Understanding and Coding MDS 3.0 Item J2710: Cardiopulmonary Surgery – Respiratory System, Including Lungs, Bronchi, Trachea, Larynx, or Vocal Cords (Open and Endoscopic)

Introduction

Purpose:
MDS Item J2710, Cardiopulmonary Surgery – Respiratory System, Including Lungs, Bronchi, Trachea, Larynx, or Vocal Cords (Open and Endoscopic), is used to document major surgical procedures related to the respiratory system. These procedures may involve open surgery or endoscopic techniques and are critical for treating conditions such as lung disease, airway obstruction, or cancers affecting the respiratory tract. This guide will explain how to properly code MDS Item J2710 according to the MDS 3.0 guidelines.

What is MDS Item J2710?

Explanation:
MDS Item J2710 refers to major surgeries involving the respiratory system, specifically the lungs, bronchi, trachea, larynx, and vocal cords. These surgeries can be performed via open surgery or endoscopic techniques (minimally invasive surgery using scopes). Common surgeries that fall under this item include:

• Lobectomy or pneumonectomy: Removing a portion or an entire lung to treat lung cancer or severe lung disease.
• Bronchoscopy: An endoscopic procedure used to diagnose or treat conditions affecting the bronchi.
• Tracheostomy: Creating an opening in the trachea to facilitate breathing.
• Laryngectomy: Partial or total removal of the larynx, often due to cancer.
• Endoscopic vocal cord surgery: Used to remove tumors, polyps, or other abnormalities from the vocal cords.

These surgeries address conditions such as lung cancer, airway obstructions, vocal cord dysfunction, and tracheal disorders, and require documentation to ensure appropriate post-surgical care and rehabilitation.

Guidelines for Coding J2710

Coding Instructions:
To correctly code Item J2710, follow these steps:

1. Review the Resident’s Medical Records:

   • Check the resident’s medical history for any major surgeries involving the lungs, bronchi, trachea, larynx, or vocal cords. These surgeries may have been performed using open or endoscopic techniques.

2. Confirm the Surgery Meets the Criteria for Major Surgery:

   • Ensure the surgery was a major procedure that required significant recovery time and involved general or regional anesthesia.

3. Code Based on the Type of Surgery:

   • Code “1” for Cardiopulmonary Surgery – Respiratory System, Including Lungs, Bronchi, Trachea, Larynx, or Vocal Cords (Open and Endoscopic) if the resident has undergone any of these significant respiratory system surgeries.
   • If the surgery was minor or did not involve these specific organs, do not code under J2710.

4. Enter the Response in Item J2710:

   • If a major surgery involving the respiratory system was performed, enter “1” in J2710.

Example Scenario 1:
A resident underwent a lobectomy to remove part of the lung due to lung cancer. Since this is a major open surgery involving the lungs, “1” would be entered in Item J2710.

Example Scenario 2:
A resident had an endoscopic laryngectomy to remove a tumor on the vocal cords. This qualifies as a major endoscopic surgery, so “1” would be entered in J2710.

Best Practices for Accurate Coding

Documentation:

• Ensure the resident’s medical records document the type of surgery, the technique used (open or endoscopic), the date of surgery, and any necessary post-operative care, such as respiratory therapy or pain management.
• Record any ongoing rehabilitation or monitoring needed, especially for residents recovering from cancer-related surgeries.

Communication:

• Collaborate with the interdisciplinary care team, including pulmonologists, thoracic surgeons, and nurses, to ensure proper follow-up care, including respiratory support, monitoring for complications, and rehabilitation.
• Discuss the recovery plan with the resident and their family, providing guidance on post-operative care, including potential respiratory rehabilitation and necessary lifestyle adjustments.

Post-Surgical Care and Monitoring:

• Monitor the resident for any post-operative complications, such as respiratory distress, infections, or airway function issues. Ensure ongoing pain management and respiratory support as required.
• Arrange follow-up appointments with respiratory specialists, especially for surgeries involving the lungs, trachea, or larynx, to track recovery progress and make adjustments to the care plan as necessary.

Conclusion

Summary:
MDS Item J2710 is used to document major respiratory system surgeries, including those involving the lungs, bronchi, trachea, larynx, and vocal cords, performed through open surgery or endoscopic techniques. Accurate coding ensures that residents receive the proper post-surgical care, monitoring, and rehabilitation they need to recover successfully. By following the guidelines provided in this article, healthcare professionals can ensure comprehensive care for residents who have undergone respiratory system surgeries.

Click here to see a detailed step-by-step on how to complete this item set

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-123] for detailed guidelines on coding major respiratory system surgeries.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item J2710: Cardiopulmonary Surgery – Respiratory System, Including Lungs, Bronchi, Trachea, Larynx, or Vocal Cords (Open and Endoscopic) was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.