Step-by-Step Coding Guide for Item Set GG0120C: Mobility Devices: Wheelchair (Manual or Electric)

This guide provides instructions for accurately coding and documenting the use of a wheelchair, whether manual or electric, in the MDS 3.0, specifically within item GG0120C.

1. Review of Medical Records

• Objective: Ascertain if the resident uses a manual or electric wheelchair for mobility.
• Key Points:
  • Look through the resident’s medical history, including physical therapy evaluations, occupational therapy notes, nursing care plans, and physician's orders, for mentions of wheelchair use.
  • Note any assessments that specify the type of wheelchair used (manual or electric) and the reasons for its recommendation.

2. Understanding Definitions

• Objective: Define "Wheelchair" in the context of mobility aids.
• Key Points:
  • Wheelchair: A chair mounted on wheels for use by individuals who cannot walk or have difficulty walking. Wheelchairs can be propelled manually by the user, pushed by someone else, or driven by electricity.

3. Coding Instructions

• Objective: Provide guidelines on accurately documenting wheelchair use.
• Key Points:
  • Code “1” if the resident uses a wheelchair (manual or electric) as their primary means of mobility within the facility during the assessment period.
  • Code “0” if the resident does not use a wheelchair.

4. Coding Tips

• Clarify the type of wheelchair used for more precise care planning, even though the coding doesn't differentiate between manual and electric.
• Review recent changes in the resident’s condition that might affect their need for a wheelchair or their ability to use one.

5. Documentation

• Objective: Ensure comprehensive documentation regarding wheelchair use.
• Key Points:
  • Document the assessment that led to the recommendation for a wheelchair, specifying whether it is manual or electric.
  • Include notes on any custom modifications to the wheelchair, training provided to the resident for safe use, and how the wheelchair use impacts their mobility and daily activities.

6. Common Errors to Avoid

• Assuming a temporary need for a wheelchair (e.g., post-surgery recovery) is a permanent situation without ongoing assessment.
• Failing to document a switch between manual and electric wheelchairs or changes in wheelchair use over time.

7. Practical Application

• Scenario: Mr. Henry Ford, recovering from a leg amputation, has been assessed by the rehabilitation team and provided with an electric wheelchair to ensure his mobility within the facility while he adjusts to his prosthetic limb. His care plan includes detailed instructions for using the electric wheelchair, including battery charging and maneuvering in tight spaces. During the assessment period, Mr. Ford's use of the electric wheelchair for all indoor mobility is noted and coded as “1” in GG0120C, reflecting his reliance on this mobility device.

The Step-by-Step Coding Guide for item GG0120C 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.