Step-by-Step Coding Guide for Item Set: GG0115B. ROM Limitation: Lower Extremity

1. Review of Medical Records

   • Begin by carefully reviewing the resident’s medical and therapy records, focusing on any documented assessments, evaluations, or mentions of lower extremity mobility issues. Look for information in physical therapy evaluations, physician’s notes, surgical histories, and nursing assessments that might indicate limitations or changes in lower extremity ROM.

2. Understanding Definitions

   • ROM Limitation: This refers to a reduction or restriction in the normal range of motion in a joint or series of joints. For the lower extremity, it involves the hips, knees, ankles, and toes.
   • Lower Extremity: Pertains to the parts of the body from the hips down, including thighs, knees, legs, ankles, and feet.

3. Coding Instructions

   • Conduct or review a targeted physical assessment focusing on the lower extremity ROM. Note any limitations in movements such as flexion, extension, abduction, adduction, and rotation for each relevant joint.
   • Document the assessment findings using the following scale:
     • 0: No impairment – full ROM without difficulty.
     • 1: Impairment present but does not significantly interfere with functional ability.
     • 2: Impairment interferes with functional ability.
     • 3: Impairment severely interferes with functional ability.
   • Both legs should be assessed to capture any bilateral differences.

4. Coding Tips

   • Be mindful of the resident’s comfort during the assessment; ensure movements are within pain-free ranges.
   • Utilize goniometers for accurate measurement of joint angles if ROM quantification is necessary.
   • Observe and document the quality of movement and any compensatory strategies the resident employs.

5. Documentation

   • Record the coding decisions within the resident’s MDS and in their medical records, detailing the specific joints assessed, the degree of limitation observed, and any notable findings such as pain or compensatory movements.

6. Common Errors to Avoid

   • Neglecting mild ROM limitations that could impact daily functions.
   • Omitting a joint in the assessment or documentation process.
   • Failing to account for pain that may restrict voluntary ROM during the assessment.

7. Practical Application

   • Example: Mr. Lee exhibits full ROM in his ankles and toes but has significant stiffness and limitation in his left knee due to a previous surgery, preventing full extension. During the assessment, he can flex his knee without issue but cannot achieve the last 10 degrees of extension, impacting his ability to walk smoothly. For GG0115B, Mr. Lee would be coded as "2" for his left knee, indicating that the impairment interferes with his functional ability, particularly in gait and mobility tasks.

The Step-by-Step Coding Guide for item GG0115B 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.