Step-by-Step Coding Guide for Item Set GG0130G5: Lower Body Dressing (OBRA/Interim Performance)

1. Review of Medical Records

• Objective: Accurately determine and document the resident's ability to dress their lower body during the OBRA/Interim assessment period.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, physical therapy assessments, occupational therapy reports, and previous functional assessments.
  2. Identify Documentation of Lower Body Dressing Ability: Look for documented instances where the resident’s ability to dress their lower body was assessed or observed.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Lower Body Dressing: This refers to the resident’s ability to dress and undress below the waist, including undergarments, pants, skirts, shoes, and socks.
• OBRA/Interim Performance: The resident's ability to perform this task during the OBRA (Omnibus Budget Reconciliation Act) or interim assessment period.
• Key Points:
  • Level of Independence: The degree of assistance the resident requires to perform lower body dressing.
  • Performance: This assessment focuses on the resident's actual performance during the specified assessment period, not what they could potentially do or have done in the past.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the resident’s ability to dress their lower body during the OBRA/Interim assessment period.
  2. Verify Documentation: Ensure that the performance is clearly noted in the records, including specifics about the level of independence and assistance required.
  3. Code Appropriately: Enter the appropriate code for the resident’s OBRA/Interim performance in item set GG0130G5 based on their level of independence:
     • 01: Dependent
     • 02: Substantial/maximal assistance
     • 03: Partial/moderate assistance
     • 04: Supervision or touching assistance
     • 05: Setup or clean-up assistance
     • 06: Independent
     • 07: Resident refused
     • 09: Not applicable
     • 10: Not attempted due to environmental limitations
     • 88: Not attempted due to medical condition or safety concerns

4. Coding Tips

• Accurate Identification: Ensure the resident’s performance is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s ability to dress their lower body.
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Nursing Notes: Detailed notes from nursing staff documenting the resident’s performance in dressing their lower body.
  • Physical Therapy Assessments: Assessments from physical therapists detailing the resident’s mobility and ability to perform lower body dressing.
  • Occupational Therapy Reports: Reports from occupational therapists noting the resident’s performance and any assistance required.
  • Previous Functional Assessments: Any previous assessments that have documented the resident’s ability to dress their lower body.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s performance through multiple records and notes.
• Incomplete Documentation: Make sure all relevant nursing notes, physical therapy assessments, and occupational therapy reports are included to support the performance documented.
• Assumptions: Do not assume the resident’s performance without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Alice, an 85-year-old resident, was assessed during the OBRA/Interim period for her ability to dress her lower body.
  • Steps:
    1. Review Records: The nurse reviews Alice’s medical records, noting the physical therapy and occupational therapy assessments documenting Alice’s ability to dress her lower body.
    2. Identify Performance: It is confirmed through the documentation that Alice requires partial/moderate assistance to dress her lower body.
    3. Document and Code: The nurse documents Alice’s performance in her records and codes GG0130G5 as "03".
  • Outcome: Alice’s ability to dress her lower body with partial/moderate assistance 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 GG0130G5 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.