J2810: Genitourinary Surgery - Kidneys, Ureter, Adrenals, and Bladder (Open, Laparoscopic), Step-by-Step

Step-by-Step Coding Guide for J2810: Genitourinary Surgery - Kidneys, Ureter, Adrenals, and Bladder (Open, Laparoscopic)

1. Review of Medical Records

• Objective: Confirm accurate documentation of any recent genitourinary surgeries involving the kidneys, ureter, adrenals, or bladder, performed via open or laparoscopic procedures.
• Actions:
  • Access medical and surgical records to verify whether the resident has undergone surgery on the kidneys, ureter, adrenals, or bladder within the 30-day look-back period.
  • Review physician progress notes, discharge summaries, and relevant diagnostic reports for details on the surgery, recovery process, and post-operative care requirements.
  • Ensure the surgery is documented in relation to the resident’s SNF (Skilled Nursing Facility) admission and continued care needs.

2. Understanding Definitions

• J2810: Genitourinary Surgery: This item refers to surgical procedures performed on the kidneys, ureter, adrenals, or bladder, either through open or laparoscopic techniques. These surgeries can be part of ongoing treatment or recovery processes for conditions affecting these organs.
• Open vs. Laparoscopic:
  • Open Surgery: Involves a large incision to access the surgical site.
  • Laparoscopic Surgery: A minimally invasive approach using small incisions and specialized tools​.

3. Coding Instructions

• Step-by-Step:
  • Step 1: Determine if the resident underwent a genitourinary surgery during the current or prior hospital stay, specifically on the kidneys, ureter, adrenals, or bladder.
  • Step 2: Identify if the procedure was performed using open or laparoscopic techniques.
  • Step 3: If the resident had such surgery, code “1” for J2810 in the MDS (Minimum Data Set) to indicate that the surgery occurred and continues to require skilled nursing care post-discharge.
  • Step 4: Ensure documentation aligns with the resident’s current recovery plan, particularly if the surgery necessitates ongoing monitoring or treatment during the SNF stay.

4. Coding Tips

• Correct Classification: Ensure that surgeries coded under J2810 are specific to the kidneys, ureter, adrenals, or bladder. Other genitourinary procedures (e.g., involving male/female reproductive organs) should be coded elsewhere.
• Documentation: Confirm the procedure details, including whether it was open or laparoscopic, are clearly documented by the physician.
• Post-Operative Care: Verify that the care plan includes wound care, medication management, and potential follow-up procedures related to the surgery​.

5. Documentation

• Objective: Maintain comprehensive records of the surgery and its impact on the resident’s care needs.
• Actions:
  • Record all relevant information about the surgery, including the type of procedure, date, and surgeon’s notes.
  • Ensure post-operative instructions and recovery milestones are clearly outlined in the resident’s care plan.
  • Document any changes in the resident’s condition or the necessity for ongoing skilled care, including wound management, medication adjustments, and therapy.

6. Common Errors to Avoid

• Incorrect Surgery Classification: Ensure that surgeries unrelated to the kidneys, ureter, adrenals, or bladder are not mistakenly coded under J2810.
• Incomplete Documentation: Failing to document the type of surgery (open or laparoscopic) or omitting key post-operative care instructions can lead to incorrect coding and care plans.
• Overlooking Follow-Up Care: Ensure that follow-up care, such as monitoring for infection or complications, is included in the resident’s care plan.

7. Practical Application

• Example 1: A resident underwent laparoscopic surgery for the removal of a kidney stone, which requires continued post-operative monitoring and pain management in the SNF. J2810 is coded as “1” to reflect this.
• Example 2: A resident had an open surgery to remove a bladder tumor. The resident’s care plan includes wound care and monitoring for potential complications, so J2810 is coded as “1.”
• Example 3: A resident did not undergo any genitourinary surgery involving the kidneys, ureter, adrenals, or bladder. J2810 is coded as “0.”

Please note that the information provided in this guide for MDS 3.0 Item set J2810 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.