Step-by-Step Coding Guide for Item Set GG0130I1: Personal Hygiene (Admission Performance)

1. Review of Medical Records

The first step in coding for item GG0130I1 involves a thorough review of the resident’s medical records. This includes:

• Physician’s Notes: Examine progress notes, history, and physical examination records.
• Nursing Notes: Check nursing notes for observations and documentation of assistance required for personal hygiene.
• Therapy Records: Review records from occupational therapy sessions for any documented assistance or equipment used during personal hygiene activities.
• Discharge Summaries and Transfer Documents: Review summaries from hospital discharges or transfers to the current care setting.

2. Understanding Definitions

Understanding the key definitions related to this item is crucial:

• Personal Hygiene: This involves the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, and washing and drying face and hands. It excludes bathing, showers, and oral hygiene​​.

3. Coding Instructions

Follow these steps for accurate coding:

1. Observe Performance: Assess the resident’s performance of personal hygiene activities. This should be done as soon after admission as possible to capture the resident’s admission performance.
2. Determine Assistance Level: Identify the level of assistance required by the resident to complete the activity, using the six-point scale provided in the MDS manual:
   • Code 06 (Independent): The resident completes the activity by themselves with no assistance.
   • Code 05 (Setup or Clean-up Assistance): The resident requires setup or clean-up assistance only.
   • Code 04 (Supervision or Touching Assistance): The resident requires supervision or touching assistance.
   • Code 03 (Partial/Moderate Assistance): The helper does less than half the effort.
   • Code 02 (Substantial/Maximal Assistance): The helper does more than half the effort.
   • Code 01 (Dependent): The helper does all of the effort, or two or more helpers are required​​.

4. Coding Tips

• Accurate Observation: Ensure the observation is accurate and reflects the resident’s usual performance at admission. This may require multiple observations.
• Consistent Documentation: Ensure consistency between the coding and the documentation in the medical record.
• Clear Definitions: Be clear about what constitutes each level of assistance to ensure accurate coding.

5. Documentation

Accurate documentation is critical for compliance and effective care planning:

• Daily Records: Maintain thorough daily records of the resident’s personal hygiene activities and any changes.
• Care Plans: Update care plans to reflect the resident’s ability to perform personal hygiene and any assistance required.
• Interdisciplinary Communication: Ensure all team members are informed of and document any findings related to personal hygiene and its impact on the resident’s functioning.

6. Common Errors to Avoid

• Inconsistent Documentation: Avoid discrepancies between the MDS data and other medical records.
• Outdated Assessments: Ensure the assessment reflects the resident’s current ability at the time of admission, not earlier in their stay.
• Incorrect Coding: Double-check coding entries for accuracy, especially the level of assistance required.

7. Practical Application

Use case studies and scenarios to apply your knowledge:

• Example 1: A resident who requires supervision to comb their hair and shave due to mild hand tremors. The nursing assistant provides verbal cues and touching assistance to ensure safety.
  • Coding: GG0130I1 would be coded 04 (Supervision or Touching Assistance).
  • Rationale: The helper provides touching assistance and supervision during the personal hygiene activity.
• Example 2: A resident with severe arthritis who needs substantial assistance to wash and dry their face. The nursing assistant performs more than half the effort.
  • Coding: GG0130I1 would be coded 02 (Substantial/Maximal Assistance).
  • Rationale: The helper provides more than half the effort needed for the resident to complete the personal hygiene tasks​​.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130I1 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.