Step-by-Step Coding Guide for Item Set GG0100D: Functional Cognition: Prior Function

This guide outlines the process for accurately coding and documenting a resident's prior functional cognition as specified in item GG0100D of the MDS 3.0.

1. Review of Medical Records

• Objective: Gather information on the resident's cognitive abilities before the current illness, exacerbation, or injury.
• Key Points:
  • Examine medical records for notes on cognitive assessments, physician observations, therapy notes, and nursing documentation that describe the resident’s cognitive functioning prior to the current condition.
  • Pay attention to details about the resident's decision-making abilities, memory, and ability to manage daily affairs and finances.

2. Understanding Definitions

• Objective: Define "Functional Cognition" and its relevance to prior function.
• Key Points:
  • Functional Cognition: Refers to the cognitive processes required to accomplish complex everyday tasks. This includes decision-making, problem-solving, memory, and the ability to manage daily life and finances.

3. Coding Instructions

• Objective: Guide on accurately coding the resident's prior functional cognition.
• Key Points:
  • Based on gathered information, code the resident's prior functional cognition using the following scale:
    • 3: Independent (able to manage daily decisions, finances, and problem-solving)
    • 2: Needed some help (required occasional assistance or cues for complex tasks)
    • 1: Dependent (required substantial help for basic decisions and tasks)
  • If the resident's prior functional cognition level is unknown or not documented, code as 8 (unknown).

4. Coding Tips

• Cross-reference information from various sources, including family reports and prior healthcare providers, to form a comprehensive view of the resident's functional cognition before the current condition.
• Be cautious of subjective interpretations; rely on documented assessments and observations where possible.

5. Documentation

• Objective: Maintain detailed documentation supporting the coding of prior functional cognition.
• Key Points:
  • Document the source(s) of information used to determine the resident’s prior functional cognition, including dates and specifics of cognitive abilities noted.
  • In cases where functional cognition is coded as unknown, document the efforts made to obtain this information.

6. Common Errors to Avoid

• Overlooking relevant documentation that could provide insight into the resident's prior functional cognition.
• Confusing current cognitive assessments with prior functional cognition without considering the impact of recent health changes.

7. Practical Application

• Scenario: Mr. Anderson, recently admitted to the facility following a stroke, had documented evidence in his medical records of managing his own finances, medication regimen, and daily decisions with independence prior to his stroke. Based on a comprehensive review of his medical records and discussions with his family, the MDS Coordinator codes Mr. Anderson’s functional cognition as 3 (independent) in GG0100D, indicating his high level of cognitive function before the current health episode.

The Step-by-Step Coding Guide for item GG0100D 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.