MDS Alert

Published on Thu Sep 05, 2019 PDF

Know how recent surgery impacts care, versus other medical conditions.

The recently released version of the MDS, which goes “live” on Oct. 1, 2019 has a new itemset focused on identifying recent surgeries, classifying those surgeries, and assessing whether and how they will impact a Medicare Part A resident’s care.>

The final version of the Resident Assessment Instrument (RAI) Manual is not expected to have significant changes for these items, says Jane Belt, MS, RN, RAC-MT, RAC-MTA, QCP, curriculum development specialist at American Association of Post-Acute Care Nursing (AAPACN) in Denver.

The RAI Manual notes that items J2100 (Recent Surgery Requiring Active SNF Care) and J2300–2500 (Recent Surgeries Requiring Active SNF Care) have been added to the MDS because experiencing major surgery right before being admitted to a nursing facility can impact the resident’s recovery.

Look to Documentation

Even if the resident shows up with staples or sutures that indicate a very recent surgery, you must, as always, look to the clinical record.

To decide whether surgery qualifies, it must meet the following criteria, the RAI Manual says on page J-40: “The surgeries in this section must have been documented by a physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days and must have occurred during the inpatient stay that immediately preceded the resident’s Part A admission.”

Look to the resident’s clinical record, including “progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available,” the RAI Manual says. Don’t forget to look at nursing assessments or care plans, medication sheets, doctor’s orders, consults, or other diagnostic reports, as well.

Although communication with the clinician regarding the resident should be part of the interdisciplinary team (IDT) decision-making, it’s crucial that any care instructions or other resident information is documented in the clinical record, the RAI Manual says.

Even though family members or other persons who have knowledge of the resident’s health may offer that information, a clinician must document any surgeries to ensure both the validity of the information and the necessary instructions for care.

Determine Active Care Needs

While a resident may have had major surgery in the past 30 days and meet all other criteria for coding that surgery in items J2100 and J2300–J2500, the NAC — or other responsible party — must determine whether that surgery is driving the resident’s admission and stay in the skilled nursing facility.

This determination means that the surgery should correlate directly with resident’s primary diagnosis, which is the information coded in item I0020B (ICD Code), the RAI Manual says.

Basically, to code a major surgery in this item, besides meeting the criteria already listed, the resident’s condition must be ongoing, affecting his current status, and driving the specific care he needs in the seven-day lookback period (which is the timeline for the resident’s active diagnoses).

Look for notes in the clinical record that specifically state that a skilled nursing stay is required for treatment during recovery following a surgery, the RAI Manual says.

If there is no evidence that a clinician believes that skilled nursing is necessary, look for conditions or situations that are so complex that only skilled nursing can provide adequate and appropriate care. The RAI Manual lists the following examples:

     o “The management of a surgical wound that requires skilled care (e.g., managing potential infection or drainage).
     o “Daily skilled therapy to restore functional loss after surgical procedures.
     o “Administration of medication and monitoring that requires skilled nursing.”

Remember: These particular MDS items should be completed only if A0310B (Type of Assessment, PPS Assessment) is coded 01 for a five-day scheduled assessment.