Step-by-Step Coding Guide for Item Set GG0170N3: 4 Steps (Discharge Performance)

1. Review of Medical Records

• Objective: Ensure accurate coding by thoroughly reviewing the resident's medical history.
• Steps:
  1. Gather Medical Records: Collect all relevant medical records, including physical therapy notes, discharge summaries, and previous assessments.
  2. Identify Performance Records: Look for documented assessments of the resident’s ability to perform the 4 steps during their stay.
  3. Confirm Performance Level: Verify the level of assistance or independence recorded by a qualified healthcare professional.

2. Understanding Definitions

• 4 Steps (Discharge Performance): This item assesses the resident’s ability to go up and down 4 steps with or without assistance at discharge.
• Performance Levels:
  • 06. Independent: Resident completes the activity by themselves with no assistance.
  • 05. Setup or Clean-up Assistance: Resident completes the activity, but another person sets up or cleans up.
  • 04. Supervision or Touching Assistance: Resident completes the activity with verbal cues or touching/steadying assistance.
  • 03. Partial/Moderate Assistance: Resident does more than half the effort, but another person helps with less than half the effort.
  • 02. Substantial/Maximal Assistance: Resident does less than half the effort, and another person helps with more than half the effort.
  • 01. Dependent: Resident needs full assistance to complete the activity.
  • 07. Resident Refused
  • 09. Not Applicable
  • 10. Not Attempted Due to Environmental Limitations
  • 88. Not Attempted Due to Medical Condition or Safety Concerns

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set GG0170N3 on the MDS form.
  2. Verify Performance: Confirm the resident’s performance level for the 4 steps activity at discharge from documented assessments.
  3. Select the Appropriate Code: Based on the performance level, choose the correct code from the performance levels defined above.
  4. Record the Code: Enter the selected code for item set GG0170N3 on the MDS form.

4. Coding Tips

• Consistency: Ensure that the recorded performance level is consistent with all other documentation in the medical records.
• Accuracy: Double-check that the recorded performance level accurately reflects the resident’s ability at discharge.
• Updates: Update the medical records regularly to reflect any changes in the resident's performance ability.

5. Documentation

• Required:
  • Therapy Notes: Detailed notes from physical or occupational therapy sessions documenting the resident’s ability to perform the 4 steps.
  • Assessment Records: Formal assessments performed by healthcare professionals.
  • Progress Notes: Daily progress notes indicating any changes or improvements in the resident’s ability.

6. Common Errors to Avoid

• Inconsistent Documentation: Ensure all records consistently reflect the resident’s performance.
• Inaccurate Coding: Verify the correct performance level is selected based on documented assessments.
• Lack of Detail: Ensure therapy and progress notes are detailed and specific about the resident’s ability.

7. Practical Application

• Example: A resident who can go up and down 4 steps independently without any assistance should be coded as 06 (Independent). If the resident requires supervision or touching assistance, they should be coded as 04.
• Illustration:
  • Independent: Resident climbs 4 steps with no help or supervision.
  • Supervision or Touching Assistance: Resident climbs 4 steps with a nurse nearby for safety.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170N3 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.