0
No
if the resident did not have major surgery during the inpatient hospital stay
that immediately preceded the resident’s Part A admission.
DiraChart MDS item reference
J2100Section Jv1.20.1Manual page J-43
Recent Surgery Requiring Active SNF Care
Item Rationale
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
Yes
if the resident had major surgery during the inpatient hospital stay that
immediately preceded the resident’s Part A admission.
8
Unknown
if it is unknown or cannot be determined whether the resident had
major surgery during the inpatient hospital stay that immediately preceded the resident’s
Part A admission.
10
Fractures and Other Multiple Trauma
The I0020B SNF ICD-10 code is S72.22XD (Displaced subtrochanteric fracture of left femur,
subsequent encounter for closed fracture with routine healing) and J2100 is coded as 1,
Yes. J2510, Ortho surgery – repair fractures of pelvis, hip, leg, knee, or ankle, would be
checked.
Rationale: This is major surgery requiring skilled nursing care to provide wound care
and to monitor for early signs of infection or blood clots, for which Resident W was
admitted to the SNF.
Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
1. Ask the resident and their family or significant other about any surgical procedures that
occurred during the inpatient hospital stay that immediately preceded the resident’s Part A
admission.
2. Review the resident’s medical record to determine whether the resident had major surgery
during the inpatient hospital stay that immediately preceded the resident’s Part A admission.
Medical record sources include medical records received from facilities where the resident
received health care during the inpatient hospital stay that immediately preceded the
resident’s Part A admission, 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 inpatient hospital stay
that immediately preceded the resident’s Part A admission.
•
Code 1, Yes: if the resident had major surgery during the inpatient hospital stay that
immediately preceded the resident’s Part A admission.
•
Code 8, Unknown: if it is unknown or cannot be determined whether the resident had
major surgery during the inpatient hospital stay that immediately preceded the resident’s
Part A admission.
Coding Tips
•
Generally, major surgery for item J2100 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 30
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.
J2300–J5000: Recent Surgeries Requiring Active SNF Care
MDS item matrixAssessment Applicability
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7 relationships5 groups+
Assessment Applicability
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Nursing Home Subsets
Swing Bed Subsets
Shared NH/SB Subsets
Program and Policy Use
Item Subset Required Use ISC Skip Patterns
Official CMS source
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Reference details
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