Step-by-Step Coding Guide for Item Set GG0120D: Mobility Devices: Limb Prosthesis

This guide will assist in accurately coding and documenting the use of limb prostheses as a mobility device in the MDS 3.0, specifically within item GG0120D.

1. Review of Medical Records

• Objective: Identify if the resident uses a limb prosthesis.
• Key Points:
  • Thoroughly review the resident’s medical history, including notes from physical and occupational therapy, prosthetist evaluations, and physician orders, for mentions of a limb prosthesis.
  • Look for documentation on the delivery, fitting, and training associated with the prosthesis.

2. Understanding Definitions

• Objective: Define "Limb Prosthesis."
• Key Points:
  • Limb Prosthesis: An artificial substitute for a missing part of the limb. Prostheses are designed to restore, as much as possible, the function or appearance of a missing limb and can range from cosmetic devices to functional mechanical limbs.

3. Coding Instructions

• Objective: Guide on accurately documenting the use of a limb prosthesis.
• Key Points:
  • Code "1" if the resident uses a limb prosthesis as part of their mobility strategy during the assessment period.
  • Code "0" if the resident does not use a limb prosthesis.

4. Coding Tips

• Clarify whether the prosthesis is used consistently for mobility or if it’s worn occasionally. Consistent use should influence coding.
• Consider the impact of the prosthesis on the resident’s mobility when coding, particularly in how it aids or limits their function.

5. Documentation

• Objective: Ensure comprehensive documentation regarding prosthesis use.
• Key Points:
  • Document the type of prosthesis used (e.g., upper limb, lower limb), including any specific features or customizations.
  • Record training sessions, adjustments, and resident feedback on using the prosthesis, highlighting how it affects their mobility.

6. Common Errors to Avoid

• Failing to recognize a prosthesis that significantly impacts mobility, even if it's not primarily intended for mobility enhancement (e.g., upper limb prostheses used to assist in balance or support).
• Overlooking recent changes in prosthesis use, such as a resident who has stopped using the device due to discomfort or fit issues.

7. Practical Application

• Scenario: Mr. George Hill, a resident, uses a lower limb prosthesis following an amputation. His medical record includes detailed notes from his last prosthetist appointment, indicating a new socket fitting to improve comfort and mobility. Recent physical therapy notes highlight his progress in ambulating with the prosthesis and any ongoing challenges. Given this information, the MDS Coordinator codes "1" for GG0120D, accurately reflecting Mr. Hill's use of a limb prosthesis for mobility.

The Step-by-Step Coding Guide for item GG0120D 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.