Lisa: Welcome to the IRF and LTCH
Virtual Training Program Part 1.
I'm Lisa Newton
and I'll be presenting Section J Health Conditions.
I'm a registered nurse
with experience in direct patient care,
clinical education,
and executive level administration
in the acute care and LTCH settings.
Currently, I'm a senior staff associate
at Econometrica in Bethesda, Maryland.
Let's begin with an understanding
of the objectives for this session.
At the conclusion of this training,
you should be able to identify
the new and revised assessment items in Section J,
and also discuss guidance changes
for the Section J standardized data elements.
There are several important implications
regarding the changes that have been made to Section J.
First, the pain data elements are new
to both the IRF and LTCH settings.
These items are J0510, Pain Effect on Sleep,
J0520, Pain Interference with Therapy Activities,
and J0530, Pain Interference with Day-to-Day Activities.
There have also been some minor revisions to the fall items,
J1750 through J1900.
The fall items are not new to IRF and LTCH,
so we'll only be focusing on the major changes.
There's been a slight revision
to the wording of the fall items.
The fall definition has been revised
and coding examples have been enhanced for clarity
and gender-neutral language has been added.
Now, let's review the pain interview J0510 through J0530.
The intent of the pain interview items
is to assess the effect of pain on sleep,
pain interference with therapy activities,
and pain interference with day-to-day activities.
In order to have a full understanding of the pain interview,
it's also important to comprehend the rationale
for collecting these items.
The effects of unrelieved pain impact the individual
in terms of function, complications of immobility,
skin breakdown, and infections.
Pain also significantly
adversely affects a person's quality of life
and it's tightly linked to depression,
diminished self-confidence, and self-esteem,
as well as an increase in behavior problems,
particularly for patients who are cognitively impaired.
People may also limit their activities to avoid having pain.
The report of lower pain frequency
may reflect their avoidance of activity
more than it actually reflects adequate pain management.
The assessment of pain is not associated
with any particular approach to pain management.
As we know, the use of opioids
is associated with serious complications.
So alternatively, there are a wide variety
of successful nonpharmacologic and non-opioid approaches
to pain management that may be considered.
This slide provides a list
of other pain management strategies that can be utilized.
And this is just, you know, some of the examples,
but not an all-inclusive list.
You can see from the modalities identified
that a wide variety of approaches to pain management
are available.
Having a sound understanding
of the definition of pain is important
when coding these items.
As defined in the guidance,
pain is any type of physical pain
or discomfort in any part of the body.
It may be localized to one area or may be more generalized.
It may be acute or chronic,
continuous or intermittent,
or occur at rest or with movement.
Pain is very subjective,
and this is an important aspect of the definition of pain,
because pain is whatever the experiencing person says it is
and exists wherever they say it does.
The pain interview steps for assessment are as follows.
First, directly ask the patient
each item in the pain interview J0510 through J0530
in the order provided.
If the patient seems unsure or hesitant,
you can use other terms for pain or follow-up discussion.
Some patients avoid using the term pain,
but may report that they hurt, for example,
or patients may also use other terms,
such as aching or burning, to describe pain.
And two, if a patient chooses
not to answer a particular item,
accept their refusal, code 8, Unable to answer,
and move on to the next item.
And number three, if the patient is unsure about
whether the pain effect or interference
occurred in the five-day time interval,
prompt the patient to think about
the most recent episode of pain
and then try to determine
whether it occurred within the look-back period.
Here are two important coding tips
that apply to the pain interview.
First, these items should be coded
based on the patient's interpretation
of the provided response options for frequency.
And if the patient is unable to decide between two options,
then the assessor should code
for the option with a higher frequency.
Now let's look at each item in the pain interview
beginning with J0510, Pain Effect on Sleep.
Here is a screenshot of J0510.
And for this item, it's important to note
that IRF and LTCH have different skip patterns.
The J0510 steps for assessment include the following.
Read the question and response choices as written.
No predetermined definitions are offered to the patient.
This is very important.
The response should be based on the patient's interpretation
of the frequency response options.
If the patient's response does not lead to a clear answer,
repeat the patient's response,
and then try to narrow the focus of the response
with additional follow-up questions.
To make this a little clearer,
let's look at an example for J0510.
So in this example,
the assessor begins by asking the patient,
"Over the past five days, how much of the time
"has pain made it hard for you to sleep at night?"
And then reads the response choices.
The patient responds by saying,
"I always have trouble sleeping."
Then the assessor might reply,
"You always have trouble sleeping.
"Is it your pain that makes it hard for you to sleep?"
In this example, the patient's initial response
did not lead to a clear answer.
The patient, as you recall, responded with a statement,
not an answer to the assessor's question.
So the assessor repeated the patient's response,
which was "You always have trouble sleeping,"
and then proceeded to narrow down the focus of the response
with an additional follow-up question.
In terms of coding instructions for both IRF and LTCH,
you should complete the admission assessment
as close to the time of admission as possible,
and complete the discharge assessment
as close to the time of discharge as possible.
For the LTCH setting,
please note that J0510 is only completed
if A0250, reason for assessment, is 01 Admission,
or 10 Planned Discharge.
When coding J0510,
you ask the patient, "Over the past five days,
"how much of the time
"has pain made it hard for you to sleep at night?"
Response options include code 0, Does not apply,
if the patient responds
they did not have any pain or hurting in the past five days,
code 1, Rarely or not at all,
if the patient responds that pain has been present
and the pain rarely or not at all
made it hard to sleep in the past five days,
and code 2, Occasionally,
if the patient responds that pain has occasionally
made it hard to sleep in the past five days.
It's important to understand the key difference
between code 0, Does not apply,
and code 1, Rarely or not at all.
For code 0, the patient reports no pain or hurting
in the past five days.
But for code 1, the patient reports
that pain or hurting has been present in the past five days,
but has rarely or not at all impacted sleep.
And this is a very important distinction.
If the patient reports they had pain in the past five days
and the pain does not interfere with patient's sleep,
so for example,
if the pain is using pain management strategies effectively,
then you code 1, Rarely or not at all.
Additional codes for this item include code 2, Frequently,
if the patient responds that pain has frequently
made it hard to sleep in the past five days,
code 4, Almost constantly,
if the patient responds
that pain has almost constantly made it hard to sleep
in the past five days,
and code 8, Unable to answer,
if the patient is unable to answer the question,
or does not respond,
or perhaps gives a nonsensical response.
Now let's discuss J0520,
Pain Interference with Therapy Activities.
Here is the item screenshot for J0520.
Important for coding this item
is an understanding of rehabilitation therapy
as defined in the guidance.
It is a special healthcare service or programs
that help a person regain physical, mental,
and or cognitive thinking and learning abilities
that have been lost or impaired
as a result of disease, injury, or treatment.
Examples include physical therapy,
occupational therapy, speech therapy,
and cardiac and pulmonary therapies.
The steps for assessment for J0520 include the following.
One, read the question and response choices as written.
And two, confirm that the patient has been offered
rehabilitation therapies during the reference timeframe.
For this item, please note
that rehabilitation therapies may include
treatment supervised in person
by either a nurse, or a therapist, or other staff,
or it also may include the patient
carrying out a prescribed therapy program
without staff present.
The J0520 coding instructions
for the admission and discharge assessments
are the same as we discussed previously for J0510.
And they're listed on this slide.
When coding J0520,
you ask the patient, "Over the past five days,
"how often have you limited your participation
"in rehabilitation therapy session due to pain?"
Response options include code 0, Does not apply,
if the patient responds
they did not participate in rehabilitation therapy
for reasons unrelated to pain,
so for example, therapy wasn't needed
or there might have been some scheduling difficulties,
those would be examples in the past five days,
code 1, Rarely or not at all,
if the patient responds that pain has rarely or not at all
limited participation in rehabilitation therapy sessions
in the past five days,
and code 2, Occasionally, if the patient responds
that pain has occasionally limited participation
in rehabilitation therapy sessions in the past five days.
Additional codes include code 3, Frequently,
if the patient responds
that pain has frequently limited participation,
code 4, Almost constantly,
and code 8, Unable to answer,
if the patient is unable to answer the question,
does not respond, or gives a nonsensical response.
The last item in the pain interview
is J0530, Pain Interference with Day-to-Day Activities.
Here, we see a screenshot of J0530.
And for the steps for assessment,
you read the question and the response choices as written.
Again, the coding instructions
for the admission and discharge assessments
are the same as for the other two pain assessment items,
J0510 and J0520.
And they're listed on this slide.
The coding instructions for J0530 are also noted here.
When coding this item,
you ask the patient, "Over the past five days,
"how often have you limited your day-to-day activities?"
Now this is excluding rehabilitation therapy sessions
because of pain.
And the response options are noted here,
code 1, Rarely or not at all,
code 2, Occasionally,
code 3, Frequently,
code 4, Almost constantly,
and code 8, Unable to answer.
Now, let's move on to discuss the changes to the fall items.
There are three fall items, J1750, History of Falls,
this item is only collected in the IRF setting,
J1800, Any Falls Since Admission,
and J1900, Number of Falls Since Admission.
These items are not new to IRF and LTCH,
so we'll only be focusing
on a discussion of the major changes.
There have been some general revisions to the guidance
for these items.
The intent of the fall items was revised slightly
to clarify the specific data elements collected.
So item numbers were added
to the intent statement and the guidance.
And the fall definition has been clarified
with the addition of a reference
to the anticipated loss of balance
resulting from a supervised therapeutic intervention.
Let's take a closer look at the fall definition.
This is the first portion of the fall definition,
which should be familiar to you,
and it has not changed.
However, on this slide,
this is the second portion of the fall definition.
And the reference in the last bullet has been revised.
So let's spend a moment to review this.
The language noted in blue
was actually previously a coding tip.
This language was reworded for clarification
and relocated within the fall definition
as this last statement.
It now states that an anticipated loss of balance
resulting from a supervised therapeutic intervention
where the patient's balance
is being intentionally challenged
during balance training
is not considered a fall.
Let's briefly review the updates to each of the fall items.
J1750, History of Falls, is an IRF item only,
and there were minor updates made to this item.
In the steps for assessment,
the reference to the patient interview was revised slightly
to enhance clarity,
and it includes a reference
to speak with family members or significant others
to obtain the patient's fall history as appropriate.
Coding examples for this item were also updated
with gender-neutral language.
And just as a reminder, J1750 is not collected on the LCDS.
There were a few updates
to J1800, Any Falls Since Admission,
and this item is collected by both IRF and LTCH.
The skip pattern was revised for respond option "No".
This item now skips to K0520, Nutritional Approaches,
instead of M0210, Unhealed Pressure Ulcers/Injuries.
Coding examples were also revised for clarity
and updated with gender-neutral language.
For J1900, Number of Falls Since Admission,
again, collected by both IRF and LTCH,
the coding examples were also revised for clarity
and updated with gender-neutral language.
Looking more specifically at the updates for J1900
that applied to the IRF setting,
an item rationale was added
noting falls as a leading cause of morbidity and mortality
and recognizing the impact
that fear of falling has on quality of life.
A coding tip was revised to clarify how to code falls
during a program interruption.
For J1900, you include all falls that occurred
since the time of admission,
and this include any falls that occurred
during a program interruption.
For J1900, the specific updates for the LTCH setting
include that coding instructions were enhanced
to include a reminder to complete J1900
at the time of discharge,
and a new coding tip was added
regarding how to code falls during a program interruption.
Similar to IRF,
for J1900, you include all falls that occurred
since the time of admission,
and this would include any falls that occurred
during a program interruption.
So in summary, Section J contains
new pain interview items for IRF and LTCH.
These are J0510, Pain Effect on Sleep,
J0520, Pain Interference with Therapy Activities,
and J0530, Pain Interference with Day-to-Day Activities.
And general revisions were made
to the guidance for Section J
regarding the fall items to enhance clarity
and include gender-neutral language.
We've covered a lot of information in this session.
So you may find that you have questions about the content.
If you would like to submit a question
regarding this presentation,
please send it to PACTraining@econometricaInc.com
by June 3rd, 2022.
As a reminder,
a practice coding workshop will be held in June
and we encourage you to attend.
Select questions will be answered in a Q&A session
during the June 2022 virtual live event.
Thank you for reviewing this presentation
and we look forward to your attendance
at the coding workshop.