MDS Alert

Follow 5 tips to determine correct coding for this item.

If you’re poring over the medical record looking for the answer to item J1400 — Prognosis, don’t expect the physician to write that the patient has less than six months to live. Your job in coding this item is just not that easy.

Problem: You may not see a clearly written directive in the clinical record stating that the resident has six months or less to live. Why? “It may be because many who care for those with terminal conditions believe that documenting any specific life expectancy in weeks or months is akin to giving a death sentence,” explained a recent analysis by Washington, DC-based Leading Age, an advocacy organization for aging services, comprised of 6,000 non-profit entities.

So what should you look for in the medical record to determine the correct answer for J1400? Here are some tips to guide you in the right direction.

Read This Inset Box Carefully

When you’re coding J1400, a great place to begin is reading the inset box on page J-23 of the MDS 3.0 RAI User’s Manual, according to Joel VanEaton, BSN, RN, RAC-CT, reimbursement and RAI clinician and client services nurse consultant for Care Centers Management Consulting, Inc. in Johnson City, TN.

Here the manual states:

“In the physician’s judgment, the resident has a diagnosis or combination of clinical conditions that have advanced (or will continue to deteriorate) to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgment should be substantiated by a physician note.”

Focus on Communication with the Physician

“Good communication with the physician is key,” VanEaton stresses. The physician simply stating that the resident’s life expectancy may be less than six months is not enough — “it must appear in the clinical record.”

“Check the physician orders, history and physical, physician notes, etc. for this documentation,” VanEaton instructs. “If the medical record does not indicate this, you should request that the physician provide this documentation.”

Important: But do not code until the physician actually provides this documentation in the medical record, Leading Age stresses.

Look for the Phrase ‘Terminally Ill’

Also, the RAI manual indicates that a prognosis of less than six months to live is essentially synonymous with the term “terminally ill,” VanEaton says. And coding instructions on page J-24 indicate that you should code J1400 as “Yes” (1) if the documentation indicates terminal illness.

But make sure that the physician is aware of the MDS definition for “terminally ill,” particularly if she is documenting terminal illness in the medical record, Leading Age recommends.

In addition to terminal illness, hospice services being provided to the resident would also indicate that he has less than six months to live, VanEaton notes. “So documentation that supports any of these conditions or services would be adequate to support coding ‘yes’ at J1400.”

Understand How J1400 is Linked to O0100K

“J1400 is naturally connected to item O0100K — Hospice Care and is a critical element to consider when coding J1400,” VanEaton reminds. The RAI manual instructs you to review the medical record to determine whether the resident is receiving hospice services.

The RAI manual states that under the hospice program benefit regulations, a physician must document in the medical record that the patient has a life expectancy of less than six months, Leading Age says. “So if a resident is on hospice, the expectation is that the documentation is in the medical record” to code J1400 as “Yes” (1).

Caveat: “Persons who are terminally ill may not be receiving hospice services, so don’t automatically check O0100K simply because the documentation supports a terminal illness,” VanEaton warns. Instead, read the instructions on page O-4 of the RAI manual to determine when it is appropriate to code that the resident is receiving hospice services.

Don’t Forget About Care Planning

J1400 is on the MDS because residents who have a prognosis of less than six months to live “have special needs and may benefit from palliative or hospice services in the nursing home,” Leading Age states. “Additionally, care planning should be based on the resident’s preferences for goals and interventions of care whenever possible.”

“Both J1400 and O0100K represent important care planning issues” and are linked in the Care Area Assessment (CAA) process as well,” VanEaton says. In item V0200 — CAAs and Care Planning, J1400 links with V0200 “Activities” (10). And O0100K links with the following items listed for V0200:

• “Delirium” (1);
• “Cognitive Loss/Dementia” (2);
• “Urinary Incontinence and Indwelling Catheter” (6);
• “Nutritional Status” (12);
• “Pressure Ulcer” (16);
• “Pain” (19); and
• “Return to Community Referral” (20).

Note that in both CAAs “Urinary Incontinence and Indwelling Catheter” (6) and “Pressure Ulcer” (16), the term “hospice care” has been replaced with “terminal illness,” VanEaton points out.

“Therefore, while O0100K is the item that is being considered in most of these CAAs, you should remember that “hospice care,” “terminal illness” and a prognosis of six months or less to live are all essentially the same thing as you consider the elements necessary for making care planning decisions related to item J1400,” VanEaton advises.

Consider Completing a Significant Change in Status Assessment

Finally, remember to consider that “the decision to complete a significant change in status assessment is impacted when the resident has a terminal condition,” VanEaton notes. If this situation should arise, consult the instructions on pages 2-21 and 2-25 of the RAI manual.