MDS Alert

Published on Thu Dec 06, 2018 PDF

If a resident uses a CPAP machine, you’ll need to document the usage in the MDS.

If one of your residents uses a Continuous Positive Airway Pressure (CPAP) machine or Bilevel Positive Airway Pressure (BiPAP) machine to help control sleep apnea, then you’ll need to look beyond active diagnoses in Section I (and ICD-10 coding) to Section O: Special Treatments, Procedures, and Programs. Specifically, you’ll be coding the usage in item O0100G (Non-invasive Mechanical Ventilator (BiPAP/CPAP)).

The Resident Assessment Instrument (RAI) Manual provides this example:

“Mr. M has sleep apnea and requires a CPAP device to be worn when sleeping. The staff set-up the water receptacle and humidifier element of the machine. Mr. M puts on the CPAP mask and starts the machine prior to falling asleep. O0100G should be checked as Mr. M is able to breathe on his own and wears the CPAP mask when he is sleeping to manage his sleep apnea.”

The RAI Manual also provides the following guidance about how you should document a resident’s usage of such a machine, on page O-4:

“Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support his or her own spontaneous respiration by providing enough pressure when the individual inhales to keep his or her airways open, unlike ventilators that ‘breathe’ for the individual.”

Note: If your resident has sleep apnea or another disorder that requires mechanical breathing assistance, you would still code the machine use: “If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code it here.” However, if the ventilator or respirator is breathing “for” the resident and is not a substitution for a BiPAP or CPAP machine, you would need to code the respirator or ventilator usage under O0100F (Invasive Mechanical Ventilator (ventilator or respirator)). Additionally, you should code the usage of the device regardless of whether the resident needs assistance putting it on or taking it off, the RAI Manual says, “This item may be coded if the resident places or removes his/her own BiPAP/CPAP mask/device.”