Step-by-Step Coding Guide for Item GG0130F3: Upper Body Dressing (Discharge Performance)

1. Review of Medical Records

Objective:

• To collect comprehensive information on the resident’s ability to dress their upper body at discharge.

Steps:

1. Gather Medical Records:
   • Review all relevant records, including nursing notes, physical therapy reports, and occupational therapy assessments.
2. Consult Interdisciplinary Team:
   • Discuss the resident's performance and any assistance required with the interdisciplinary team, including nurses, therapists, and caregivers.
3. Interview the Resident and Family:
   • Obtain input from the resident and their family about their ability to dress independently and any challenges faced.
4. Observe the Resident:
   • Directly observe the resident performing the upper body dressing task during therapy sessions or daily routines.

Example:

• Resident A:
  • Medical records indicate assistance needed for dressing due to right-side weakness post-stroke.

2. Understanding Definitions

Objective:

• To clearly define terms and levels of assistance related to the coding item GG0130F3.

Definitions:

• Upper Body Dressing: Involves dressing and undressing above the waist, including putting on and taking off a bra, undershirt, t-shirt, button-down shirt, pullover shirt, dress, sweatshirt, sweater, nightgown, or pajama top.
• Discharge Performance: The resident’s ability to perform the task at the time of discharge, assessed over the last 3 calendar days of the Medicare Part A stay.

Example:

• Independent (06): Resident completes the activity with no assistance.
• Setup or Clean-Up Assistance (05): Helper sets up or cleans up; resident completes the activity.
• Supervision or Touching Assistance (04): Helper provides verbal cues or steadying assistance.
• Partial/Moderate Assistance (03): Helper does less than half the effort.
• Substantial/Maximal Assistance (02): Helper does more than half the effort.
• Dependent (01): Helper does all of the effort, or more than one helper is required.

3. Coding Instructions

Objective:

• To provide clear and precise steps for coding item GG0130F3 accurately.

Steps:

1. Determine Assistance Level:
   • Assess the amount of assistance the resident needs to complete upper body dressing.
2. Use the 6-Point Scale:
   • 06: Independent
   • 05: Setup or clean-up assistance
   • 04: Supervision or touching assistance
   • 03: Partial/moderate assistance
   • 02: Substantial/maximal assistance
   • 01: Dependent
3. Consider the Resident's Performance:
   • Code based on the resident’s usual performance over the assessment period, not their best or worst performance.

Example:

• Resident B:
  • Requires setup assistance to place clothes within reach but dresses independently.
  • Coding: GG0130F3 is coded as 05 (Setup or clean-up assistance).

4. Coding Tips

Objective:

• To offer practical advice to ensure accurate and consistent coding.

Tips:

1. Consistency:
   • Ensure documentation is consistent across all records.
2. Helper Involvement:
   • Accurately distinguish between different levels of assistance provided by helpers.
3. Resident's Usual Performance:
   • Focus on the resident's typical performance, not the most or least independent instance.

Example:

• Resident C:
  • Performs most dressing tasks but needs occasional touching assistance for balance.
  • Coding: GG0130F3 is coded as 04 (Supervision or touching assistance).

5. Documentation

Objective:

• To ensure thorough and accurate documentation supporting the coding of item GG0130F3.

Steps:

1. Record Details:
   • Document specific details about the resident’s ability to dress their upper body.
2. Helper Interaction:
   • Note the type and amount of assistance provided by helpers.
3. Resident Input:
   • Include resident’s and family’s input on their dressing ability and any difficulties faced.

Example:

• Resident D:
  • Documentation includes therapist notes on assistance provided during dressing and resident's self-reported challenges with buttons.

6. Common Errors to Avoid

Objective:

• To highlight frequent mistakes and provide guidance on how to avoid them.

Errors:

1. Incomplete Record Review:
   • Failing to review all relevant records comprehensively.
2. Inconsistent Documentation:
   • Recording inconsistent information across different sources.
3. Misinterpreting Assistance Levels:
   • Incorrectly coding the level of assistance required by the resident.

Tips to Avoid Errors:

• Double-Check Records:
  • Verify information across multiple sources.
• Consistent Documentation:
  • Ensure all notes and records consistently reflect the resident’s abilities and assistance required.
• Accurate Coding:
  • Clearly understand and apply the definitions for each level of assistance.

7. Practical Application

Objective:

• To apply the coding guidelines through practical examples and scenarios.

Scenario 1:

• Resident E:
  • Needs help to start putting on a shirt but can finish independently.
  • Coding: GG0130F3 is coded as 03 (Partial/moderate assistance).

Scenario 2:

• Resident F:
  • Can put on a shirt with supervision but needs help with buttons.
  • Coding: GG0130F3 is coded as 04 (Supervision or touching assistance).

Illustrations:

• Include diagrams or flowcharts illustrating the coding process for item GG0130F3.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130F3 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.