J2920: Major Surgery - Endocrine Organs (Thyroid, Parathyroid), Neck, Lymph Nodes, and Thymus-Open, Step-by-Step
Step-by-Step Coding Guide for J2920: Major Surgery - Endocrine Organs (Thyroid, Parathyroid), Neck, Lymph Nodes, and Thymus—Open
1. Review of Medical Records
Objective: Confirm whether the resident underwent open surgery involving the endocrine organs, including the thyroid, parathyroid, lymph nodes, or thymus during the inpatient stay before their SNF admission.
Actions:
- Access the resident’s medical records, including surgical reports, discharge summaries, and transfer documents.
- Verify if the resident underwent surgery involving any of the endocrine organs listed, and ensure it was performed via open surgery (as opposed to minimally invasive techniques like laparoscopic surgery).
2. Understanding Definitions
J2920: Major Surgery - Endocrine Organs (Thyroid, Parathyroid), Neck, Lymph Nodes, and Thymus - Open: This item captures any major surgical procedure involving open surgery on endocrine organs such as the thyroid or parathyroid glands, lymph nodes in the neck, or the thymus.
- Endocrine Organs: Includes thyroid, parathyroid, lymph nodes, or thymus.
- Open Surgery: Involves a traditional approach where a large incision is made to access the surgical site, as opposed to minimally invasive techniques.
Illustration 1:
Scenario: A resident underwent a thyroidectomy (removal of the thyroid gland) via open surgery due to thyroid cancer. The resident required postoperative care for the surgical wound and hormone therapy.
Result: J2920 is coded "Yes" because the surgery was open, involved an endocrine organ, and took place during the inpatient hospital stay prior to SNF admission.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the medical records to confirm if the resident had open surgery involving the endocrine organs, neck, lymph nodes, or thymus during their recent hospital stay.
- Step 2: Ensure the surgery was open and not minimally invasive.
- Step 3: If open surgery on any of these organs was performed, mark J2920 as "Yes".
- Step 4: If no such surgery was performed, or if the surgery was minimally invasive, mark "No".
Illustration 2:
Scenario: A resident had a lymph node dissection to remove cancerous lymph nodes in the neck through open surgery. The resident was transferred to an SNF for wound care and recovery.
Result: J2920 is coded "Yes", as the surgery was open and involved the neck lymph nodes.
4. Coding Tips
- Ensure Surgical Method: Make sure the surgery was open and not performed using minimally invasive methods (e.g., laparoscopic).
- Related Diagnoses: The surgery should be directly related to the resident’s primary SNF diagnosis and involve active care during their SNF stay (e.g., wound care, hormone replacement therapy).
5. Documentation
Objective: Ensure that the medical record clearly documents the open surgery and its connection to the resident’s ongoing care needs in the SNF.
Actions:
- Record the type of surgery, the organ involved (e.g., thyroid), and the surgical approach (open).
- Document any follow-up care needed during the SNF stay, such as wound management or hormone therapy.
Illustration 3:
Scenario: A resident’s chart includes details of an open parathyroidectomy (removal of the parathyroid gland). The resident requires close monitoring of calcium levels and postoperative wound care.
Documentation: Ensure the surgery and follow-up care are clearly documented, and J2920 is coded "Yes".
6. Common Errors to Avoid
- Misclassifying Surgery: Do not code minimally invasive procedures, such as laparoscopic surgeries, under J2920. Only open surgeries should be coded here.
- Incomplete Documentation: Ensure that all relevant documentation, such as surgical reports and physician notes, explicitly states the surgery type and the organ involved.
Illustration 4:
Scenario: A resident had a laparoscopic thyroidectomy. Since this is not an open surgery, J2920 should be coded "No".
7. Practical Application
- Example 1: A resident underwent an open thymectomy (removal of the thymus) and was admitted to the SNF for post-surgical care, including wound monitoring. J2920 is coded "Yes".
- Example 2: A resident had laparoscopic parathyroid surgery before admission to the SNF. J2920 is coded "No", as it was not an open surgery.
Please note that the information provided in this guide for MDS 3.0 Item set J2920 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.
