Step-by-Step Coding Guide for Item Set GG0170C3: Lying to Sitting on Side of Bed (Discharge Performance)

1. Review of Medical Records

• Objective: Ensure comprehensive review and accurate documentation of the resident’s ability to move from lying to sitting on the side of the bed at discharge.
• Steps:
  1. Gather Information: Collect all relevant medical records, including physical therapy notes, nursing notes, and discharge summaries.
  2. Identify Performance: Look for documented evidence of the resident’s ability to move from lying to sitting on the side of the bed at the time of discharge.
  3. Confirm Details: Verify the specific assistance level required and the resident’s performance.

2. Understanding Definitions

• Lying to Sitting on Side of Bed: The ability of a resident to move from a lying position in bed to sitting on the side of the bed with feet flat on the floor.
• Discharge Performance: The resident’s functional status in performing the activity at the time of discharge.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through medical records that the resident’s ability to perform the activity was assessed at discharge.
  2. Verify Documentation: Ensure that the documentation clearly supports the resident’s performance level.
  3. Code Appropriately: Enter the appropriate code for item set GG0170C3 based on the resident’s performance:
     • 06: Independent - Resident completes the activity by themselves with no assistance.
     • 05: Setup or clean-up assistance - Resident completes the activity with setup or clean-up assistance.
     • 04: Supervision or touching assistance - Resident completes the activity with supervision or light touch assistance.
     • 03: Partial/moderate assistance - Resident completes the activity with partial/moderate assistance.
     • 02: Substantial/maximal assistance - Resident completes the activity with substantial/maximal assistance.
     • 01: Dependent - Resident cannot perform the activity or requires full assistance from one or more persons.
     • 07: Resident refused.
     • 09: Not applicable - Activity not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
     • 88: Not attempted due to medical condition or safety concerns.

4. Coding Tips

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

5. Documentation

• Required:
  • Physical Therapy Notes: Detailed notes from physical therapy sessions documenting the resident’s ability to perform the activity.
  • Nursing Notes: Documentation of the resident’s performance and assistance required.
  • Discharge Summaries: Summaries that include the resident’s functional status at discharge.

6. Common Errors to Avoid

• Misclassification: Ensure accurate identification by verifying the performance level through multiple records and observations.
• Incomplete Documentation: Make sure all relevant physical therapy notes, nursing notes, and discharge summaries are included to support the documented performance.
• Assumptions: Do not assume the performance level without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Maria, a resident recovering from hip surgery, is assessed for her ability to move from lying to sitting on the side of the bed at discharge.
  • Steps:
    1. Review Records: The nurse reviews Maria’s medical records, noting the physical therapy and nursing notes documenting her performance.
    2. Identify Performance: It is confirmed through the documentation that Maria can perform the activity with supervision.
    3. Document and Code: The nurse documents Maria’s performance in her records and codes GG0170C3 as "04" (Supervision or touching assistance).
  • Outcome: Maria’s ability to move from lying to sitting on the side of the bed at discharge 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 GG0170C3 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.