Understanding and Coding MDS 3.0 Item J2930: Major Surgery - The Breast

Understanding and Coding MDS 3.0 Item J2930: Major Surgery – The Breast

Introduction

Purpose:
MDS Item J2930, Major Surgery – The Breast, is used to document significant surgical procedures involving the breast. This includes surgeries related to breast cancer, reconstruction, or other conditions affecting the breast. Accurate coding ensures that the resident's surgical history is captured, allowing healthcare professionals to provide appropriate post-surgical care and follow-up. This guide offers a step-by-step explanation of how to code MDS Item J2930 based on the MDS 3.0 guidelines.

What is MDS Item J2930?

Explanation:
MDS Item J2930 refers to major surgeries involving the breast, such as:

• Mastectomy: The removal of one or both breasts, commonly performed as part of breast cancer treatment.
• Lumpectomy: The removal of a breast lump or tumor, also typically for cancer treatment.
• Breast reconstruction: Surgical procedures to rebuild the shape and appearance of the breast after mastectomy or lumpectomy.
• Other breast surgeries: These may include biopsies, reduction surgeries, or surgeries to treat breast infections or abscesses.

Documenting breast surgery is essential for planning post-surgical care, managing recovery, and ensuring that residents receive appropriate support during rehabilitation.

Guidelines for Coding J2930

Coding Instructions:
To accurately code Item J2930, follow these steps:

1. Review the Resident’s Medical Records:

   • Review the medical history to confirm whether the resident has undergone a major breast surgery such as mastectomy, lumpectomy, breast reconstruction, or any other significant breast-related procedure.

2. Confirm the Surgery Qualifies as Major Surgery:

   • Ensure the surgery involves general or regional anesthesia, requires significant recovery time, and may require follow-up care such as wound management or rehabilitation.

3. Code Based on the Type of Surgery:

   • Code “1” for Major Surgery – The Breast if the resident has undergone any significant breast surgery, whether for cancer treatment or another condition.
   • If no major breast surgery has been performed, leave this item unmarked.

4. Enter the Response in Item J2930:

   • If a major breast surgery is identified, enter “1” in J2930.

Example Scenario 1:
A resident underwent a bilateral mastectomy as part of breast cancer treatment. In this case, “1” would be entered in Item J2930 to document the surgery.

Example Scenario 2:
A resident had a lumpectomy to remove a benign tumor from the breast. Since this qualifies as a significant surgery, “1” would be entered in J2930.

Best Practices for Accurate Coding

Documentation:

• Ensure that the resident’s medical records include detailed documentation of the breast surgery, such as the date, type of surgery, and any follow-up care required (e.g., wound care, physical therapy, or prosthesis).
• If the surgery was performed for breast cancer, document the stage of cancer and the type of surgical intervention in the resident’s care plan.

Communication:

• Share details of the surgery with the interdisciplinary care team, including the attending physician, nurses, and rehabilitation specialists, to ensure that the resident receives appropriate care during recovery.
• Discuss the surgery and its recovery process with the resident and their family, especially regarding post-operative needs such as pain management, mobility concerns, or emotional support.

Post-Surgical Care and Monitoring:

• Monitor the resident for post-operative complications, such as infection, lymphedema, or wound healing issues, and provide ongoing care as needed.
• Coordinate follow-up appointments, especially if the surgery was cancer-related, to ensure the resident receives ongoing evaluation for cancer recurrence or other concerns.

Conclusion

Summary:
MDS Item J2930 is used to document major surgeries of the breast, such as mastectomies, lumpectomies, and breast reconstruction. Accurate coding of this item ensures that residents receive the appropriate post-surgical care, whether for breast cancer treatment or other breast-related conditions. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure comprehensive care for residents who have undergone breast surgery.

Click here to see a detailed step-by-step on how to complete this item set

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-126] for detailed guidelines on coding major surgeries involving the breast.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item J2930: Major Surgery – The Breast was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.