Long-Term Care Survey Alert
Try Your Hand at Coding These 2 RAI Manual Scenarios at J1100: Shortness of Breath (dyspnea)
How would you code the following examples at J1100? 1.
2.
"Mr. T. has used an inhaler for years. He is not typically noted to be short of breath," states the RAI manual. "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.""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."Source: The preceding coding instructions have been printed verbatim from the
RAI User's Manual.CODING QUIZZER ANSWERS
1.
"Coding: J1100A and J1100C would be checked. Rationale: Mrs. W. reported being short of breath when lying down as well as during outings that required ambulating longer distances," states the RAI manual.2.
"Coding: J1100A and J1100B would be checked. Rationale: Mr. T. was short of breath at rest and was noted to avoid activities because of shortness of breath," states the RAI manual.Source: Printed verbatim from the
RAI User's Manual.Editor's note: The preceding Coding Quizzer example hasn't changed in the April 1 version of the
RAI User's Manual. For a free MDS Alert article on the manual revisions, e-mail the editor at KarenL@Eliresearch.com.Long-Term Care Survey Alert
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