J1100A: Shortness of Breath or Trouble Breathing: With Activity, Step-by-Step
Step-by-Step Coding Guide for Item Set J1100A: "Shortness of Breath or Trouble Breathing: With Activity"
1. Review of Medical Records
- Objective: Ensure accurate documentation of the resident's shortness of breath or trouble breathing during activities.
- Actions:
- Review the resident's MDS assessment and care plan, focusing on respiratory symptoms and related care notes.
- Check for staff documentation indicating when the resident experienced shortness of breath, especially during physical activity, such as walking, transferring, or participating in daily care tasks.
- Review any diagnoses related to respiratory conditions (e.g., COPD, heart failure) that may contribute to shortness of breath during activity.
2. Understanding Definitions
- J1100A: Shortness of Breath or Trouble Breathing With Activity: This item records whether the resident experienced shortness of breath during physical activities, including routine movements like transferring, bathing, or walking, in the 7-day look-back period. Even if the resident avoids activity due to shortness of breath, this item should be coded as present.
3. Coding Instructions
- Step-by-Step:
- Step 1: Review documentation to identify any episodes of shortness of breath or trouble breathing related to physical activity.
- Step 2: Interview the resident, if possible, to determine if they experience shortness of breath during activity. If the resident is unable to communicate, consult staff members who provide daily care.
- Step 3: If shortness of breath is reported or observed during activities, code J1100A as checked.
- Step 4: If no shortness of breath occurred during activities or if staff and medical records indicate no issues, leave J1100A unchecked.
4. Coding Tips
- Avoiding Misinterpretation: Ensure that shortness of breath related specifically to activities (such as walking or transferring) is documented under J1100A. Shortness of breath during rest or while lying down should be coded in J1100B and J1100C, respectively.
- Resident Avoidance: If a resident avoids activity due to shortness of breath, still code J1100A as present.
5. Documentation
- Objective: Ensure that the documentation provides clear information on when and why the resident experienced shortness of breath.
- Actions:
- Document the types of activities during which the resident experienced shortness of breath.
- Ensure that the care plan reflects interventions for managing shortness of breath, such as oxygen use or activity modifications.
- Record the frequency and intensity of symptoms during different activities.
6. Common Errors to Avoid
- Misclassification: Do not mistakenly code shortness of breath at rest under J1100A. This should only capture instances when shortness of breath occurred during activity.
- Lack of Documentation: Ensure that the staff notes and medical records reflect the observation of shortness of breath during activities to support accurate coding.
7. Practical Application
- Example 1: A resident with COPD experiences shortness of breath when transferring from bed to chair and while walking short distances. These activities are documented as causing breathing difficulties, and J1100A is coded as checked.
- Example 2: A resident avoids getting out of bed due to fear of shortness of breath. Although the resident limits activity, J1100A is still coded as checked due to their avoidance of activity related to breathing difficulties.
Please note that the information provided in this guide for MDS 3.0 Item set J1100A was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
