Step-by-Step Coding Guide for Item Set J1100C: Shortness of Breath/Trouble Breathing - Lying Flat

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s experiences of shortness of breath or trouble breathing while lying flat.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, physician evaluations, and respiratory assessments.
  2. Identify Breathing Issues: Look for documented instances of shortness of breath or trouble breathing specifically when the resident is lying flat.
  3. Confirm Details: Verify the consistency and frequency of these symptoms through various sources within the medical records.

2. Understanding Definitions

• Shortness of Breath/Trouble Breathing: Difficulty in breathing, also known as dyspnea, which can vary in severity.
• Lying Flat: The position where the resident is lying horizontally on their back without elevation.

3. Coding Instructions

• Steps:
  1. Identify Breathing Issues: Confirm that the resident has experienced shortness of breath or trouble breathing while lying flat from the medical records.
  2. Verify Documentation: Ensure these episodes are well-documented in nursing notes and physician evaluations.
  3. Code Appropriately: Code J1100C as:
     • 0: No, the resident does not have shortness of breath or trouble breathing when lying flat.
     • 1: Yes, the resident has shortness of breath or trouble breathing when lying flat.

4. Coding Tips

• Accurate Identification: Ensure the symptoms are specifically associated with the resident lying flat and not in other positions.
• Consistent Terminology: Use consistent terminology when documenting and coding shortness of breath or trouble breathing.
• Consult Healthcare Team: If there is any uncertainty, consult with the resident’s healthcare team, including respiratory therapists and physicians, for clarification.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes documenting instances of shortness of breath or trouble breathing, including the resident's position when symptoms occur.
  • Physician Evaluations: Include evaluations from physicians that detail the resident’s respiratory status.
  • Respiratory Assessments: Document any respiratory assessments that note the resident’s difficulty breathing while lying flat.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s symptoms through multiple sources.
• Incomplete Documentation: Make sure all relevant details about the resident’s respiratory issues are thoroughly documented.
• Assumptions: Do not assume the presence or absence of symptoms without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: John, a 78-year-old resident, reports difficulty breathing when lying flat.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, including nursing notes and physician evaluations documenting his shortness of breath when lying flat.
    2. Identify Symptoms: It is confirmed that John consistently experiences shortness of breath when lying flat.
    3. Document and Code: The nurse documents the symptoms in John’s records and codes J1100C as "1".
  • Outcome: John’s difficulty breathing when lying flat is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set J1100C 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.