GG0110E: Orthotics/Prosthetics, Step-by-Step

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

1. Review of Medical Records

Objective: Assess the resident’s use of orthotics or prosthetics prior to the current episode of care.

Actions:

• Review the resident’s medical history, nursing notes, and therapy records to determine prior use of orthotic or prosthetic devices.
• Interview staff, caregivers, or family members about the resident’s past use of orthotics or prosthetics.
• Observe if the resident currently uses or has used devices like artificial limbs, braces, or orthopedic support before admission.

2. Understanding Definitions

GG0110E: Orthotics/Prosthetics: This item records whether the resident used any orthotic or prosthetic devices (such as braces, artificial limbs, or supports) prior to the current episode of care.

Example Scenarios:

• Resident A: The resident uses a below-knee prosthesis for mobility. They have been using it for years prior to the current care episode. This would be coded as 1: Yes (used prior to admission).
• Resident B: The resident has never used orthotics or prosthetics before. This would be coded as 0: No (not used prior to admission).

3. Coding Instructions

Step-by-Step:

• Step 1: Determine if the resident used orthotic or prosthetic devices prior to this care episode.
• Step 2: Identify the correct code:
  • 1: Yes - Resident used an orthotic or prosthetic device before the current care episode.
  • 0: No - Resident did not use any orthotic or prosthetic device before the current care episode.

4. Coding Tips

• Document History Accurately: Ensure that the resident’s prior use of orthotics or prosthetics is clearly documented in medical records, including the type of device used.
• Devices Included: Orthotics include braces for support, and prosthetics refer to artificial limbs. Ensure the device is for movement or support.
• Exclude Recent Devices: Do not code for orthotics or prosthetics introduced during the current episode of care.

5. Documentation

Objective: Accurately document the resident’s history of using orthotics or prosthetics.

Actions:

• Record any prior use of orthotic or prosthetic devices, including the type of device (e.g., artificial limb, leg brace).
• Note whether these devices were used regularly and for which part of the body they were applied.

6. Common Errors to Avoid

• Coding New Devices: Do not code for orthotic or prosthetic devices introduced during the current episode of care. This item is specifically for prior use.
• Incomplete History: Ensure thorough documentation of the resident’s use of orthotics/prosthetics prior to admission. Incomplete records could lead to incorrect coding.

7. Practical Application

Example 1: A resident has used a left-leg prosthesis for 10 years before being admitted to the facility. This would be coded as 1: Yes.
Example 2: A resident was fitted for an arm brace only after admission to the facility. This would be coded as 0: No, as the device was not used prior to the current episode of care.

Please note that the information provided in this guide for MDS 3.0 Item set GG0110E 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.