, RN-BC, RAC-CT, CPC, RAC-MT, director of education at Hansen Hunter & Co. P.C. in Vancouver, Washington.

Understand the Coding Instructions

There are some chemotherapy medications that team members may administer within your facility, and discerning what qualifies as chemotherapy may be tricky.

Hint: If the medication or agent is used primarily for the treatment of cancer, then code in O0100A (Special Treatments, Procedures, and Programs, Chemotherapy). If the medication is used to take advantage of its side effects, don’t code in this subitem, even if the drug is usually used as a chemotherapy agent.

“Code any type of chemotherapy agent administered as an antineoplastic given by any route in this item. Each medication should be evaluated to determine its reason for use before coding it here. Medications coded here are those actually used for cancer treatment. For example, megestrol acetate is classified as an antineoplastic drug. One of its side effects is appetite stimulation and weight gain. If megestrol acetate is being given only for appetite stimulation, do not code it as chemotherapy in this item, as the resident is not receiving the medication for chemotherapy purposes in this situation. Hormonal and other agents administered to prevent the recurrence or slow the growth of cancer should not be coded in this item, as they are not considered chemotherapy for the purpose of coding the MDS,” says the RAI Manual 3.0 1.16, effective Oct. 1, 2018 (italicized statements are new to this year’s version and left in for emphasis), on page O-2.

“Only antineoplastic agents used to treat cancer are coded as chemotherapy. If the antineoplastic medication is used for another reason (i.e., Megace for appetite stimulation) do not code as chemotherapy,” Maher says. This is true even if the medication is used topically, like for a skin cancer.

Check out this new coding scenario in the RAI Manual, too, for more clarification on how to discern when certain agents should be coded as chemotherapy: “Ms. J was diagnosed with estrogen receptor-positive breast cancer and was treated with chemotherapy and radiation. After her cancer treatment, Ms. J was prescribed tamoxifen (a selective estrogen receptor modulator) to decrease the risk of recurrence and/or decrease the growth rate of cancer cells. Since the hormonal agent is being administered to decrease the risk of cancer recurrence, it cannot be coded as chemotherapy.”

Code Column 1 and 2 Per Clinical Record

The coding instructions are relatively simple for O0100A (Special Treatments, Procedures, and Programs, Chemotherapy), once you have all of the pertinent information and know what you’re working with.

“Check all treatments, procedures, and programs received or performed by the resident prior to admission/entry or reentry to the facility and within the 14-day look-back period. Leave Column 1 blank if the resident was admitted/entered or reentered the facility more than 14 days ago. If no items apply in the last 14 days, check Z, none of the above,” the RAI Manual says on page O-2.

“Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period,” the RAI Manual says on page O-2.

Note Extenuating Circumstances

There may be situations in which the resident leaves your facility for an extended period in order to receive chemotherapy treatment. In these cases, other rules about admission and residency kick in. If, for example, the resident is gone from the facility for more than 24 hours, even if receiving chemotherapy treatment at a hospital while not admitted as a patient, the discharge and readmission process begins. This is relatively simple to code on the MDS, but may present a headache in terms of other paperwork.

“Since the resident will be at the hospital more than 24 hours, even if not admitted, it would result in a discharge from the SNF. On readmission, you will restart the PPS schedule again at day 1. The chemo would be coded ‘while not a resident’ since it would have been given prior to the readmission,” Maher says.