Step-by-Step Coding Guide for Item Set GG0170J1: Walk 50 Feet with Two Turns (Admission Performance)

This detailed guide is designed to assist in accurately coding and documenting a resident's ability to walk 50 feet with two turns upon admission, as specified in item GG0170J1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's capability to walk 50 feet and make two turns upon admission.
• Key Points:
  • Review the resident’s medical records thoroughly, focusing on nursing assessments, physical and occupational therapy evaluations, and care plans for information regarding the resident’s ability to walk 50 feet with two turns.
  • Look for assessments that evaluate the resident's gait, balance, endurance, and use of assistive devices or need for human assistance.

2. Understanding Definitions

• Objective: Clarify the activity "Walk 50 Feet with Two Turns."
• Key Points:
  • Walk 50 Feet with Two Turns: Refers to the resident's ability to walk a distance of 50 feet and successfully navigate two turns. This task assesses the resident's mobility, including balance, coordination, and the ability to change direction while walking.

3. Coding Instructions

• Objective: Accurately document the resident's admission performance in walking 50 feet with two turns.
• Key Points:
  • Use the following scale to code 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 coding on the resident’s most dependent episode of walking 50 feet with two turns observed during the first three days of the SNF stay.
• Consider the use of assistive devices and whether they allow the resident to complete the task safely and effectively.

5. Documentation

• Objective: Ensure thorough documentation to support the coding decision.
• Key Points:
  • Document detailed observations of the resident’s ability to walk 50 feet with two turns, including any required assistance, use of equipment, or modifications.
  • Note specific conditions or impairments affecting the resident's ability to perform this task and any interventions aimed at improving mobility.

6. Common Errors to Avoid

• Overlooking the need for occasional assistance or the use of assistive devices, potentially leading to an overestimation of the resident's independence.
• Failing to document the entire process, including how the resident manages turns and any difficulty or hesitation encountered.

7. Practical Application

• Scenario: Upon admission, Ms. Elizabeth Nguyen demonstrates the ability to walk 50 feet but requires supervision for safety during turns due to mild balance issues. Physical therapy notes indicate she uses a cane for support and navigates turns cautiously. Accordingly, she is coded as 4 (supervision or touching assistance) in GG0170J1.

The Step-by-Step Coding Guide for item GG0170J1 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.