When can a surgical procedure be coded

When can a surgical procedure be coded in J2100 – J2300 without documentation from a physician or physician extender? a) All surgical procedures must be documented by a physician or physician extender. b) When 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. C) Any surgical procedures can be coded on the MDS as long as the resident or family has reported the surgery to the staff. D) All surgical procedures must be documented by a physician or physician extender with supporting documentation from the hospital where the surgery occurred.

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