Step-by-Step Coding Guide for Item Set GG0170G1: Car Transfer (Admission Performance)

This comprehensive guide will assist in accurately coding and documenting a resident's admission performance in car transfers, as specified in item GG0170G1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to transfer in and out of a car upon admission.
• Key Points:
  • Examine the resident’s medical records for details from nursing assessments, physical and occupational therapy evaluations, and care plans regarding the resident’s ability to perform car transfers.
  • Look for mentions of the resident's ability to sit down into and stand up from a car seat, including the need for assistance or use of assistive devices.

2. Understanding Definitions

• Objective: Define "Car Transfer."
• Key Points:
  • Car Transfer: Refers to the ability to move into and out of a car seat. This includes the actions of sitting down into the car seat from a standing position and standing up from the car seat to exit the car, which may require assistance or the use of assistive devices.

3. Coding Instructions

• Objective: Accurately document the resident's admission performance in car transfers.
• Key Points:
  • Utilize the following scale to code car transfer performance:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • Code 88 if the activity did not occur during the assessment period.

4. Coding Tips

• Base the coding on the resident’s most dependent episode of car transfer during the first three days of the SNF stay.
• Assess the entire process of the car transfer, including the ability to navigate to/from the car if that was part of the transfer observed.

5. Documentation

• Objective: Maintain comprehensive documentation to support the coding decision.
• Key Points:
  • Document observations of the resident’s car transfer process, noting any required assistance, use of equipment, or modifications to the vehicle.
  • Include notes on any conditions or impairments that affect the resident’s ability to perform car transfers and any interventions aimed at improving this function.

6. Common Errors to Avoid

• Misinterpreting the use of assistive devices or the car's modifications as full independence.
• Failing to recognize and document the need for occasional assistance or supervision.

7. Practical Application

• Scenario: Upon admission, Mr. John Doe required partial assistance to transfer in and out of a car due to knee arthritis, which limited his mobility. Physical therapy evaluations noted that while Mr. Doe could perform some parts of the transfer independently, he needed assistance to lower himself into the car seat and to stand up. Consequently, he is coded as 3 (partial/moderate assistance) in GG0170G1.

The Step-by-Step Coding Guide for item GG0170G1 in MDS 3.0 Section GG is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.