Step-by-Step Coding Guide for Item Set J2710: "Cardiopulmonary Surgery - Respiratory System, Including Lungs, Bronchi, Trachea, Larynx, or Vocal Cords – Open and Endoscopic"

1. Review of Medical Records

• Objective: Confirm whether the resident underwent respiratory system surgery within the last 30 days that required skilled nursing facility (SNF) care.
• Actions:
  • Access the resident’s medical records, including progress notes, hospital discharge summaries, and transfer documents, to verify the date, type, and nature of the cardiopulmonary surgery.
  • Review notes to ensure the surgery involves the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords.

2. Understanding Definitions

• J2710: Cardiopulmonary Surgery - Respiratory System: This item refers to surgeries involving the respiratory system conducted through open or endoscopic methods. These surgeries must have been performed during the inpatient hospital stay preceding the resident’s SNF admission.
  • Respiratory System: Includes lungs, bronchi, trachea, larynx, or vocal cords.
  • Open Surgery: A procedure where a large incision is made to access the area of surgery.
  • Endoscopic Surgery: Minimally invasive procedure using an endoscope to view and perform surgery within the body.

3. Coding Instructions

• Step-by-Step:
  • Step 1: Determine whether the surgery took place during the resident’s most recent inpatient stay, which immediately preceded their SNF admission.
  • Step 2: Identify the type of surgery (open or endoscopic) from the medical records.
  • Step 3: If the resident underwent cardiopulmonary surgery involving the respiratory system, lungs, bronchi, trachea, larynx, or vocal cords, mark item J2710 as "Yes".
  • Step 4: If no such surgery was performed, or if the surgery does not involve these body parts, mark "No".

4. Coding Tips

• Document Thoroughly: Ensure that the medical record explicitly states that the surgery involved the respiratory system and whether it was open or endoscopic.
• Clarify with Medical Team: If there is any uncertainty regarding the type of surgery or body part involved, consult the surgeon's notes or follow up with the medical team.
• Related Diagnoses: Check that the surgery aligns with the resident's primary SNF diagnosis (I0020B) and that it requires active care during the SNF stay.

5. Documentation

• Objective: Ensure that documentation reflects the surgery performed and its connection to ongoing care.
• Actions:
  • Include specific notes on the type of surgery (open or endoscopic) and the part of the respiratory system involved.
  • Document any follow-up care, therapies, or monitoring required during the resident’s SNF stay due to the surgery.

6. Common Errors to Avoid

• Misclassifying Surgery: Do not classify surgeries involving other body systems or organs as J2710. This item is specific to surgeries involving the respiratory system.
• Incomplete Documentation: Avoid coding this item without supporting documentation from hospital discharge notes or surgical records.
• Overlooking Endoscopic Procedures: Endoscopic surgeries may sometimes be overlooked. Ensure all surgical methods are reviewed.

7. Practical Application

• Example 1: A resident underwent a bronchoscopy and partial lung resection (open surgery) due to a tumor in the lung. This surgery requires post-surgical care in the SNF for wound management and respiratory therapy. J2710 is marked as "Yes".
• Example 2: A resident received an endoscopic procedure to remove a growth from the vocal cords. The resident requires ongoing care for respiratory support and wound healing, so J2710 is marked "Yes".
• Example 3: A resident was admitted for post-surgical care following heart valve surgery (not involving the respiratory system). Since the surgery did not involve the respiratory system, J2710 is marked "No".

Please note that the information provided in this guide for MDS 3.0 Item set J2710 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.