Understanding and Coding MDS 3.0 Item J2920: Major Surgery – Endocrine Organs, Neck, Lymph Nodes, and Thymus (Open Surgery)

Introduction

Purpose:
MDS Item J2920, Major Surgery – Endocrine Organs (Thyroid, Parathyroid), Neck, Lymph Nodes, and Thymus (Open Surgery), documents significant surgical procedures involving the neck, endocrine organs, and lymphatic system through open surgery. Accurately coding these surgeries is essential for monitoring post-operative care and ensuring that residents receive the proper treatment and rehabilitation. This article provides a comprehensive guide to coding MDS Item J2920 based on the MDS 3.0 guidelines.

What is MDS Item J2920?

Explanation:
MDS Item J2920 refers to major open surgeries involving:

• Endocrine organs such as the thyroid and parathyroid glands, which regulate metabolism and calcium levels.
• Lymph nodes in the neck or other regions that may be removed or biopsied during cancer treatments or infection control.
• Thymus, a key organ for immune system function, especially in young people or those undergoing treatments for autoimmune disorders or cancer.
• Other neck surgeries, including procedures for head and neck cancer, structural deformities, or trauma repair.

These surgeries are typically performed as open surgeries, meaning they involve a larger incision to access the targeted organs and tissues. Common surgeries under this category include:

• Thyroidectomy (removal of the thyroid),
• Parathyroidectomy (removal of parathyroid glands),
• Lymph node dissection,
• Thymectomy (removal of the thymus),
• Other open neck surgeries for cancer, tumors, or structural repairs.

These procedures often involve complex recovery and may require follow-up care, pain management, and rehabilitation.

Guidelines for Coding J2920

Coding Instructions:
To accurately code Item J2920, follow these steps:

1. Review the Resident’s Medical Records:

   • Check the medical history for any open surgery involving the thyroid, parathyroid, lymph nodes, thymus, or other neck surgeries that meet the criteria for major open surgery.

2. Confirm the Surgery Was Performed as Open Surgery:

   • Ensure that the procedure involved an open surgical approach with significant recovery time and potential need for follow-up care, such as pain management or rehabilitation.

3. Code Based on the Type of Surgery:

   • Code “1” for Major Surgery – Endocrine Organs (Thyroid, Parathyroid), Neck, Lymph Nodes, and Thymus (Open Surgery) if the resident underwent any major open surgery involving these organs.
   • If the surgery was minimally invasive (e.g., laparoscopic surgery), it should not be coded under J2920.

4. Enter the Response in Item J2920:

   • If major open surgery on any of the specified organs was performed, enter “1” in J2920.

Example Scenario 1:
A resident underwent a thyroidectomy for thyroid cancer using open surgery. In this case, “1” would be entered in Item J2920 to document the procedure.

Example Scenario 2:
A resident had an open lymph node dissection in the neck as part of cancer treatment. Since this qualifies as major open surgery, “1” would be entered in J2920.

Best Practices for Accurate Coding

Documentation:

• Ensure that the resident’s medical records provide detailed information about the type of surgery, including whether it was performed as an open surgery, the date of the procedure, and the surgeon’s report.
• Record post-surgical recovery needs, including pain management, wound care, and any follow-up treatments such as radiation therapy or chemotherapy for cancer-related surgeries.

Communication:

• Communicate the details of the surgery to the interdisciplinary care team, including physicians, nurses, and rehabilitation specialists, to ensure that the resident receives appropriate follow-up care and support.
• Discuss the surgery and recovery process with the resident and their family members, ensuring they understand any long-term care needs, such as ongoing cancer treatments or endocrine management.

Post-Surgical Care and Monitoring:

• Monitor the resident closely for post-operative complications, such as infections, lymphedema (swelling due to lymph node removal), or issues with hormone regulation if endocrine organs were removed.
• Coordinate regular follow-up appointments with specialists, such as oncologists or endocrinologists, to ensure the resident’s recovery is progressing as expected.

Conclusion

Summary:
MDS Item J2920 is used to document major open surgeries involving the endocrine organs, neck, lymph nodes, and thymus. Accurate coding of this item helps ensure residents receive the necessary post-surgical care, whether for cancer treatment, endocrine disorders, or other health conditions affecting these areas. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure comprehensive care for residents who have undergone major open surgery.

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 open surgeries involving the endocrine organs, neck, and lymph nodes.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item J2920: Major Surgery – Endocrine Organs (Thyroid, Parathyroid), Neck, Lymph Nodes, and Thymus (Open Surgery) 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.