MDS Alert

Published on Mon Jan 28, 2013 PDF

Whether you breathe easy when coding dyspnea scenarios or scratch your head, reviewing the fundamentals can improve your accuracy and compliance. Check out what items J1100 includes and then try your hand at two scenarios.

First, Check These J1100 Items

Before you try your hand at the below examples, remind yourself what items J1100 includes by examining this below:

"Coding Instructions:

Check all that apply during the 7-day look-back period. Any evidence of the presence of a symptom of shortness of breath should be captured in this item. A resident may have any combination of these symptoms.

1. Check J1100A: if shortness of breath or trouble breathing is present when the resident is engaging in activity. Shortness of breath could be present during activity as limited as turning or moving in bed during daily care or with more strenuous activity such as transferring, walking, or bathing. If the resident avoids activity or is unable to engage in activity because of shortness of breath, then code this as present.

2. Check J1100B: if shortness of breath or trouble breathing is present when the resident is sitting at rest.

3. Check J1100C: if shortness of breath or trouble breathing is present when the resident attempts to lie flat. Also code this as present if the resident avoids lying flat because of shortness of breath.

4. Check J1100Z: if the resident reports no shortness of breath or trouble breathing and the medical record and staff interviews indicate that shortness of breath appears to be absent or well controlled with current medication."

Scenario 1: Pay Attention to ‘Out of Breath’

Suppose Mrs. W. has diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure. She is on 2 liters of oxygen and daily respiratory treatments. With oxygen she is able to ambulate and participate in most group activities. She reports feeling ‘winded’ when going on outings that require walking one or more blocks and has been observed having to stop to rest several times under such circumstances. Recently, she describes feeling ‘out of breath’ when she tries to lie down.

What J1100 item should you check?

Solution: You should check J1100A and J1100C. The reason is that Mrs. W. reported being short of breath when lying down as well as during outings that required ambulating longer distances.

Scenario 2: Don’t Overlook Limiting Activities

Mr. T. has used an inhaler for years. He is not typically noted to be short of breath. Three days ago, during a respiratory illness, he had mild trouble with his breathing, even when sitting in bed. His shortness of breath also caused him to limit group activities.

Which items in J1100 would you check for this?

Solution: You should check J1100A and J1100B. The reason is that Mr. T. was short of breath at rest and was noted to avoid activities because of shortness of breath.

Source: Printed verbatim from the RAI User’s Manual.