Step-by-Step Coding Guide for Item Set GG0170O1: 12 Steps (Admission Performance)

1. Review of Medical Records

• Objective: Accurately determine and document the resident's performance in walking up 12 steps during the admission assessment.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physical therapy notes, physician assessments, nursing notes, and previous functional assessments.
  2. Identify Documentation of Mobility: Look for documented instances where the resident’s ability to walk up 12 steps was assessed or observed.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• 12 Steps (Admission Performance): This refers to the resident's ability to walk up 12 steps during the admission assessment.
• Key Points:
  • Performance: This assessment focuses on the resident's actual performance, not what they could potentially do or have done in the past.
  • Admission Assessment: The period during which the resident's initial functional status is evaluated upon entering the care facility.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the resident’s performance in walking up 12 steps during the admission assessment.
  2. Verify Documentation: Ensure that the performance is clearly noted in the records, including specifics about the resident’s ability to complete the task independently or with assistance.
  3. Code Appropriately: Enter the appropriate code for the resident’s performance in item set GG0170O1 based on their level of independence:
     • 01: Dependent
     • 02: Substantial/maximal assistance
     • 03: Partial/moderate assistance
     • 04: Supervision or touching assistance
     • 05: Setup or clean-up assistance
     • 06: Independent
     • 07: Resident refused
     • 09: Not applicable
     • 10: Not attempted due to environmental limitations
     • 88: Not attempted due to medical condition or safety concerns

4. Coding Tips

• Accurate Identification: Ensure the resident’s performance is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s ability to walk up 12 steps.
• Clarify with the Resident: If there is any uncertainty, clarify with the resident or their legal representative to ensure accurate coding.

5. Documentation

• Required:
  • Physical Therapy Notes: Detailed notes from physical therapists documenting the resident’s performance in walking up 12 steps.
  • Physician Assessments: Assessments from physicians detailing the resident’s mobility and any limitations.
  • Nursing Notes: Observations and reports from nursing staff related to the resident’s ability to walk up 12 steps.
  • Previous Functional Assessments: Any previous assessments that have documented the resident’s ability to walk up 12 steps.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s performance through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physical therapy notes, physician assessments, and nursing notes are included to support the performance documented.
• Assumptions: Do not assume the resident’s performance without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Tom, a 72-year-old resident, was assessed upon admission for his ability to walk up 12 steps.
  • Steps:
    1. Review Records: The nurse reviews Tom’s medical records, noting the physical therapy notes and physician assessments documenting Tom’s ability to walk up 12 steps.
    2. Identify Performance: It is confirmed through the documentation that Tom requires partial/moderate assistance to walk up 12 steps.
    3. Document and Code: The nurse documents Tom’s performance in his records and codes GG0170O1 as "03".
  • Outcome: Tom’s ability to walk up 12 steps with partial/moderate assistance 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 GG0170O1 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.