DiraChart MDS item reference
Track Changes
Use the item-specific response choices below when structured codes apply.
This row introduces a grouped MDS item. Complete the applicable child items shown in the current item set.
Review what the item asks, how to choose the response, and what should be verified before submission.
1. Review the resident’s medical record (e.g., rehabilitation therapy evaluation and treatment
records, mental health professional progress notes) and consult with each of the qualified
care providers to collect the information required for this item.
O0390: Therapy Services (cont.)
Check each therapy service that was administered for at least 15 minutes per day on one or more
days in the last 7 days. Check none of the above if the resident did not receive therapy services
for at least 15 minutes per day on one or more days in the last 7 days.
A day of therapy is defined as skilled treatment for 15 or more minutes during the day.
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O0390A, Speech-Language Pathology and Audiology Services
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O0390B, Occupational Therapy
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O0390C, Physical Therapy
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O0390D, Respiratory Therapy
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O0390E, Psychological Therapy
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O0390Z, None of the above were provided
and Special Populations
•
Psychological Therapy is provided by any licensed mental health professional, such as
psychiatrists, psychologists, clinical social workers, and clinical nurse specialists in
mental health as allowable under applicable state laws. Psychiatric technicians are not
considered to be licensed mental health professionals, and their services may not be
counted in this item.
Minutes of Therapy
•
Includes only therapies that were provided once the individual is actually living/being
cared for at the long-term care facility. Do NOT include therapies that occurred while
the person was an inpatient at a hospital or recuperative/rehabilitation center or other
long-term care facility, or a recipient of home care or community-based services.
•
If a resident returns from a hospital stay, an initial evaluation must be performed after
entry/reentry to the facility, and only those therapies that occurred since
admission/reentry to the facility and after the initial evaluation shall be counted, except
in the case of an interrupted stay.
•
O0390 therapy items do not require at least 15 minutes of a single mode of therapy to be
checked on the MDS. Minutes from the same therapy discipline (e.g., physical therapy)
but different therapy modes (e.g., individual and concurrent) may be combined to meet
the “at least 15 minutes” of skilled therapy in a day requirement.
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The therapist’s time spent on documentation or on initial evaluation is not included.
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The therapist’s time spent on subsequent reevaluations, conducted as part of the
treatment process, should be counted.
•
Family education when the resident is present is counted and must be documented in the
resident’s record.
O0390: Therapy Services (cont.)
•
Only skilled therapy time (i.e., requires the skills, knowledge, and judgment of a qualified
therapist and all the requirements for skilled therapy are met) shall be recorded on the
MDS. In some instances, the time during which a resident received a treatment modality
includes partly skilled and partly unskilled time; only time that is skilled may be recorded
on the MDS. Therapist time during a portion of a treatment that is non-skilled; during a
non-therapeutic rest period; or during a treatment that does not meet the therapy mode
definitions may not be included.
•
The time required to adjust equipment or otherwise prepare the treatment area for skilled
rehabilitation service is the set-up time and is to be included in the count of minutes of
therapy delivered to the resident. Set up may be performed by the therapist, therapy
assistant, or therapy aide.
•
Respiratory therapy—only minutes that the respiratory therapist or respiratory nurse
spends with the resident shall count towards the 15 minutes per day on one or more days
when coding the MDS. This time includes resident evaluation/assessment, treatment
administration and monitoring, and setup and removal of treatment equipment. Time that
a resident self-administers a nebulizer treatment without supervision of the respiratory
therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do
not include administration of metered-dose and/or dry powder inhalers in respiratory
minutes.
•
For Speech-Language Pathology Services (SLP), Physical Therapy (PT), Occupational
Therapy (OT), include only skilled therapy services. Skilled therapy services must meet
all of the following conditions (Refer to Medicare Benefit Policy Manual, Chapters 8
and 15, for detailed requirements and policies):
for Part A, services must be ordered by a physician. For Part B, the plan of care must
be certified by a physician following the therapy evaluation;
the services must be directly and specifically related to an active written treatment
plan that is approved by the physician after any needed consultation with the
qualified therapist and is based on an initial evaluation performed by a qualified
therapist prior to the start of therapy services in the facility;
the services must be of a level of complexity and sophistication, or the condition of
the resident must be of a nature that requires the judgment, knowledge, and skills of a
therapist;
the services must be provided with the expectationbased on the assessment of the
resident’s restoration potential made by the physicianthat the condition of the
patient will improve materially in a reasonable and generally predictable period of
time; or, the services must be necessary for the establishment of a safe and effective
maintenance program; or, the services must require the skills of a qualified therapist
for the performance of a safe and effective maintenance program.
O0390: Therapy Services (cont.)
the services must be considered under accepted standards of medical practice to be
specific and effective treatment for the resident’s condition; and,
the services must be reasonable and necessary for the treatment of the resident’s
condition; this includes the requirement that the amount, frequency, and duration of
the services must be reasonable, and they must be furnished by qualified personnel.
•
Include services provided by a qualified occupational/physical therapy assistant who is
employed by (or under contract with) the long-term care facility only if they are under
the direction of a qualified occupational/physical therapist. Medicare does not recognize
speech-language pathology assistants; therefore, services provided by these individuals
are not to be coded on the MDS.
•
For purposes of the MDS, when the payer for therapy services is not Medicare Part B,
follow the definitions and coding for Medicare Part A.
•
Do not round therapy minutes (e.g., reporting) to the nearest 5th minute when
counting therapy minutes. The conversion of units to minutes or minutes to units is not
appropriate. Please note that therapy logs are not an MDS requirement but reflect a
standard clinical practice expected of all therapy professionals. These therapy logs may
be used to verify the provision of therapy services in accordance with the plan of care
and to validate information reported on the MDS assessment.
•
When therapy is provided, staff need to document the different modes of therapy and set
up minutes that are being included on the MDS. It is important to keep records of time
included for each.
•
For purposes of the MDS, providers should record services for respiratory and
psychological therapies (items O0390D and O0390E) when the following criteria are
met:
the physician orders the therapy;
the physician’s order includes a statement of frequency, duration, and scope of
treatment;
the services must be directly and specifically related to an active written treatment
plan that is based on an initial evaluation performed by qualified personnel (See
Glossary in Appendix A for definitions of respiratory and psychological therapies);
the services are required and provided by qualified personnel (See Glossary in
Appendix A for definitions of respiratory and psychological therapies); and
the services must be reasonable and necessary for treatment of the resident’s
condition.
O0390: Therapy Services (cont.)
Non-Skilled Services
•
Services provided at the request of the resident or family that are not medically necessary
(sometimes referred to as family-funded services) shall not be counted in items O0390
Therapy Services or O0425 Part A Therapies, even when performed by a therapist or an
assistant.
•
As noted above, therapy services can include the actual performance of a maintenance
program in those instances where the skills of a qualified therapist are needed to
accomplish this safely and effectively. However, when the performance of a maintenance
program does not require the skills of a therapist because it could be accomplished safely
and effectively by the patient or with the assistance of non-therapists (including unskilled
caregivers), such services are not considered therapy services in this context. Sometimes
a nursing home may nev
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