Step-by-Step Coding Guide for Item Set J0600: Pain Intensity

1. Review of Medical Records:

• Begin by reviewing the resident's medical records, including physician's notes, nursing notes, and pain assessment tools, to gather information on pain reports and observations during the 5-day look-back period.

2. Understanding Definitions:

• Pain Intensity: Refers to the resident's self-report or, if unable, staff assessment of the severity of pain, considering both the presence and the intensity of pain experienced.
• Look-back period: 5 days prior to the assessment (excluding the day of assessment).

3. Coding Instructions:

• J0600A (Pain Effect on Function): Ask the resident to rate the intensity of pain on a scale from 0 to 10, where 0 means "no pain" and 10 means "worst imaginable pain".
• J0600B (Pain Presence): If the resident cannot provide a self-report, observe and consult with staff about the resident's non-verbal signs of pain or discomfort.

4. Coding Tips:

• Utilize a consistent method for pain assessment to ensure reliability and accuracy.
• Pay attention to non-verbal signs of pain in residents who are unable to communicate effectively, such as grimacing, moaning, or restlessness.

5. Documentation:

• Record the resident's self-reported pain score or staff-assessed observations in the medical record, including the date and time of assessment.
• Document any interventions implemented to manage pain and their outcomes.

6. Common Errors to Avoid:

• Overlooking non-verbal signs of pain in non-communicative residents.
• Failing to assess pain regularly or as condition changes.
• Incorrectly coding based on outdated or incomplete information.

7. Practical Application:

• Example 1: A resident verbally reports their pain as a 4 on a 0 to 10 scale. You would code J0600A as "4".
• Example 2: A non-verbal resident shows consistent grimacing and agitation when moved. Staff assess the pain level as moderate based on observations. You would code J0600B as present and describe the observed behaviors in the medical record.

The Step-by-Step Coding Guide for item J0600 in MDS 3.0 Section J is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, it is crucial for healthcare professionals to ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.