Step-by-Step Coding Guide for Item Set J2930: Major Surgery - The Breast

1. Review of Medical Records

• Objective: Accurately document if the resident has undergone major surgery involving the breast.
• Steps:
  1. Collect Information: Gather comprehensive medical records, including surgical reports, progress notes, oncology reports, and relevant interdisciplinary team (IDT) notes.
  2. Identify Documentation of Breast Surgery: Look for documented evidence of breast surgeries such as mastectomies, lumpectomies, or reconstructive surgeries.
  3. Confirm Details: Verify the consistency and accuracy of the breast surgery documentation across various sources within the medical records.

2. Understanding Definitions

• Major Surgery - The Breast: Refers to significant surgical procedures performed on the breast, including but not limited to mastectomies, lumpectomies, and reconstructive surgeries.
• Key Points:
  • Surgery Types: Includes any major surgical intervention on the breast for reasons such as cancer treatment, reconstruction, or other medical conditions.
  • Documentation Requirements: Clear and detailed documentation of the surgical procedure, including the type of surgery and the date performed.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records whether the resident has undergone major surgery on the breast.
  2. Verify Documentation: Ensure that the documentation clearly supports the occurrence of the breast surgery.
  3. Code Appropriately: Enter the appropriate code for item set J2930 based on the documented surgery:
     • 0: No, the resident has not undergone major surgery on the breast.
     • 1: Yes, the resident has undergone major surgery on the breast.

4. Coding Tips

• Accurate Identification: Ensure that breast surgeries are correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the surgery.
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Surgical Reports: Detailed reports of the breast surgery, including the type of surgery performed, date, and any complications or follow-up required.
  • Progress Notes: Notes from healthcare providers detailing the resident’s surgical history and post-operative care.
  • Oncology Reports: Documentation from oncologists, if applicable, detailing the breast cancer treatment plan and surgeries performed.
  • IDT Notes: Notes from interdisciplinary team meetings discussing the resident’s surgical history and related care planning.

6. Common Errors to Avoid

• Misclassification: Ensure accurate identification by verifying the breast surgery through multiple records and observations.
• Incomplete Documentation: Make sure all relevant surgical reports, progress notes, and oncology reports are included to support the documented surgery.
• Assumptions: Do not assume the surgery status without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Mary, a resident, has a history of breast cancer and underwent a mastectomy.
  • Steps:
    1. Review Records: The nurse reviews Mary’s medical records, noting the surgical report and oncology notes indicating the mastectomy.
    2. Identify Surgery: It is confirmed through the documentation that Mary underwent a major surgery on the breast.
    3. Document and Code: The nurse documents the surgery in Mary’s records and codes J2930 as "1" (Yes, major surgery on the breast).
  • Outcome: Mary’s breast surgery 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 J2930 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.