Step-by-Step Coding Guide for Item Set GG0130G3: Lower Body Dressing (Discharge Performance)

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s ability to dress their lower body at discharge.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, physical and occupational therapy reports, and progress notes.
  2. Identify Performance: Look for documented assessments of the resident’s lower body dressing ability.
  3. Confirm Details: Verify the consistency of the resident’s lower body dressing performance through various sources within the medical records.

2. Understanding Definitions

• Lower Body Dressing: The ability to dress and undress below the waist; includes putting on and taking off lower body clothing and prosthetics/orthotics when applicable.
• Discharge Performance: The resident’s ability to perform lower body dressing tasks at the time of discharge from the facility.

3. Coding Instructions

• Steps:
  1. Assess Performance: Confirm the resident’s ability to perform lower body dressing tasks based on the most recent and comprehensive assessments before discharge.
  2. Determine Code: Use the following scale to determine the resident’s level of independence:
     • Code 01: Dependent - Helper does all of the effort.
     • Code 02: Substantial/maximal assistance - Helper does more than half the effort.
     • Code 03: Partial/moderate assistance - Helper does less than half the effort.
     • Code 04: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance.
     • Code 05: Setup or clean-up assistance - Helper sets up or cleans up, resident completes activity.
     • Code 06: Independent - Resident completes the activity by themselves without assistance.
  3. Code Appropriately: Code GG0130G3 with the appropriate number based on the resident’s level of independence.

4. Coding Tips

• Accurate Assessment: Ensure assessments are current and accurately reflect the resident’s abilities at the time of discharge.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s performance.
• Interdisciplinary Input: Consider input from various healthcare providers (e.g., nurses, physical therapists, occupational therapists) for a comprehensive assessment.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes documenting the resident’s lower body dressing performance.
  • Therapy Reports: Include assessments from physical and occupational therapy sessions.
  • Discharge Summary: Document the resident’s abilities and any assistance required at discharge.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s ability through multiple sources.
• Incomplete Documentation: Make sure all relevant details about the resident’s lower body dressing performance are thoroughly documented.
• Assumptions: Do not assume the resident’s abilities without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: John, a 78-year-old resident, is being discharged from the facility. His ability to dress his lower body has been assessed.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, including therapy reports and nursing notes documenting his lower body dressing performance.
    2. Identify Performance: It is confirmed that John requires only setup assistance for lower body dressing at discharge.
    3. Document and Code: The nurse documents John’s performance as setup assistance and codes GG0130G3 as "05".
  • Outcome: John’s lower body dressing performance is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130G3 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.