Step-by-Step Coding Guide for Item Set: GG0115A. ROM Limitation: Upper Extremity

1. Review of Medical Records

   • Start by thoroughly reviewing the resident's medical records for any documented assessments or evaluations of the upper extremities. This includes physical therapy evaluations, nursing assessments, and physician notes. Look for mentions of range of motion limitations, pain during movement, or previous diagnoses affecting the upper extremities.

2. Understanding Definitions

   • ROM Limitation: Refers to any restriction or loss of the normal range of motion in a joint or series of joints. In the context of upper extremity, it focuses on shoulders, elbows, wrists, and hands.
   • Upper Extremity: Involves the limbs attached to the upper torso, including shoulders, arms, forearms, wrists, and hands.

3. Coding Instructions

   • Perform or review a physical assessment of the resident's upper extremity ROM. Note limitations in any joint movements including flexion, extension, abduction, adduction, and rotation.
   • Use a standardized scale for documentation:
     • 0: No impairment
     • 1: Impairment present but does not interfere significantly with functional ability
     • 2: Impairment interferes with functional ability
     • 3: Impairment severely interferes with functional ability
   • Consider bilateral assessment for a comprehensive evaluation.

4. Coding Tips

   • Ensure the assessment is done in a pain-free manner, adjusting techniques as necessary for resident comfort.
   • Use visual aids or diagrams for more accurate documentation of specific limitations.
   • Compare findings to normative ROM values for each joint for a more objective assessment.

5. Documentation

   • Document the findings and chosen codes in the resident's medical record, clearly indicating the joints assessed and the degree of limitation observed. Include specific measurements if possible, and note any observed pain or discomfort.

6. Common Errors to Avoid

   • Overlooking mild limitations that could impact the resident's functional ability.
   • Failing to assess each joint within the upper extremities individually.
   • Not considering the impact of pain on ROM limitation assessment.

7. Practical Application

   • Example: Mrs. Jones has arthritis affecting her right shoulder, limiting her ability to abduct her arm beyond 90 degrees. During the assessment, she demonstrates full ROM in her elbows, wrists, and left shoulder but has significant limitations in right shoulder abduction and flexion. She reports pain during these movements. For GG0115A, Mrs. Jones would be coded as "2" for her right shoulder, indicating that the impairment interferes with her functional ability, especially in tasks requiring reaching overhead.

The Step-by-Step Coding Guide for item GG0115A 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.