Step-by-Step Coding Guide for J1300: Current Tobacco Use Coding Guide

1. Review of Medical Records

• Begin with a comprehensive review of the resident's medical records, focusing on any documentation related to tobacco use. This includes physician's notes, nursing notes, and any other clinical assessments that mention smoking habits, use of chewing tobacco, or nicotine replacement therapies.

2. Understanding Definitions

• Tobacco Use: Refers to the current use of products containing tobacco or nicotine. This includes cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, and nicotine delivery systems such as patches, gums, or electronic cigarettes.

3. Coding Instructions

• Code 0, No: If the resident has not used tobacco in any form in the last 14 days.
• Code 1, Yes: If the resident has used tobacco in any form in the last 14 days.

4. Coding Tips

• Always verify the frequency and type of tobacco use directly with the resident if possible.
• Consult with family members or significant others for residents who are unable to communicate effectively.
• Pay attention to the use of nicotine replacement products as they also indicate current nicotine use.

5. Documentation

• Document the source of information (resident, family member, medical records).
• Note the type of tobacco product used and the frequency of use in the last 14 days.
• Include any plans for tobacco cessation or use of nicotine replacement therapies.

6. Common Errors to Avoid

• Failing to code residents using nicotine replacement therapies as "Yes".
• Overlooking occasional tobacco use within the 14-day period.
• Misinterpreting "current use" and excluding residents who have used tobacco products even once in the last 14 days.

7. Practical Application

Example 1:

• A resident, Mr. A, has smoked two cigarettes in the past 14 days. Despite being a sporadic user, he is coded as "Yes" for current tobacco use. His care plan includes support for smoking cessation and monitoring for withdrawal symptoms.

Example 2:

• Ms. B uses nicotine patches as part of her plan to quit smoking. She hasn't smoked a cigarette in the last 14 days but uses nicotine patches daily. She should be coded as "Yes" for current tobacco use, and her use of nicotine replacement therapy should be documented.

The Step-by-Step Coding Guide for item J1300 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.