GG0170F3: Toilet Transfer (Discharge Performance), Step-by-Step

Step-by-Step Coding Guide for GG0170F3: Toilet Transfer (Discharge Performance)

1. Review of Medical Records

Objective: Assess the resident’s ability to safely transfer on and off a toilet or bedside commode at the time of discharge.

Actions:

• Review the resident’s medical records, including nursing notes, therapy assessments, and mobility flow sheets.
• Observe or obtain reports about the resident's performance in transferring to and from the toilet during the 3-day discharge assessment period.

2. Understanding Definitions

GG0170F3: Toilet Transfer (Discharge Performance): This item captures the resident’s ability to transfer to and from the toilet or commode at the time of discharge. The assessment focuses on physical assistance needed during the transfer, without considering toileting hygiene or clothing management.

Key Definitions:

• Manual assistance: Any physical support provided to the resident while transferring to the toilet.
• Assistive devices: Includes equipment like grab bars, raised toilet seats, or bedside commodes.

Illustration 1:

• Scenario: A resident uses a walker to approach the toilet, and a nurse provides support by steadying the resident as they sit on the toilet. No further help is needed.
• Result: GG0170F3 is coded 04: Supervision or touching assistance.

3. Coding Instructions

Step-by-Step:

• Step 1: Assess the resident’s ability to transfer to the toilet at the time of discharge.
• Step 2: Determine the level of assistance required and select the appropriate code:
  • 06: Independent: The resident transfers on and off the toilet without any assistance.
  • 05: Setup or clean-up assistance: A helper only sets up or cleans up (e.g., adjusting footrests or commodes).
  • 04: Supervision or touching assistance: A helper provides only 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 the effort.
  • 01: Dependent: Two or more helpers are needed, or the helper performs all the effort​​.

Illustration 2:

• Scenario: A resident needs significant weight-bearing assistance from a nurse while transferring to and from the toilet.
• Result: GG0170F3 is coded 02: Substantial/maximal assistance.

4. Coding Tips

• Exclude Clothing Management and Hygiene: These activities are coded separately under GG0130C (Toileting hygiene) and should not be considered when coding GG0170F3.
• Mechanical Lifts: If two helpers or a mechanical lift are required, the resident is coded as 01: Dependent​.

5. Documentation

Objective: Ensure the resident’s ability to transfer to and from the toilet and the level of assistance provided is clearly documented in the discharge assessment.

Actions:

• Document the type of transfer performed (e.g., stand-pivot or squat-pivot) and any equipment used.
• Record the level of assistance required by the resident to complete the transfer.

6. Common Errors to Avoid

• Misclassifying Setup Assistance: Ensure that if the helper only provides setup assistance, such as adjusting a commode, it is coded as 05: Setup or clean-up assistance.
• Inadequate Documentation: Avoid coding GG0170F3 without fully documenting the resident’s performance and the level of help provided​.

7. Practical Application

• Example 1: A resident uses a grab bar and transfers independently to the toilet. GG0170F3 is coded 06: Independent.
• Example 2: A resident requires two helpers to transfer to the toilet using a mechanical lift. GG0170F3 is coded 01: Dependent.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170F3 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.