Step-by-Step Coding Guide for Item Set GG0170G3: Car Transfer (Discharge Performance)

1. Review of Medical Records

• Objective: Accurately document the resident’s car transfer ability at discharge.
• Steps:
  1. Collect Information: Gather medical records, including therapy notes, nursing observations, and interdisciplinary team (IDT) reports.
  2. Identify Relevant Documentation: Look for documented evidence of the resident’s ability to transfer into and out of a car.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Car Transfer (Discharge Performance): Refers to the resident’s ability to transfer in and out of a car at the time of discharge.
• Key Points:
  • Complete Activity: This involves both getting into and out of a car.
  • Assistance Levels: Understanding the level of assistance required by the resident to perform this task (independent, with help, or unable).

3. Coding Instructions

• Steps:
  1. Identify Performance Level: Based on documentation, determine the resident’s performance level for car transfers at discharge.
  2. Verify Documentation: Ensure that the documentation clearly supports the performance level.
  3. Code Appropriately: Enter the appropriate code for item set GG0170G3 based on the performance level:
     • 06: Independent
     • 05: Setup or clean-up assistance
     • 04: Supervision or touching assistance
     • 03: Partial/moderate assistance
     • 02: Substantial/maximal assistance
     • 01: Dependent

4. Coding Tips

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

5. Documentation

• Required:
  • Therapy Notes: Records from physical and occupational therapy sessions that detail the resident’s car transfer ability.
  • Nursing Observations: Notes that detail observations of the resident’s car transfer performance.
  • IDT Reports: Documentation from interdisciplinary team meetings discussing the resident’s car transfer ability and related care planning.
  • Discharge Summary: A summary of the resident’s abilities and assistance needs 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 therapy notes, nursing observations, and IDT reports are included to support the documented performance level.
• Assumptions: Do not assume the performance level without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: John, a resident, has been observed during therapy sessions and nursing care over the past week.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, noting therapy notes and nursing observations indicating John’s car transfer ability.
    2. Identify Performance Level: It is confirmed through the documentation that John requires supervision for car transfers.
    3. Document and Code: The nurse documents the performance level in John’s records and codes GG0170G3 as "04" (Supervision or touching assistance).
  • Outcome: John’s car transfer ability 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 GG0170G3 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.