Step-by-Step Coding Guide for Item Set GG0110D: Walker

1. Review of Medical Records

• Objective: Ensure accurate coding by thoroughly reviewing the resident's medical history.
• Steps:
  1. Gather Medical Records: Collect all relevant medical records, including physical therapy notes, physician orders, and previous assessments.
  2. Identify Usage Records: Look for documented use of a walker, including when and how it is used.
  3. Confirm Necessity: Verify the necessity of a walker as part of the resident’s care plan.

2. Understanding Definitions

• Walker: A device used by residents to provide stability and support while walking. Types of walkers include standard walkers, rolling walkers, and knee walkers.
• Performance Levels:
  • Does Not Use a Walker: The resident does not use a walker at all.
  • Uses a Walker: The resident uses a walker for mobility.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set GG0110D on the MDS form.
  2. Determine Walker Usage: Confirm whether the resident uses a walker based on documented assessments and therapy notes.
  3. Select the Appropriate Code:
     • 0: Does not use a walker.
     • 1: Uses a walker.
  4. Record the Code: Enter the selected code for item set GG0110D on the MDS form.

4. Coding Tips

• Consistency: Ensure the recorded usage is consistent with all other documentation in the medical records.
• Accuracy: Double-check that the recorded walker usage accurately reflects the resident’s current use.
• Specificity: Be specific about the type of walker used if mentioned in the documentation.

5. Documentation

• Required:
  • Therapy Notes: Detailed notes from physical or occupational therapy sessions documenting the resident’s use of a walker.
  • Physician Orders: Orders prescribing the use of a walker for the resident.
  • Assessment Records: Formal assessments performed by healthcare professionals indicating the use of a walker.

6. Common Errors to Avoid

• Inconsistent Documentation: Ensure all records consistently reflect the resident’s walker usage.
• Inaccurate Coding: Verify the correct usage status is selected based on documented assessments.
• Lack of Detail: Ensure therapy and progress notes are detailed and specific about the resident’s use of a walker.

7. Practical Application

• Example: A resident who uses a rolling walker for mobility should be coded as 1 (Uses a walker). If the resident does not use a walker at all, they should be coded as 0.
• Illustration:
  • Uses a Walker: Resident is observed using a standard walker to move from the bed to the bathroom.
  • Does Not Use a Walker: Resident is observed walking independently or with another assistive device (e.g., cane) but not a walker.

Please note that the information provided in this guide for MDS 3.0 Item set GG0110D was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.