Step-by-Step Coding Guide for Item Set GG0100B: Indoor Mobility (Ambulation): Prior Function

This guide will help ensure accurate coding and documentation for a resident's prior indoor mobility function, as required in item GG0100B of the MDS 3.0.

1. Review of Medical Records

• Objective: Collect information on the resident's indoor mobility abilities before the current illness, exacerbation, or injury.
• Key Points:
  • Examine medical records, including therapy evaluations, nursing notes, and physician's documentation, for descriptions of the resident’s ability to move around indoors prior to admission.
  • Specifically, look for mentions of the resident's ability to walk or use a wheelchair inside, including transferring to and from the wheelchair.

2. Understanding Definitions

• Objective: Define "Prior Function in Indoor Mobility."
• Key Points:
  • Indoor Mobility (Ambulation): Refers to the resident's ability to move around inside the facility or their home before the onset of the current condition. This includes walking with or without a device and wheelchair use.

3. Coding Instructions

• Objective: Guide on accurately coding the resident's prior indoor mobility function.
• Key Points:
  • Based on gathered information, code the resident’s indoor mobility prior function using the following options:
    • 3: Independent in indoor mobility.
    • 2: Required some help with indoor mobility.
    • 1: Was dependent on others for indoor mobility.
  • Code as 8 (unknown) if there's insufficient information to determine prior indoor mobility function.

4. Coding Tips

• Confirm details through multiple sources when possible, such as family interviews or previous facility records, to ensure accuracy.
• Understand the distinction between various mobility aids or assistance levels the resident may have used.

5. Documentation

• Objective: Ensure thorough documentation supporting coding decisions.
• Key Points:
  • Record the source(s) of information used to assess the resident’s prior indoor mobility function, noting specific details that led to the coding choice.
  • Document any discrepancies in reports of prior functions and how they were resolved.

6. Common Errors to Avoid

• Misinterpreting descriptions of mobility aids or assistance as full independence or dependence.
• Overlooking relevant information that could change the coding, such as the occasional use of a wheelchair for longer distances.

7. Practical Application

• Scenario: Ms. Angela White was admitted to the facility following a hip fracture. Before her injury, according to both her family and physical therapy notes from two months earlier, Ms. White was able to walk throughout her home with the use of a cane but needed help when going outside. For indoor mobility, Ms. White is coded as 2 in GG0100B, indicating she required some help for indoor ambulation, specifically supported by the information that she used a cane for indoor mobility and needed assistance for more challenging outdoor mobility.

The Step-by-Step Coding Guide for item GG0100B in MDS 3.0 Section GG is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.