Understanding and Coding MDS 3.0 Item J2910: Major Surgery - GI Tract and Abdominal Contents (Open or Laparoscopic)

Understanding and Coding MDS 3.0 Item J2910: Major Surgery – GI Tract and Abdominal Contents (Open or Laparoscopic)

Introduction

Purpose:
MDS Item J2910, Major Surgery – The GI Tract and Abdominal Contents from the Esophagus to the Anus, Biliary Tree, Gall Bladder, Liver, Pancreas, Spleen (Open or Laparoscopic), documents significant surgeries involving the gastrointestinal (GI) tract and abdominal organs. These surgeries may be performed using either open or laparoscopic techniques. Accurate coding of this item ensures that post-surgical care is appropriately managed, and the resident’s surgical history is thoroughly documented. This guide explains how to code MDS Item J2910 according to MDS 3.0 guidelines.

What is MDS Item J2910?

Explanation:
MDS Item J2910 refers to major surgeries involving the gastrointestinal tract and abdominal organs, performed through open surgery or laparoscopic surgery. These surgeries target:

• The GI tract: Includes surgeries on the esophagus, stomach, small intestine, large intestine, and rectum.
• The biliary tree and gallbladder: Common procedures include cholecystectomy (gallbladder removal) and bile duct surgeries.
• The liver: Includes liver resection or liver transplant.
• The pancreas: Surgeries such as pancreaticoduodenectomy (Whipple procedure) are included.
• The spleen: Includes splenectomy (removal of the spleen).

These surgeries are typically performed for conditions such as cancer, gastrointestinal diseases, gallstones, liver failure, and trauma.

Guidelines for Coding J2910

Coding Instructions:
To accurately code Item J2910, follow these steps:

1. Review the Resident’s Medical Records:

   • Examine the medical history for any major surgeries involving the GI tract or abdominal organs (esophagus to anus, gallbladder, liver, pancreas, spleen, etc.).
   • Verify whether the procedure was performed using an open or laparoscopic technique.

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

   • Ensure that the surgery involved either an open approach or a laparoscopic technique with a significant recovery period and potential need for follow-up care.

3. Code Based on the Type of Surgery:

   • Code “1” for Major Surgery – The GI Tract and Abdominal Contents (Open or Laparoscopic) if the resident underwent a major surgery involving any of the listed organs.
   • If the surgery does not involve one of the specified organs or is a minor procedure, leave this item unmarked.

4. Enter the Response in Item J2910:

   • If a major open or laparoscopic surgery of the GI tract or abdominal organs was performed, enter “1” in J2910.

Example Scenario 1:
A resident underwent an open colectomy for colon cancer, which involved removing a portion of the colon. In this case, “1” would be entered in Item J2910 to document the procedure.

Example Scenario 2:
A resident had a laparoscopic cholecystectomy to remove the gallbladder due to gallstones. Since this is a major laparoscopic surgery, “1” would be entered in J2910.

Best Practices for Accurate Coding

Documentation:

• Ensure that the resident’s medical records detail the type of surgery performed, whether it was open or laparoscopic, the date of the procedure, and any follow-up care needed, such as dietary modifications or wound care.
• Record post-surgical recovery needs, including pain management, mobility support, and rehabilitation, especially after major abdominal surgeries.

Communication:

• Communicate the details of the surgery with the interdisciplinary care team, including nurses, physicians, and dietitians, to ensure that the resident receives proper recovery support and follow-up care.
• Discuss the surgery with the resident and their family, explaining any long-term recovery processes and necessary lifestyle changes (e.g., dietary adjustments or medication management).

Post-Surgical Care and Monitoring:

• Monitor the resident for post-operative complications, such as infection, bleeding, or digestive issues. Ensure ongoing wound care, especially after open surgeries, and provide pain management as needed.
• Coordinate follow-up appointments with specialists, such as gastroenterologists or hepatologists, to manage ongoing care after surgeries like liver resections or GI tract surgeries.

Conclusion

Summary:
MDS Item J2910 is used to document major surgeries involving the gastrointestinal tract and abdominal contents, whether performed through open or laparoscopic surgery. Accurate coding ensures that residents who have undergone these complex surgeries receive appropriate post-surgical care and follow-up. By following the guidelines and best practices outlined in this article, healthcare professionals can provide comprehensive care for residents recovering from major GI or abdominal 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 3-125] for detailed guidelines on coding major surgeries involving the GI tract, biliary tree, liver, pancreas, and spleen.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item J2910: Major Surgery – GI Tract and Abdominal Contents (Open or Laparoscopic) 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.