Step-by-Step Coding Guide for J2300-J5000. Recent Surgery Requiring Active SNF Care

1. Review of Medical Records

Before coding for recent surgeries requiring active SNF care, a thorough review of the resident's medical records is essential. This includes hospital discharge summaries, surgical reports, physician notes, and nursing documentation within the defined look-back period. The review should identify any surgeries that occurred within the last 100 days before the ARD (Assessment Reference Date) that necessitated active care in the SNF setting.

2. Understanding Definitions

• Recent Surgery: Any surgical procedure that the resident underwent in a hospital operating room under general, spinal, or regional anesthesia within the last 100 days from the ARD.
• Active SNF Care: Care that requires the specialized services provided in a skilled nursing facility (SNF) to manage, observe, and evaluate the care needs of the resident post-surgery.

3. Coding Instructions

• J2300-J5000: Code for each surgery that occurred in the last 100 days if the resident required and received active care in the SNF for their recovery.
  • Enter the surgery codes (ICD-10-CM codes) for up to five surgeries, starting with the most recent.

4. Coding Tips

• Focus on surgeries that directly influence the resident's care plan and require active management in the SNF setting.
• Use the ICD-10-CM code that best describes the surgery. If multiple surgeries occurred, prioritize those with the most significant impact on the resident's current functional status and care needs.

5. Documentation

• Ensure that the resident's medical record clearly documents the surgery, including the date of surgery, type of anesthesia, and the necessity for active SNF care.
• Record the rationale for how the surgery impacts the resident's current care needs and any specific interventions or monitoring required.

6. Common Errors to Avoid

• Failing to identify all relevant surgeries within the 100-day look-back period.
• Incorrectly coding surgeries that did not require active SNF care for recovery.
• Overlooking documentation that supports the need for active SNF care post-surgery.

7. Practical Application

Example 1: A resident had a hip replacement surgery 60 days ago and was admitted to the SNF for post-operative care, including wound care and physical therapy.

• Coding: Code J2300 with the ICD-10-CM code for hip replacement surgery.
• Documentation: Include details of the surgery, the care provided in the SNF, and the resident's progress.

Example 2: A resident underwent abdominal surgery for a hernia repair 30 days ago and required intravenous antibiotics and nutritional support in the SNF.

• Coding: Code J2400 with the ICD-10-CM code for hernia repair.
• Documentation: Document the surgery, the need for IV antibiotics, nutritional support, and any complications or interventions.

The Step-by-Step Coding Guide for item J2300-J5000 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.