BriggsNetNews

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

CMS has posted a 5-page RAI Manual Errata document dated October 1, 2018.  The revisions addressed by this Errata document are to Section J of the MDS 3.0 Item Set, v1.16.1, specifically J2000 –  Prior Surgery.  “The criteria for major surgery needed to be modified to remove the requirement for general anesthesia.”  The associated examples for this item were also modified.  The changed pages in the RAI Manual are found in Chapter 3, pages J-36 and J-37.  The last 2 pages of this Errata document contain the actual manual replacement pages that reflect this significant change.

You may recall that prior to the posting of this errata document, the October 2018 RAI Manual spoke to the requirement for 3 conditions to be met in order to code 1, Yes to resident had major surgery during the 100 days prior to admission.  Those requirements were:

1. the resident was an inpatient in an acute care hospital for at least one day in the 100 days prior to admission to the skilled nursing facility (SNF),
2. the resident had general anesthesia during the procedure, and
3. the surgery carried some degree of risk to the resident’s life or the potential for severe disability.

This Errata document changes that.  Now there are only 2 conditions for coding J2000.  Here’s what those manual pages look like now (10/1/2018 changes are italicized and in red font):

J2000: Prior Surgery (cont.)

Steps for Assessment

1. Ask the resident and his or her family or significant other about any surgical procedures in the 100 days prior to admission.
2. Review the resident’s medical record to determine whether the resident had major surgery during the 100 days prior to admission.

Medical record sources include medical records received from facilities where the resident received health care during the previous 100 days, the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.

Coding Instructions

• Code 0, No, if the resident did not have major surgery during the 100 days prior to admission.
• Code 1, Yes, if the resident had major surgery during the 100 days prior to admission.
• Code 8, Unknown, if it is unknown or cannot be determined whether the resident had major surgery during the 100 days prior to admission.

Coding Tips

• Generally, major surgery for item J2000 refers to a procedure that meets the following criteria:

1. the resident was an inpatient in an acute care hospital for at least one day in the 100 days prior to admission to the skilled nursing facility (SNF), and
2. the surgery carried some degree of risk to the resident’s life or the potential for severe disability.

Examples

1. Mrs. T reports that she required surgical removal of a skin tag from her neck a month and a half ago. She had the procedure as an outpatient. Mrs. T reports no other surgeries in the last 100 days.

 

Coding: J2000 would be coded 0, No.

Rationale: Mrs. T’s skin tag removal surgery did not require an acute care inpatient stay; therefore, the skin tag removal does not meet the required criteria to be coded as major surgery. Mrs. T did not have any other surgeries in the last 100 days.

2. Mr. A’s wife informs his nurse that six months ago he was admitted to the hospital for five days following a bowel resection (partial colectomy) for diverticulitis. Mr. A’s wife reports Mr. A has had no other surgeries since the time of his bowel resection.

Coding: J2000 would be coded 0, No.

Rationale: Bowel resection is a major surgery that has some degree of risk for death or severe disability, and Mr. A required a five-day hospitalization. However, the bowel resection did not occur in the last 100 days; it happened six months ago, and Mr. A has not undergone any surgery since that time.

3. Mrs. G was admitted to the facility for wound care related to dehiscence of a surgical wound subsequent to a complicated cholecystectomy. The attending physician also noted diagnoses of anxiety, diabetes, and morbid obesity in her medical record. She was transferred to the facility immediately following a four-day acute care hospital stay.

Coding: J2000 would be coded 1, Yes.

Rationale: In the last 100 days, Mrs. G underwent a complicated cholecystectomy, which required a four-day hospitalization. She additionally had comorbid diagnoses of diabetes, morbid obesity, and anxiety contributing some additional degree of risk for death or severe disability.