Step-by-Step Coding Guide for Item Set GG0110E: Orthotics/Prosthetics

This guide aims to assist in accurately coding and documenting the use of orthotic and prosthetic devices as specified in item GG0110E of the MDS 3.0.

1. Review of Medical Records

• Objective: Identify if the resident uses any orthotic or prosthetic devices.
• Key Points:
  • Review the resident’s medical history, physical and occupational therapy assessments, and care plans for mentions of orthotic (supports, braces) or prosthetic (artificial limbs) devices.
  • Look for documentation from specialists who may have recommended or fitted these devices.

2. Understanding Definitions

• Objective: Clarify the terms “Orthotics” and “Prosthetics.”
• Key Points:
  • Orthotics: Devices designed to support or correct the function of a limb or the torso. Common examples include braces for limbs, spinal orthoses, and foot orthotics.
  • Prosthetics: Artificial devices that replace missing parts of the body. Examples include artificial limbs like arms and legs.

3. Coding Instructions

• Objective: Accurately document the resident's use of these devices.
• Key Points:
  • Code “1” if the resident is currently using any orthotic or prosthetic devices as of the assessment reference date.
  • Code “0” if the resident is not using any such devices.

4. Coding Tips

• Clarify with therapy teams whether temporary devices used post-surgery or for injury recovery are considered under this item.
• Be mindful of devices that the resident may only use periodically; if they are used within the assessment period, they should be reported.

5. Documentation

• Objective: Ensure detailed and accurate documentation of device use.
• Key Points:
  • Document the type(s) of devices used, the date of initiation, and the specific needs they address in the resident’s care plan.
  • Include notes on the resident’s adaptation to the device, any challenges faced, and plans for reassessment or adjustment.

6. Common Errors to Avoid

• Neglecting to update the resident’s records if a device is no longer in use or if a new device has been introduced.
• Confusing temporary supports used for rehabilitation with permanent orthotic or prosthetic needs.

7. Practical Application

• Scenario: Mrs. Beatrice Allen uses a knee brace (orthotic) following her knee replacement surgery and a prosthetic device for her left arm lost due to an accident years ago. During her MDS assessment, the review of her medical records and consultation with her physical therapist confirm the ongoing use of both devices for mobility and daily activities. Accordingly, GG0110E is coded as “1,” and detailed documentation regarding each device, including the purposes they serve and any related care instructions, is included in her care plan.

The Step-by-Step Coding Guide for item GG0110E 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.