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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MDS Lookup
Prior Surgery
Item Rationale
Matrix review
3 matrix group(s) are already attached for review on this item.
Answer coverage
3 governed answer row(s) are attached for this item.
Answer Codes
Code 0
No
if the resident did not have major surgery during the 100 days prior to admission.
Code 1
Yes
if the resident had major surgery during the 100 days prior to admission.
Code 8
Unknown
if it is unknown or cannot be determined whether the resident had major surgery during the 100 days prior to admission.
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-42
- CMS exact locator: Manual page J-42
- This item has 3 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-42
CMS exact locator
Manual page J-42
Full CMS Text
Item Rationale
Health-related Quality of Life
A recent history of major surgery during the 100 days prior to admission can affect a resident’s recovery.
Planning for Care
This item identifies whether the resident has had major surgery during the 100 days prior to the start of the Medicare Part A stay. 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 in the 100 days prior to admission.
2. Review the resident’s medical record to determine whether
the resident had major surgery during the 100 days prior to admission. Medical record sources include medical records received from facilities where the resident received health care during the previous 100 days, 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 100 days prior to
admission.
Code 1, Yes: if the resident had major surgery during the 100 days prior to admission.
Code 8, Unknown: if it is unknown or cannot be determined whether the resident had
major surgery during the 100 days prior to admission.
DEFINITION
MAJOR SURGERY Refers to a procedure that meets the following criteria:
1. The resident was an inpatient in an acute care hospital for at least 1 day in the 100 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.
Examples
1. Resident T reports that they required surgical removal of a skin tag from their neck a month
and a half ago. They had the procedure as an outpatient. Resident T report no other surgeries in the last 100 days.
Coding: J2000 would be coded 0, No.
Rationale: Resident T’s skin tag removal surgery did not require an acute care
inpatient stay; therefore, the skin tag removal does not meet the required criteria to be coded as major surgery. Resident T did not have any other surgeries in the last 100 days.
2. Resident A’s spouse informs their nurse that six months ago Resident A was admitted to the
hospital for five days following a bowel resection (partial colectomy) for diverticulitis. Resident A’s spouse reports Resident A has had no other surgeries since the time of their bowel resection.
Coding: J2000 would be coded 0, No.
Rationale: Bowel resection is a major surgery that has some degree of risk for death or
severe disability, and Resident A required a five-day hospitalization. However, the bowel resection did not occur in the last 100 days; it happened six months ago, and Resident A has not undergone any surgery since that time.
3. Resident G was admitted to the facility for wound care related to dehiscence of a surgical
wound subsequent to a complicated cholecystectomy. The attending physician also noted diagnoses of anxiety, diabetes, and morbid obesity in their medical record. They were transferred to the facility immediately following a four-day acute care hospital stay.
Coding: J2000 would be coded 1, Yes.
Rationale: In the last 100 days, Resident G underwent a complicated cholecystectomy,
which required a four-day hospitalization. They additionally had comorbid diagnoses of diabetes, morbid obesity, and anxiety contributing some additional degree of risk for death or severe disability.
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
NHQI Quality Measures
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
QRP Quality Measures (Includes risk adjustment)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4