Step-by-Step Coding Guide for Item Set GG0170A5: Roll Left and Right (OBRA/Interim Performance)

Step-by-Step Coding Guide for Item Set GG0170A5: Roll Left and Right (OBRA/Interim Performance)

1. Review of Medical Records

• Objective: To determine the resident's ability to roll left and right in bed.
• Process:
  • Therapy Notes: Review physical and occupational therapy notes that evaluate the resident’s bed mobility, specifically rolling left and right.
  • Nursing Notes: Examine daily nursing notes for documented instances of assistance provided to the resident for rolling in bed.
  • Care Plans: Look at the care plans for specific interventions related to bed mobility and rolling.
  • Direct Observation: Conduct or review direct observations of the resident's ability to roll left and right.

2. Understanding Definitions

• Rolling Left and Right: This task involves the resident’s ability to roll from their back to their side and vice versa without significant assistance. This is a key component of bed mobility, ensuring the resident can reposition themselves to prevent pressure ulcers and improve comfort.

3. Coding Instructions

• Code GG0170A5:
  • 06: Independent - Resident completes the activity by themselves with no assistance.
  • 05: Setup or clean-up assistance - Resident completes the activity but requires setup or clean-up help from another person.
  • 04: Supervision or touching assistance - Resident completes the activity with verbal cues or light touch assistance.
  • 03: Partial/moderate assistance - Resident does more than half of the effort, but helper does less than half.
  • 02: Substantial/maximal assistance - Helper does more than half of the effort.
  • 01: Dependent - Helper does all of the effort.
• Example: If a resident can roll from side to side but requires assistance to initiate the roll, this might be coded as '04'.

4. Coding Tips

• Consistency: Ensure the assessment captures the resident’s usual performance, not an isolated incident.
• Detailed Observation: Directly observe the resident performing the task multiple times if possible to get an accurate assessment.

5. Documentation

• Required Documentation:
  • Assessment Records: Detailed notes from occupational therapy and nursing staff documenting the resident’s ability and the level of assistance required.
  • Care Plan Entries: Specific goals and interventions related to bed mobility.
  • Observation Records: Document observations from staff and direct assessments.
• Example: "On 05/10/2024, during morning care, the resident required moderate assistance to roll from their back to their left side and vice versa."

6. Common Errors to Avoid

• Inconsistent Reporting: Avoid discrepancies between different staff reports and observations.
• Ignoring Adaptive Devices: Ensure the use of bed rails or other devices is documented and considered in the assessment.
• Overlooking Variability: Consider variations in the resident’s ability based on time of day, fatigue, or health status.

7. Practical Application

• Scenario: A resident with limited mobility due to stroke can initiate rolling but requires moderate assistance to complete the movement. During an assessment, the therapist documents the need for moderate assistance, and the care plan is updated to include interventions for improving bed mobility. Based on these consistent observations, GG0170A5 is coded as '03'.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170A5 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.