GG0130A1: Eating (Admission Performance), Step-by-Step
Step-by-Step Coding Guide for Item Set GG0130A1: Eating (Admission Performance)
1. Review of Medical Records
- Objective: To accurately assess the resident’s ability to eat upon admission.
- Steps:
- Gather Records: Collect all relevant medical records, including physician notes, nursing assessments, dietary intake records, and any prior assessments of eating abilities.
- Identify Documentation: Look for documented evidence of the resident’s eating abilities and any assistance they require during meals.
- Verify Information: Cross-check the identified information across different records to ensure consistency.
2. Understanding Definitions
- Eating: The process of putting food and liquids into the mouth, chewing, and swallowing.
- Performance Levels: The levels range from independent to dependent based on the amount of assistance the resident requires.
3. Coding Instructions
- Steps:
- Locate Item Set: Find item set GG0130A1 on the MDS form.
- Determine Performance Level:
- 06. Independent: Resident completes the activity by themselves with no assistance.
- 05. Setup or clean-up assistance: Resident completes the activity, but someone else sets up or cleans up.
- 04. Supervision or touching assistance: Resident completes the activity with verbal cues, supervision, or light touch assistance.
- 03. Partial/moderate assistance: Resident completes more than half of the activity, but needs help with less than half.
- 02. Substantial/maximal assistance: Resident completes less than half of the activity, but needs help with more than half.
- 01. Dependent: Resident needs full assistance for the activity.
- 07. Resident refused: Resident refuses to complete the activity.
- 09. Not applicable: Activity did not occur during the assessment period.
- 88. Not attempted due to medical condition or safety concerns: Activity was not attempted due to medical condition or safety concerns.
- Code the Item:
- Input the appropriate code in the designated field for item set GG0130A1 based on the resident's performance level.
- Complete Entry: Double-check the entered code for accuracy.
4. Coding Tips
- Accurate Documentation: Ensure the resident’s ability to eat is well-documented, including any assistance needed.
- Observation: Observe the resident during meals if possible to accurately determine their performance level.
- Consistent Information: Verify that the information is consistent across all records and sources.
5. Documentation
- Required:
- MDS Form: Correctly filled entry for item set GG0130A1 indicating the resident’s eating performance level upon admission.
- Physician Notes: Documentation from physicians regarding any conditions affecting eating ability.
- Nursing Assessments: Reports from nursing staff detailing the resident’s eating abilities and required assistance.
- Dietary Intake Records: Records showing the resident’s food and liquid intake.
- Prior Assessments: Any previous assessments of the resident’s eating abilities.
6. Common Errors to Avoid
- Incorrect Performance Level: Avoid coding a higher level of independence if the resident requires assistance.
- Inconsistent Records: Ensure all records consistently reflect the resident’s eating abilities.
- Overlooking Documentation: Do not overlook any dietary intake records or nursing assessments that document eating abilities.
7. Practical Application
- Example:
- Resident Background: Ms. Jane Doe is a new admission who has difficulty eating independently due to a recent stroke.
- Review Process: Access Ms. Doe’s medical records, including physician notes and nursing assessments.
- Verification: Confirm the level of assistance required for eating from the documentation.
- Coding Process:
- Step 1: Locate item set GG0130A1 on the MDS form.
- Step 2: Identify the level of assistance Ms. Doe needs (e.g., substantial/maximal assistance).
- Step 3: Enter the code "02" indicating substantial/maximal assistance.
- Step 4: Verify the entered code with the documentation.
- Illustration:
- Provide a sample MDS form showing item set GG0130A1 with the correct code entered.
- Include an example of a nursing assessment report documenting the required level of assistance for eating.
Please note that the information provided in this guide for MDS 3.0 Item set GG0130A1 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
