J1100. Shortness of Breath (dyspnea), Step-by-Step

Step-by-Step Coding Guide for J1100. Shortness of Breath (dyspnea)

1. Review of Medical Records

Start by reviewing the resident's medical records, focusing on recent assessments, physician notes, nurse's notes, and respiratory therapy notes. Look for documented episodes of shortness of breath, any diagnoses related to respiratory issues (e.g., COPD, heart failure), and any treatments or interventions in place to manage these conditions.

2. Understanding Definitions

• Shortness of Breath (Dyspnea): An uncomfortable awareness of breathing that is inappropriate to the level of exertion. It's important to understand that dyspnea is subjective and must be reported by the resident unless they are unable to communicate, in which case caregiver observations are used.

3. Coding Instructions

• Code 0, No: If the resident has not had shortness of breath or trouble breathing, as observed or reported by the resident, in the last 30 days.
• Code 1, Yes, when lying flat: The resident experiences shortness of breath when lying flat but it improves when sitting up or with the head of the bed elevated.
• Code 2, Yes, with exertion: The resident experiences shortness of breath with minimal, moderate, or strenuous exertion.
• Code 3, Yes, when sitting at rest: The resident experiences shortness of breath even when sitting at rest.

4. Coding Tips

• Always consider the resident's ability to communicate their experience. If unable, rely on observations and documented evidence.
• Understand that dyspnea can fluctuate; consider the entirety of the 30-day look-back period.
• Note that positioning and activity levels can affect the presence and severity of dyspnea.

5. Documentation

Document the resident's reports of dyspnea, observations of signs of respiratory distress, any known conditions that might contribute to shortness of breath, and any interventions or treatments used to alleviate symptoms. Include details on the position or activities that trigger dyspnea.

6. Common Errors to Avoid

• Not considering the entire 30-day look-back period.
• Overlooking resident's nonverbal signs of dyspnea, especially in non-communicative residents.
• Failing to document or review medical records thoroughly.
• Misinterpretation of the resident's verbal reports or failure to seek clarification.

7. Practical Application

Example Scenario: Mrs. Smith reports feeling short of breath when walking to the bathroom. Her medical record notes COPD. During assessment, she states, "I have to stop and catch my breath even when just walking a short distance."

• Step: Based on Mrs. Smith's report and medical history, J1100 should be coded as "2, Yes, with exertion."

Illustration: Create an image depicting a clinician reviewing a resident's file, then sitting beside the resident, gently asking about their breathing. The resident gestures towards their chest to indicate discomfort while walking. The clinician makes notes.

The Step-by-Step Coding Guide for item J1100 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.