PDPM!  I am sure you have heard about this new payment system by now, right? As you prepare and position yourself for this major change, we have to not only understand all of the moving parts, but more importantly, how all of those moving parts affect resident classification. MDS Section J will play a major role in determining resident classification and is no “J”oking matter!

 

Let’s take a look at the current RAI manual instructions for Section J, specifically section J2000, where the question is asking, “Did the resident have major surgery during the 100 days prior to admission?” Why is this important? The RAI manual explains that if the resident had a major surgery during the 100 days prior to the SNF admission, this surgery can affect the resident’s recovery.

 

How to assess? Ask the resident and his or her family or significant other about any surgical procedures in the 100 days prior to the SNF admission.  Review the resident’s medical record to determine whether the resident had major surgery. Review records received from facilities where the resident received care during the previous 100 days. The most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available are crucial for proof of the major surgery.  Receiving paperwork from the hospital is extremely important, especially surgical reports.  We need to work diligently to receive the supporting documentation from the hospital to ensure appropriate resident care is provided in the SNF as well as to appropriate classify the resident into an appropriate PDPM classification.

 

CMS defines a ‘major surgery’ that meets all of the following criteria in the MDS 3.0 RAI User’s Manual

  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 SNF, and
  2. The surgery carried some degree of risk to the resident’s life or the potential for severe disability.

 

In the draft item set in section J2100, the MDS asks the question, “Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?” If the Nurse Assessment Coordinator answers ‘Yes’ (J2100=1), the next step is to check all that apply in the following areas:

 

Major Joint Replacement.

J2300. Knee Replacement – partial or total.

J2310. Hip Replacement – partial or total.

J2320. Ankle Replacement – partial or total.

J2330. Shoulder Replacement – partial or total

 

Spinal Surgery.

J2400. Involving the spinal cord or major spinal nerves.

J2410. Involving fusion of spinal bones.

J2420. Involving Iamina, discs, or facets .

J2499. Other major spinal surgery.

J2599. Other major orthopedic surgery.

 

Other Orthopedic Surgery.

J2500. Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand).

J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot).

J2520. Repair but not replace joints.

J2530. Repair other bones (such as hand, foot, jaw).

 

Neurological Surgery.

J2600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves).

J2610. Involving the peripheral or autonomic nervous system – open or percutaneous.

J2620. Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices J2699. Other major neurological surgery.

 

Cardiopulmonary Surgery.

J2700. Involving the heart or major blood vessels – open or percutaneous procedures.

J2710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords – open or endoscopic.

J2799. Other major cardiopulmonary surgery .

 

Genitourinary Surgery.

J2800. Involving male or female organs (such as prostate, testes, ovaries, uterus, vagina, external genitalia).

J2810. Involving the kidneys, ureters, adrenal glands, or bladder – open or laparoscopic (includes creation or removal of nephrostomies or urostomies).

J2899. Other major genitourinary surgery.

 

Other Major Surgery.

J2900. Involving tendons, ligaments, or muscles.

J2910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, or spleen – open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair).

J2920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus – open.

J2930. Involving the breast.

J2940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant.

J5000. Other major surgery not listed above

 

Why is it important for classification to ensure proper coding of major surgery under PDPM? By coding appropriately, there may be a change in the component clinical category. Some ICD-10-CM codes can map to a different clinical category if the resident received a surgical procedure during the prior inpatient hospital stay that relates to the primary reason for the SNF Part A admission. In order for this change, the surgical procedure must be recorded in section J of the MDS (J2000).

 

Gina Tomcsik
Director of Compliance and Regulatory Strategy