Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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Recent Surgery Requiring Active SNF Care
Item Rationale
Matrix review
5 matrix group(s) are already attached for review on this item.
Answer coverage
4 governed answer row(s) are attached for this item.
Answer Codes
Code 0
No
if the resident did not have major surgery during the inpatient hospital stay that immediately preceded the resident’s Part A admission.
Code 1
Yes
if the resident had major surgery during the inpatient hospital stay that immediately preceded the resident’s Part A admission.
Code 10
Fractures and Other Multiple Trauma
The I0020B SNF ICD-10 code is S72.22XD (Displaced subtrochanteric fracture of left femur, subsequent encounter for closed fracture with rou...
Code 8
Unknown
if it is unknown or cannot be determined whether the resident had major surgery during the inpatient hospital stay that immediately precede...
What this item is
Item Rationale
When to use it
Use this item when the facility is completing content tied to Section J and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page J-43
- CMS exact locator: Manual page J-43
- This item has 4 governed answer row(s) attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page J-43
CMS exact locator
Manual page J-43
Full CMS Text
Item Rationale
Health-related Quality of Life
A recent history of major surgery during the inpatient stay that preceded the resident’s Part A admission can affect a resident’s recovery.
Planning for Care
This item identifies whether the resident had major surgery during the inpatient stay that immediately preceded the resident’s Part A admission. A recent history of major surgery can affect a resident’s recovery.
Steps for Assessment
1. Ask the resident and their family or significant other about any surgical procedures that
occurred during the inpatient hospital stay that immediately preceded the resident’s Part A admission.
2. Review the resident’s medical record to determine whether the resident had major surgery
during the inpatient hospital stay that immediately preceded the resident’s Part A admission. Medical record sources include medical records received from facilities where the resident received health care during the inpatient hospital stay that immediately preceded the resident’s Part A admission, the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.
Coding Instructions
Code 0, No: if the resident did not have major surgery during the inpatient hospital stay
that immediately preceded the resident’s Part A admission.
Code 1, Yes: if the resident had major surgery during the inpatient hospital stay that
immediately preceded the resident’s Part A admission.
Code 8, Unknown: if it is unknown or cannot be determined whether the resident had
major surgery during the inpatient hospital stay that immediately preceded the resident’s Part A admission.
Coding Tips
Generally, major surgery for item J2100 refers to a procedure that meets the following criteria:
1. the resident was an inpatient in an acute care hospital for at least one day in the 30
days prior to admission to the skilled nursing facility (SNF), and
2. the surgery carried some degree of risk to the resident’s life or the potential for severe
disability. J2300–J5000: Recent Surgeries Requiring Active SNF Care
Item Rationale
Health-related Quality of Life
A recent history of major surgery during the inpatient stay that preceded the resident’s Part A admission can affect a resident’s recovery.
Planning for Care
This item identifies whether the resident had major surgery during the inpatient stay that immediately preceded the resident’s Part A admission. A recent history of major surgery can affect a resident’s recovery.
Steps for Assessment
1. Identify recent surgeries: 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. Medical record sources for recent surgeries include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. Although open communication regarding resident information between the physician and other members of the interdisciplinary team is important, it is also essential that resident information communicated verbally be documented in the medical record by the physician to ensure follow-up. Surgery information, including past history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity and follow-up.
2. Determine whether the surgeries require active care during the SNF stay: Once a recent
surgery is identified, it must be determined if the surgery requires active care during the SNF stay. Surgeries requiring active care during the SNF stay are surgeries that have a direct relationship to the resident’s primary SNF diagnosis, as coded in I0020B. Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the 7-day look-back period, as these would be considered surgeries that do not require active care during the SNF stay. Check the following information sources in the medical record for the last 30 days to identify “active” surgeries: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor’s orders, consults and official diagnostic reports, and other sources as available. J2300–J5000: Recent Surgeries Requiring Active SNF Care
Coding Instructions
Code surgeries that are documented to have occurred in the last 30 days, and during the inpatient stay that immediately preceded the resident’s Part A admission, that have a direct relationship to the resident’s primary SNF diagnosis, as coded in I0020B. Check off each surgery requiring active SNF care as defined above, as follows: — Surgeries are listed by major surgical category: Major Joint Replacement, Spinal Surgery, Orthopedic Surgery, Neurologic Surgery, Cardiopulmonary Surgery, Genitourinary Surgery, Other Major Surgery. — Examples of surgeries are included for each surgical category. For example, J2810, Genitourinary surgery - the kidneys, ureter, adrenals, and bladder—open, laparoscopic, includes open or laparoscopic surgeries on the kidneys, ureter, adrenals, and bladder, but not other components of the genitourinary system. Check all that apply. Major Joint Replacement J2300, Knee Replacement - partial or total J2310, Hip Replacement - partial or total J2320, Ankle Replacement - partial or total J2330, Shoulder Replacement - partial or total Spinal Surgery J2400, Spinal surgery - spinal cord or major spinal nerves J2410, Spinal surgery - fusion of spinal bones J2420, Spinal surgery - lamina, discs, or facets J2499, Spinal surgery - other Orthopedic Surgery J2500, Ortho surgery - repair fractures of shoulder or arm J2510, Ortho surgery - repair fractures of pelvis, hip, leg, knee, or ankle J2520, Ortho surgery - repair but not replace joints J2530, Ortho surgery - repair other bones J2599, Ortho surgery - other J2300–J5000: Recent Surgeries Requiring Active SNF Care
Neurologic Surgery J2600, Neuro surgery - brain, surrounding tissue or blood vessels J2610, Neuro surgery - peripheral and autonomic nervous system - open and percutaneous J2620, Neuro surgery - insertion or removal of spinal and brain neurostimulators, electrodes, catheters, and CSF drainage devices J2699, Neuro surgery - other Cardiopulmonary Surgery J2700, Cardiopulmonary surgery - heart or major blood vessels - open and percutaneous procedures J2710, Cardiopulmonary surgery - respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open and endoscopic J2799, Cardiopulmonary surgery - other Genitourinary Surgery J2800, Genitourinary surgery - male or female organs J2810, Genitourinary surgery - the kidneys, ureter, adrenals, and bladder - open, laparoscopic J2899, Genitourinary surgery - other Other Major Surgery J2900, Major surgery - tendons, ligament, or muscles J2910, Major surgery - the GI tract and abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, spleen - open or laparoscopic J2920, Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, and thymus - open J2930, Major surgery - the breast J2940, Major surgery - repair of deep ulcers, internal brachytherapy, bone marrow, or stem cell harvest or transplant J5000, Major surgery - not listed above J2300–J5000: Recent Surgeries Requiring Active SNF Care
Coding Tips
The following information may assist assessors in determining whether a surgery should be coded as requiring active care during the SNF stay. There may be specific documentation in the medical record by a physician, nurse practitioner, physician assistant, or clinical nurse specialist. — The physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) may specifically indicate that the SNF stay is for treatment related to the surgical intervention. Specific documentation may be found in progress notes, most recent history and physical, transfer notes, hospital discharge summary, etc. In the rare circumstance of the absence of specific documentation that a surgery requires active SNF care, the following indicators may be used to confirm that the surgery requires active SNF care: The inherent complexity of the services prescribed for a resident is such that they can be performed safely and/or effectively only by or under the general supervision of skilled nursing. For example: — The management of a surgical wound that requires skilled care (e.g., managing potential infection or drainage). — Daily skilled therapy to restore functional loss after surgical procedures. — Administration of medication and monitoring that requires skilled nursing. Examples of surgeries requiring active SNF care and related to the primary SNF diagnosis 1. Resident V was hospitalized for gram-negative pneumonia. Since this was their second episode of pneumonia in the past six months, a diagnostic bronchoscopy was performed while in the hospital. They also have Parkinson’s disease and rheumatoid arthritis. They were discharged to a SNF for continued antibiotic treatment for their pneumonia and require daily skilled care.
Coding: I0020 is coded as 13, Medically Complex Conditions, and the I0020B SNF
ICD-10 code is J15.6, Pneumonia due to other aerobic Gram-negative bacteria. There is no documentation that the resident had major surgery; therefore, J2100 is coded 0, No.
Rationale: Resident V did not receive any major surgery during the prior inpatient stay,
and they were admitted to the SNF for continued care due to pneumonia. J2300–J5000: Recent Surgeries Requiring Active SNF Care
2. Resident O, a diabetic, was hospitalized for sepsis from an infection due to Methicillin
susceptible Staphylococcus aureus that developed after outpatient bunion surgery. A central line was placed to administer antibiotics. They were discharged to a SNF for continued antibiotic treatment and monitoring.
Coding: I0020 is coded as 13, Medically Complex Conditions. The I0020B SNF ICD-
10 code is A41.01 (Sepsis due to Methicillin susceptible Staphylococcus aureus). There is no documentation that the resident had major surgery; therefore, J2100 is coded 0, No.
Rationale: Neither the placement of a central line nor the outpatient bunion surgery is
considered to be a major surgery, but the resident was admitted to the SNF for continued antibiotic treatment and monitoring.
3. Resident H was hospitalized for severe back pain from a compression fracture of a lumbar
vertebral body, which was caused by their age-related osteoporosis. They were treated with a kyphoplasty that relieved their pain. They were transferred to a SNF after discharge because of their mild dementia and need to regulate their anticoagulant treatment for atrial fibrillation.
Coding: I0020 is coded 10, Fractures and Other Multiple Trauma. The I0020B SNF
ICD-10 code is M80.08XD (Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing). There was no documentation that the resident had major surgery; therefore, J2100 is coded 0, No.
Rationale: Resident H was treated with a kyphoplasty during the inpatient stay prior to
SNF admission. Although kyphoplasty is a minor surgery and does not require SNF care in and of itself, the resident has other conditions requiring skilled care that are unrelated to the kyphoplasty surgery.
4. Resident J had a craniotomy to drain a subdural hematoma after suffering a fall at home.
They have COPD and use oxygen at night. In addition, they have moderate congestive heart failure, are moderately overweight, and have hypothyroidism. After a six-day hospital stay, they were discharged to a SNF for continuing care. The hospital discharge summary indicated that the patient had a loss of consciousness of 45 minutes.
Coding: I0020 is coded 07, Other Neurological Conditions. The I0020B SNF ICD-10
code is S06.5X2D (Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter). J2100 would be coded 1, Yes. J2600, Neuro surgery - brain, surrounding tissue or blood vessels, would be checked.
Rationale: The craniotomy surgery during the inpatient stay immediately preceding the
SNF stay requires continued skilled care and skilled monitoring for wound care, as well as therapies to address any deficits that led to their fall or any functional deficits resulting from their fall. J2300–J5000: Recent Surgeries Requiring Active SNF Care
5. Resident D was admitted to an acute care hospital for cytoreductive surgery for metastatic
renal cell carcinoma. They were admitted to the SNF for further treatment of the metastatic renal cell carcinoma and post-surgical care.
Coding: I0020 is coded as 13, Medically Complex Conditions. The I0020B SNF ICD-
10 code is C79.01 (Secondary malignant neoplasm of the right kidney and renal pelvis). J2100 would be coded 1, Yes. J2810, Genitourinary surgery – the kidneys, ureter, adrenals, and bladder – open, laparoscopic, would be checked.
Rationale: Resident D was treated with a surgical procedure, genitourinary surgery of
the kidney, and admitted to the SNF for further treatment of the metastatic kidney cancer and post-surgical care.
6. Resident G was admitted to an acute care hospital for severe abdominal pain. They were
found to have diverticulitis of the small intestine with perforation and abscess without bleeding. They had surgery to repair the perforation. They were admitted to the SNF for continued antibiotics and post-surgical care.
Coding: I0020 is coded 13, Medically Complex Conditions. The I0020B SNF ICD-10
code is K57.00 (Diverticulitis of small intestine with perforation and abscess without bleeding), and J2100 would be coded 1, Yes. J2910, Major surgery – the GI tract and abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, spleen – open or laparoscopic, would be checked.
Rationale: Resident G was treated with a surgical procedure, repair of the small
intestine perforation, which is a major surgical procedure. They were admitted to the SNF for continued antibiotics and post-surgical care.
7. Resident W underwent surgical repair for a left fractured hip (i.e., subtrochanteric fracture)
during an inpatient hospitalization. They were admitted to the SNF for post-surgical care.
Coding: I0020 is coded as Code 10, Fractures and Other Multiple Trauma. The I0020B
SNF ICD-10 code is S72.22XD (Displaced subtrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing) and J2100 is coded as 1, Yes. J2510, Ortho surgery – repair fractures of pelvis, hip, leg, knee, or ankle, would be checked.
Rationale: This is major surgery requiring skilled nursing care to provide wound care
and to monitor for early signs of infection or blood clots, for which Resident W was admitted to the SNF. Intent: The items in this section are intended to assess the many conditions that could affect the resident’s ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietary staff to ensure that items in this section have been assessed and calculated accurately.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Swing Bed Subsets
SP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
PDPM
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Shared NH/SB Subsets
IPA - Interim Payment
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Item Subset Required Use ISC Skip Patterns
PDPM (A0310B = 01 or 08)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4