Step-by-Step Coding Guide for Item Set GG0100C: Stairs: Prior Function

This detailed guide aims to assist in accurately coding and documenting a resident's ability to navigate stairs before the current illness, exacerbation, or injury, as specified in item GG0100C of the MDS 3.0.

1. Review of Medical Records

• Objective: Gather information on the resident's ability to use stairs prior to the current health episode.
• Key Points:
  • Examine medical records, therapy evaluations, nursing notes, and physician documentation for mentions of the resident’s ability to navigate stairs.
  • Look for details on the use of aids, assistance required, or any limitations noted in climbing stairs.

2. Understanding Definitions

• Objective: Define "Prior Function with Stairs."
• Key Points:
  • Stairs: Prior Function refers to the resident’s reported or observed ability to navigate stairs before the onset of their current condition. This includes climbing up or down stairs, with or without the use of aids or assistance.

3. Coding Instructions

• Objective: Provide guidance on accurately coding the resident's prior ability to navigate stairs.
• Key Points:
  • Code the resident’s prior function with stairs based on the information available:
    • 3: Independent (able to navigate stairs without assistance or supervision, may use an aid).
    • 2: Needed some help (required physical assistance or supervision for safety).
    • 1: Dependent (unable to use stairs without someone physically assisting).
  • If the prior function is unknown or not documented, code as 8 (unknown).

4. Coding Tips

• If documentation varies (e.g., different reports from family vs. medical records), prioritize clinical documentation or seek clarification.
• Pay attention to notes indicating a change in ability leading up to the current condition, as this may impact coding accuracy.

5. Documentation

• Objective: Ensure comprehensive documentation to support coding decisions.
• Key Points:
  • Document the source of information regarding the resident's ability to navigate stairs, including dates and details of assessments or reports.
  • In cases of conflicting information, note the rationale for the chosen code in the resident's medical record.

6. Common Errors to Avoid

• Coding a resident as independent without considering the use of aids or the need for supervision for safety.
• Overlooking recent changes in ability when reviewing historical data.

7. Practical Application

• Scenario: Mrs. Barbara Johnson, prior to her hospitalization for pneumonia, lived in a two-story home and was able to navigate the stairs multiple times a day with the use of a handrail but did not require physical assistance. Based on this information, the MDS Coordinator codes Mrs. Johnson’s ability to navigate stairs as 3 (independent) in GG0100C, noting in her documentation the source of this information and the specifics regarding the use of a handrail for support.

The Step-by-Step Coding Guide for item GG0100C 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.