Step-by-Step Coding Guide for Item Set GG0170L5: Walk 10 Feet (OBRA/Interim Performance)

This guide facilitates the accurate coding and documentation of a resident's performance in walking 10 feet during an OBRA or interim assessment period, as indicated in item GG0170L5 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to walk 10 feet during the OBRA or interim assessment period.
• Key Points:
  • Thoroughly examine the resident’s medical records, including nursing assessments, physical and occupational therapy evaluations, and care plans for mentions of the resident’s ability to walk 10 feet.
  • Note any documentation regarding the use of assistive devices, the need for human assistance, or modifications to the walking environment.

2. Understanding Definitions

• Objective: Define "Walk 10 Feet."
• Key Points:
  • Walk 10 Feet: Involves the resident's ability to walk 10 feet in a straight line, which may include initiating the walk, maintaining balance, navigating turns if necessary, and safely stopping, with or without the use of assistive devices or human assistance.

3. Coding Instructions

• Objective: Document the resident's OBRA/interim performance in walking 10 feet accurately.
• Key Points:
  • Utilize 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 was not attempted during the assessment period.

4. Coding Tips

• Base coding on the resident’s most dependent episode of walking 10 feet observed during the OBRA or interim assessment period.
• Consider any assistive devices or verbal cues provided to ensure safety and their impact on coding for independence.

5. Documentation

• Objective: Ensure comprehensive documentation to support the coding decision.
• Key Points:
  • Document detailed observations of the resident's ability to walk 10 feet, including any assistance required, use of equipment, or environmental adaptations.
  • Record any relevant conditions affecting the resident's walking ability and interventions aimed at improving this function.

6. Common Errors to Avoid

• Not accounting for the occasional need for assistance or the use of assistive devices, potentially overestimating the resident's independence.
• Failing to update documentation based on the most current assessment, leading to inaccurate coding.

7. Practical Application

• Scenario: During the OBRA assessment period, Mr. Kevin Smith demonstrated the ability to walk 10 feet with the use of a walker for stability and occasional supervision to navigate around obstacles. His progress notes from physical therapy indicate improvement in balance and strength, reducing his need for close supervision. Therefore, he is coded as 4 (supervision or touching assistance) in GG0170L5, reflecting his need for supervision for safe navigation.

The Step-by-Step Coding Guide for item GG0170L5 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.