Steps for Assessment
1. Identify recent surgeries: The surgeries in this section must have been documented by a
physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable
under state licensure laws) in the last 30 days and must have occurred during the inpatient
stay that immediately preceded the resident’s Part A admission.
•
Medical record sources for recent surgeries include progress notes, the most recent
history and physical, transfer documents, discharge summaries, diagnosis/problem list,
and other resources as available.
•
Although open communication regarding resident information between the physician and
other members of the interdisciplinary team is important, it is also essential that resident
information communicated verbally be documented in the medical record by the
physician to ensure follow-up.
•
Surgery information, including past history obtained from family members and close
contacts, must also be documented in the medical record by the physician to ensure
validity and follow-up.
2. Determine whether the surgeries require active care during the SNF stay: Once a recent
surgery is identified, it must be determined if the surgery requires active care during the SNF
stay. Surgeries requiring active care during the SNF stay are surgeries that have a direct
relationship to the resident’s primary SNF diagnosis, as coded in I0020B.
•
Do not include conditions that have been resolved, do not affect the resident’s current
status, or do not drive the resident’s plan of care during the 7-day look-back period, as
these would be considered surgeries that do not require active care during the SNF stay.
•
Check the following information sources in the medical record for the last 30 days to
identify “active” surgeries: transfer documents, physician progress notes, recent history
and physical, recent discharge summaries, nursing assessments, nursing care plans,
medication sheets, doctor’s orders, consults and official diagnostic reports, and other
sources as available.
J2300–J5000: Recent Surgeries Requiring Active SNF Care
(cont.)