Step-by-Step Coding Guide for J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days

1. Review of Medical Records

• Objective: Identify all documented instances of pain or possible pain over the last 5 days.
• Procedure: Examine the resident’s medical records, including nursing notes, pain assessment reports, physician's notes, and therapy reports for any mention of pain or behaviors that might indicate pain.

2. Understanding Definitions

• Pain: A distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components.
• Possible Pain Indicators: Behaviors such as facial expressions, moaning, restlessness, guarding, or refusal of care that may suggest pain in non-verbal or cognitively impaired residents.

3. Coding Instructions

• 0 - No indicator observed: If the resident showed no signs of pain or possible pain indicators in the last 5 days.
• 1 - Indicator observed in 1 to 2 of the last 5 days: If signs of pain or possible pain indicators were documented on 1 to 2 days within the 5-day period.
• 2 - Indicator observed in 3 to 4 of the last 5 days: If signs of pain or possible pain indicators were documented on 3 to 4 days within the 5-day period.
• 3 - Indicator observed daily: If signs of pain or possible pain indicators were documented daily throughout the 5-day period.

4. Coding Tips

• Comprehensive Review: Ensure a thorough review of all pertinent medical records over the last 5 days.
• Interdisciplinary Input: Consult with nursing, therapy staff, and direct care workers for additional insights into the resident's pain experience.
• Non-verbal Indicators: Pay special attention to non-verbal indicators of pain, especially in residents with communication barriers.

5. Documentation

• Detailing Evidence: Clearly document in the MDS assessments the basis for the coding choice, including specific instances of observed pain or possible pain indicators.
• Interdisciplinary Notes: Include references to observations from various care team members that support the coding decision.

6. Common Errors to Avoid

• Overlooking Non-verbal Cues: Failing to account for non-verbal signs of pain in non-communicative or severely cognitively impaired residents.
• Incomplete Record Review: Not reviewing the entire 5-day period or missing documentation from other disciplines.
• Misinterpretation of Behaviors: Incorrectly attributing pain behaviors to other causes without thorough assessment.

7. Practical Application

Example: A resident with advanced dementia has been restless, refusing care, and moaning during movement over the past week. Nursing notes indicate these behaviors on 4 of the last 5 days, and the physical therapist documented wincing during therapy sessions on 3 of these days.

• Coding: Based on the evidence, J0850 would be coded as "2 - Indicator observed in 3 to 4 of the last 5 days," given the consistent documentation of possible pain indicators over the majority of the period.

The Step-by-Step Coding Guide for item J0850 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. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must 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.