J2940: Major Surgery - Repair of Deep Ulcers, Internal Brachytherapy, Bone Marrow or Stem Cell Harvest or Transplant, Step-by-Step

Step-by-Step Coding Guide for J2940: Major Surgery - Repair of Deep Ulcers, Internal Brachytherapy, Bone Marrow or Stem Cell Harvest or Transplant

1. Review of Medical Records

Objective: Confirm if the resident underwent any of the following major surgeries during the last inpatient stay prior to the skilled nursing facility (SNF) admission:

• Repair of deep ulcers
• Internal brachytherapy
• Bone marrow or stem cell harvest or transplant

Actions:

• Access the resident’s medical records, including hospital discharge summaries, progress notes, and surgical reports.
• Verify if any of the specified surgeries were performed during the hospital stay prior to the resident’s admission to the SNF.

2. Understanding Definitions

J2940: Major Surgery - This item refers to specific high-risk procedures, such as:

• Repair of deep ulcers: Surgery to treat severe ulcerations that may involve skin grafts or other major interventions.
• Internal brachytherapy: A type of radiation treatment where radioactive material is placed inside the body to treat cancer.
• Bone marrow or stem cell harvest/transplant: Procedures related to the collection and transplantation of bone marrow or stem cells to treat certain cancers or blood disorders​.

Illustration 1:

Scenario: A resident underwent a bone marrow transplant for the treatment of leukemia prior to their SNF admission.

Result: J2940 is coded "Yes" because the resident received a major surgery involving a stem cell transplant.

3. Coding Instructions

Step-by-Step:

• Step 1: Review the hospital discharge summaries and surgical notes to identify if any of the surgeries listed under J2940 occurred during the resident’s last inpatient stay prior to SNF admission.
• Step 2: Confirm that the surgery is directly related to the resident’s ongoing care needs in the SNF.
• Step 3: If any of the specified surgeries were performed, check J2940 as "Yes".
• Step 4: If none of these surgeries were performed, mark "No".

Illustration 2:

Scenario: A resident underwent internal brachytherapy for prostate cancer during their recent hospital stay. The resident requires follow-up care for managing side effects of the radiation therapy.

Result: J2940 is coded "Yes", as brachytherapy is a major surgery that requires ongoing skilled care.

4. Coding Tips

• Verify Documentation: Ensure that the surgery is well-documented and involves one of the major procedures listed in J2940.
• Related to Ongoing Care: The surgery must require ongoing care during the SNF stay, such as wound management, radiation therapy follow-up, or monitoring of bone marrow transplant complications​​.

5. Documentation

Objective: Ensure that all relevant surgeries are properly documented in the medical records.
Actions:

• Record the type of surgery, including details such as date of the procedure, the surgical method used, and any follow-up care required.
• Include any relevant information regarding post-operative care or therapies needed during the SNF stay.

Illustration 3:

Scenario: A resident had deep ulcer repair surgery involving skin grafts. Documentation confirms that the wound requires ongoing skilled monitoring and care.

Documentation: The surgery is clearly noted in the medical records, and J2940 is coded "Yes".

6. Common Errors to Avoid

• Missing Documentation: Do not code J2940 without clear documentation from a physician or surgeon regarding the specific surgery performed.
• Incorrect Surgery Type: Ensure the surgery falls within the scope of J2940 and is not another unrelated surgical procedure.

Illustration 4:

Scenario: A resident had surgery to place a central line for IV antibiotics but no ulcer repair, brachytherapy, or stem cell transplant.

Error: Do not code J2940 for a central line placement. This does not meet the criteria for major surgery under this item.

7. Practical Application

• Example 1: A resident was admitted after a stem cell transplant for lymphoma. They require monitoring for graft-versus-host disease. J2940 is coded "Yes".
• Example 2: A resident had surgery for a hernia repair during their recent hospital stay. Since this is not a surgery listed under J2940, J2940 is coded "No".

Please note that the information provided in this guide for MDS 3.0 Item set J2940 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.