Step-by-Step Coding Guide for Item Set GG0130H1: Putting on/Taking off Footwear (Admission Performance)

1. Review of Medical Records

• Objective: Accurately determine and document the resident's ability to put on and take off footwear at the time of admission.
• 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 Footwear Management: Look for documented instances where the resident’s ability to put on and take off footwear 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

• Putting on/Taking off Footwear: This refers to the resident’s ability to put on and remove socks, shoes, or other footwear.
• Admission Performance: The resident's ability to perform this task during the admission assessment period.
• Key Points:
  • Level of Independence: The degree of assistance the resident requires to put on and take off footwear.
  • 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 put on and take off footwear during the admission 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 admission performance in item set GG0130H1 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 put on and take off footwear.
• 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 putting on and taking off footwear.
  • Physical Therapy Assessments: Assessments from physical therapists detailing the resident’s mobility and ability to perform the footwear management task.
  • 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 put on and take off footwear.

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: Sarah, an 82-year-old resident, was assessed during the admission period for her ability to put on and take off footwear.
  • Steps:
    1. Review Records: The nurse reviews Sarah’s medical records, noting the physical therapy and occupational therapy assessments documenting Sarah’s ability to manage her footwear.
    2. Identify Performance: It is confirmed through the documentation that Sarah requires supervision or touching assistance to put on and take off footwear.
    3. Document and Code: The nurse documents Sarah’s performance in her records and codes GG0130H1 as "04".
  • Outcome: Sarah’s ability to put on and take off footwear with supervision or touching 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 GG0130H1 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.