GG0130B3: Oral Hygiene (Discharge Performance), Step-by-Step

Step-by-Step Coding Guide for GG0130B3: Oral Hygiene (Discharge Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to perform oral hygiene during the discharge assessment period.

Actions:

• Review nursing documentation, therapy records, and any relevant oral care assessments.
• Observe or inquire about the resident's performance in cleaning their teeth or gums (for edentulous residents) during the last three days prior to discharge.

2. Understanding Definitions

GG0130B3: Oral Hygiene: This item measures the resident’s ability to clean their teeth or dentures and manage oral hygiene, including rinsing and spitting. For edentulous residents, this includes cleaning gums.

Example Scenarios:

• Resident A: Cleans their teeth but requires help with setting up a toothbrush and applying toothpaste. This would be coded as 05: Setup or clean-up assistance​.

3. Coding Instructions

Step-by-Step:

• Step 1: Evaluate the resident’s ability to clean their teeth, dentures, or gums.
• Step 2: Determine the level of assistance required:
  • 06: Independent: The resident performs oral hygiene without any help.
  • 05: Setup or clean-up assistance: The resident performs the task but requires assistance with setup (e.g., putting toothpaste on the brush).
  • 04: Supervision or touching assistance: The resident needs verbal cues or light physical assistance.
  • 03: Partial/moderate assistance: The helper provides less than half the effort.
  • 02: Substantial/maximal assistance: The helper provides more than half the effort.
  • 01: Dependent: The resident requires two or more helpers​.

Illustration:

• Scenario: Resident B starts brushing their teeth but becomes fatigued midway, requiring a caregiver to complete the task. This would be coded as 02: Substantial/maximal assistance​.

4. Coding Tips

• Include Denture Care: If the resident has dentures, their ability to clean them should be considered as part of oral hygiene.
• Edentulous Residents: For residents without teeth, cleaning gums should be assessed similarly to oral hygiene with teeth​.

5. Documentation

Objective: Clearly document the resident’s oral hygiene performance, including the level of assistance and any adaptive equipment used.

Actions:

• Record the type of assistance provided and whether the resident used any adaptive devices, such as a toothbrush holder​.

6. Common Errors to Avoid

• Misclassifying Assistance: Ensure setup assistance (e.g., placing toothpaste on the brush) is coded as 05: Setup or clean-up assistance, not as 04.
• Incomplete Documentation: Do not code GG0130B3 without documenting the exact level of assistance provided during the discharge period​.

7. Practical Application

• Example 1: A resident brushes their teeth independently but needs help with preparing the toothbrush. Code GG0130B3 as 05: Setup or clean-up assistance.
• Example 2: A resident needs help to clean their dentures due to fatigue and dexterity issues. This should be coded as 03: Partial/moderate assistance​.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130B3 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.