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Manual page J-45DiraChart MDS item reference
J2600Section Jv1.20.1Manual page J-45
Neuro surgery - brain, surrounding tissue or blood vessels
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Check all that apply
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Condition does not apply under the item instruction.
Manual page J-45Item-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. 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.)
Coding Instructions
Code surgeries that are documented to have occurred in the last 30 days, and during the
inpatient stay that immediately preceded the resident’s Part A admission, that have a direct
relationship to the resident’s primary SNF diagnosis, as coded in I0020B.
•
Check off each surgery requiring active SNF care as defined above, as follows:
— Surgeries are listed by major surgical category: Major Joint Replacement, Spinal
Surgery, Orthopedic Surgery, Neurologic Surgery, Cardiopulmonary Surgery,
Genitourinary Surgery, Other Major Surgery.
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Coding Tips
The following information may assist assessors in determining whether a surgery should be
coded as requiring active care during the SNF stay.
•
There may be specific documentation in the medical record by a physician, nurse
practitioner, physician assistant, or clinical nurse specialist.
— The physician (nurse practitioner, physician assistant, or clinical nurse specialist if
allowable under state licensure laws) may specifically indicate that the SNF stay is
for treatment related to the surgical intervention. Specific documentation may be
found in progress notes, most recent history and physical, transfer notes, hospital
discharge summary, etc.
•
In the rare circumstance of the absence of specific documentation that a surgery
requires active SNF care, the following indicators may be used to confirm that the
surgery requires active SNF care:
The inherent complexity of the services prescribed for a resident is such that they can be
performed safely and/or effectively only by or under the general supervision of skilled
nursing. For example:
— The management of a surgical wound that requires skilled care (e.g., managing
potential infection or drainage).
— Daily skilled therapy to restore functional loss after surgical procedures.
— Administration of medication and monitoring that requires skilled nursing.
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