Step-by-Step Coding Guide for J2100. Recent Surgery Requiring Active SNF Care

1. Review of Medical Records

• Objective: Identify any surgical procedures that required an inpatient hospital stay of at least one night in the last 100 days, which now necessitates active care in the SNF setting.
• Process: Examine hospital discharge summaries, operative reports, and physician orders. Look for details on the type of surgery, the date it was performed, and any post-operative care requirements that necessitate SNF services.

2. Understanding Definitions

• Recent Surgery: Any surgical operation that required at least a one-night inpatient hospital stay in the last 100 days.
• Active SNF Care: Ongoing skilled nursing or rehabilitation services related to post-surgical care, such as wound care, physical therapy, or monitoring for complications.

3. Coding Instructions

• Code 0, No: If the resident did not have surgery in the last 100 days requiring active SNF care.
• Code 1, Yes: If the resident had surgery in the last 100 days requiring active SNF care.

4. Coding Tips

• Verify the surgery date to ensure it falls within the 100-day timeframe.
• Collaborate with interdisciplinary team members to determine if the surgery necessitates active SNF care.

5. Documentation

• Necessity: Clearly document the type of surgery, date of surgery, and specific skilled care being provided in relation to the surgery.
• Location: Record this information in the resident's medical chart, care plan, and MDS assessment.

6. Common Errors to Avoid

• Overlooking surgeries because of incomplete review of hospital records.
• Failing to consider all forms of active SNF care that might relate to post-surgical needs.
• Incorrectly calculating the 100-day period from the date of surgery.

7. Practical Application

• Example: A resident underwent hip replacement surgery 90 days ago and is receiving physical therapy for mobility and strength in the SNF. This scenario should be coded as "1, Yes" for J2100, indicating the resident's need for active SNF care post-surgery.

The Step-by-Step Coding Guide for item J2100 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.