Step-by-Step Coding Guide for Item Set GG0110A: Manual Wheelchair

This guide will assist in accurately coding and documenting information related to a resident's use of a manual wheelchair, as specified in item GG0110A of the MDS 3.0.

1. Review of Medical Records

• Objective: Identify any documented use of a manual wheelchair.
• Key Points:
  • Examine the resident’s medical records, including therapy notes, nursing documentation, and physician orders, for mentions of manual wheelchair use.
  • Look for assessments or evaluations that discuss the resident's mobility and any specific references to their ability or requirement to use a manual wheelchair.

2. Understanding Definitions

• Objective: Clarify what is meant by "Manual Wheelchair."
• Key Points:
  • Manual Wheelchair: A wheelchair that requires the resident or an assistant to push it, distinguishing it from power wheelchairs or scooters. It is used by residents who cannot walk independently or who require it for longer distances.

3. Coding Instructions

• Objective: Guide on how to accurately code for the use of a manual wheelchair.
• Key Points:
  • Determine the resident's need and use of a manual wheelchair based on their current functional status and medical recommendations.
  • Code the item based on the resident’s ability to use a manual wheelchair safely and effectively. Options typically include:
    • 3: Independent
    • 2: Needed some help
    • 1: Dependent
    • 8: Activity did not occur during assessment period

4. Coding Tips

• Verify whether the resident has been specifically assessed for manual wheelchair use, including their ability to propel themselves and navigate safely.
• Consider the resident's entire period of stay when coding, focusing on their most typical level of function.

5. Documentation

• Objective: Ensure comprehensive documentation supporting the coding of manual wheelchair use.
• Key Points:
  • Document the assessment or evaluation results that support the resident’s level of independence with a manual wheelchair.
  • Note any changes in the resident's ability to use the manual wheelchair during their stay and the reasons for these changes.

6. Common Errors to Avoid

• Coding the resident as independent without considering their ability to safely navigate different terrains or obstacles.
• Failing to update the resident’s manual wheelchair use status if their condition changes during the assessment period.

7. Practical Application

• Scenario: Mr. John Doe has been using a manual wheelchair due to lower limb weakness. Upon assessment, the physical therapist notes that Mr. Doe can propel himself in his wheelchair over a flat surface but requires help for ramps and uneven surfaces. For item GG0110A, the MDS Coordinator codes him as 2 (needed some help), reflecting his need for assistance with more challenging terrains. This coding decision is supported by detailed documentation in the therapy notes, which outline Mr. Doe’s specific abilities and limitations with his wheelchair.

The Step-by-Step Coding Guide for item GG0110A 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.