GG0130C3: Toileting Hygiene (Discharge Performance), Step-by-Step

Step-by-Step Coding Guide for GG0130C3: Toileting Hygiene (Discharge Performance)

1. Review of Medical Records

Objective: Assess the resident’s ability to manage toileting hygiene during the discharge assessment period.

Actions:

• Review the resident’s medical records, including nursing notes and self-care flow sheets.
• Evaluate the resident’s ability to manage clothing and perineal hygiene before and after using the toilet, commode, or bedpan during toileting activities.

2. Understanding Definitions

GG0130C3: Toileting Hygiene: This item captures the resident’s ability to manage clothing and perform perineal hygiene during and after using the toilet. It includes both voiding and bowel movements.

Key Aspects:

• Managing clothing: Lowering pants/undergarments before and pulling them up afterward.
• Perineal hygiene: Cleaning the perineal area after voiding or a bowel movement​​.

Example Scenarios:

• Resident A: The resident can manage clothing independently but requires help with perineal hygiene. This would be coded as 03: Partial/moderate assistance​.

3. Coding Instructions

Step-by-Step:

• Step 1: Assess the resident’s ability to manage clothing and perform perineal hygiene.
• Step 2: Determine the level of assistance required and choose the appropriate code:
  • 06: Independent: The resident performs the activity without help.
  • 05: Setup or clean-up assistance: A helper sets up or retrieves supplies but does not assist with the task.
  • 04: Supervision or touching assistance: A helper provides verbal cues or light touch.
  • 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 full assistance from two or more helpers​.

Illustration:

• Scenario: Resident B uses a commode and requires help both with lowering their pants and cleaning themselves after voiding. This should be coded 02: Substantial/maximal assistance​.

4. Coding Tips

• Exclude Transfers: Assistance with transferring onto or off the toilet is not included in this item; it is coded separately under GG0170F (Toilet Transfer).
• Indwelling Catheters/Ostomies: If the resident uses an indwelling catheter or ostomy, perineal hygiene around the site should be included, but management of the equipment itself is excluded​.

5. Documentation

Objective: Ensure the resident’s toileting hygiene abilities and the level of assistance required are fully documented.

Actions:

• Record how much of the task is completed by the resident versus the caregiver.
• Include any adaptive equipment used (e.g., grab bars or raised toilet seats)​.

6. Common Errors to Avoid

• Misclassifying Assistance: Ensure you accurately code the assistance based on the helper's involvement in managing clothing and hygiene.
• Incomplete Documentation: Avoid coding GG0130C3 without clear documentation of the resident’s abilities and required assistance​.

7. Practical Application

• Example 1: A resident who independently manages their clothing but needs help with cleaning after a bowel movement should be coded as 03: Partial/moderate assistance.
• Example 2: A resident with mobility issues who needs assistance managing both their clothing and hygiene should be coded as 02: Substantial/maximal assistance​.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130C3 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.