GG0130H3: Putting on/Taking off Footwear (Discharge Performance), Step-by-Step
Step-by-Step Coding Guide for GG0130H3: Putting on/Taking off Footwear (Discharge Performance)
1. Review of Medical Records
Objective: Determine the resident’s ability to put on and take off footwear at the time of discharge.
Actions:
- Review the resident’s medical records, including nursing notes, therapy assessments, and mobility sheets.
- Directly observe the resident during the activity or discuss with caregivers about the resident’s ability to put on/take off footwear during the discharge period.
2. Understanding Definitions
GG0130H3: Putting on/Taking off Footwear: This item captures the resident’s ability to put on and take off socks, shoes, and other footwear, including any assistive devices (e.g., orthotic devices or prosthetics) required. It evaluates both the physical act of putting on and removing footwear and any assistance needed from a caregiver.
Example Scenarios:
- Resident A uses an ankle-foot orthosis (AFO) and needs touching assistance from a caregiver to maintain balance while putting on and taking off the orthosis and shoes. This would be coded as 04: Supervision or touching assistance.
3. Coding Instructions
Step-by-Step:
- Step 1: Evaluate the resident’s ability to put on and take off footwear.
- Step 2: Determine the level of assistance required and choose the appropriate code:
- 06: Independent: The resident can complete the activity without any help.
- 05: Setup or clean-up assistance: The resident performs the task independently but requires help retrieving or setting up shoes.
- 04: Supervision or touching assistance: The resident requires 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 of the effort.
- 01: Dependent: The activity requires the assistance of two or more helpers.
Illustration:
- Scenario: Resident B, who has a neurological condition affecting fine motor skills, requires help to thread their socks and shoes over their feet, while they complete the rest of the task.
- Result: Code GG0130H3 as 02: Substantial/maximal assistance.
4. Coding Tips
- Include Prosthetics/Orthotics: If the resident uses prosthetic devices, such as an ankle-foot orthosis, consider this as part of their footwear when determining the level of assistance needed.
- Medical Exclusions: If the resident has bilateral lower limb amputations and did not perform the activity, code as 09: Not applicable.
5. Documentation
Objective: Ensure the resident’s ability to put on and take off footwear is fully documented in their discharge assessment.
Actions:
- Record the type of assistance provided and any equipment used, such as assistive devices or orthotics.
- Document the frequency of assistance and the specifics of the caregiver’s involvement in the activity.
6. Common Errors to Avoid
- Misclassifying Assistance: Ensure that the correct level of assistance is coded. For example, if a helper merely retrieves the footwear, it should be coded as 05: Setup or clean-up assistance.
- Incomplete Documentation: Avoid coding GG0130H3 without sufficient documentation of the resident’s ability and the amount of assistance provided.
7. Practical Application
- Example 1: A resident puts on shoes independently but needs a helper to place the shoes within reach. Code GG0130H3 as 05: Setup or clean-up assistance.
- Example 2: A resident requires a certified nursing assistant to help with threading the socks onto their feet due to fine motor impairment. Code GG0130H3 as 02: Substantial/maximal assistance.
Please note that the information provided in this guide for MDS 3.0 Item set GG0130H3 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.
