Step-by-Step Coding Guide for Item Set GG0120A: Mobility Devices: Cane/Crutch

This guide provides detailed instructions for accurately coding and documenting the use of a cane or crutch as a mobility device in the MDS 3.0, specifically within item GG0120A.

1. Review of Medical Records

• Objective: Identify if the resident uses a cane or crutch for mobility.
• Key Points:
  • Examine the resident's medical records, including physical and occupational therapy assessments, nursing notes, and physician orders, for mentions of cane or crutch use.
  • Look for equipment orders or prescriptions specifically for canes or crutches.

2. Understanding Definitions

• Objective: Define "Cane/Crutch" as a mobility device.
• Key Points:
  • Cane: A stick used to provide support and improve balance while walking. Canes can be single-point or quad-point.
  • Crutch: A support used under the arm or forearm to assist with walking, typically used in pairs.

3. Coding Instructions

• Objective: Guide on how to accurately code for the use of cane or crutch.
• Key Points:
  • Code "1" if the resident uses a cane or crutch as part of their mobility strategy inside and/or outside of the facility during the assessment period.
  • Code "0" if the resident does not use a cane or crutch.

4. Coding Tips

• Verify the type of mobility aid used to ensure accurate coding, especially if the resident uses multiple aids at different times.
• Consult with therapy staff for clarification if there is any ambiguity about the device's use.

5. Documentation

• Objective: Maintain comprehensive documentation regarding cane or crutch use.
• Key Points:
  • Document the assessment or recommendation for a cane or crutch, including the healthcare professional’s name and the date of the recommendation.
  • Keep a record of any training provided to the resident on the proper use of the cane or crutch.

6. Common Errors to Avoid

• Failing to update the resident’s mobility aid usage if a transition occurs from using to not using a cane or crutch, or vice versa.
• Misclassifying other mobility devices (e.g., walkers) as canes or crutches.

7. Practical Application

• Scenario: Mrs. Emily Park was recently assessed by the physical therapy team due to her decreased balance and mobility following a minor leg injury. After evaluation, it was determined that she would benefit from using a quad-point cane. The therapy team provided Mrs. Park with the cane and trained her on its use. During her assessment period, Mrs. Park consistently used the cane for all ambulation activities. The MDS Coordinator codes "1" for GG0120A, accurately reflecting her use of a cane as a mobility aid.

The Step-by-Step Coding Guide for item GG0120A 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.