Step-by-Step Coding Guide for Item Set GG0170R5: Wheel 50 Feet with Two Turns (OBRA/Interim Performance)

1. Review of Medical Records

Start by reviewing the resident’s medical records to identify their current mobility status and any recent changes or interventions. Look for previous assessments of mobility, particularly those involving a wheelchair, and notes from physical therapy sessions that may detail the resident's ability to maneuver a wheelchair.

2. Understanding Definitions

Wheel 50 Feet with Two Turns: This item assesses the resident's ability to wheel at least 50 feet and make two turns while seated in a wheelchair. This task evaluates both distance endurance and maneuverability.

3. Coding Instructions

For GG0170R5:

• Code 06, Independent, if the resident wheels 50 feet and makes two turns independently.
• Code 05, Set-up or clean-up assistance, if the resident requires help only before or after the task.
• Code 04, Supervision or touching assistance, if the resident requires oversight or light physical support.
• Code 03, Partial/moderate assistance, if the resident does some of the effort but needs help to complete the task.
• Code 02, Substantial/maximal assistance, if the resident contributes less than half the effort.
• Code 01, Dependent, if the resident does less than 10% of the effort or none at all.
• Code 07, Resident refused.
• Code 09, Not applicable.
• Code 10, Not attempted due to environmental limitations.
• Code 88, Not attempted due to medical condition or safety concerns.

4. Coding Tips

• Observe the resident performing the task in a real environment, if possible, to ensure accurate coding.
• Consider the consistency of performance across several attempts or days to account for variations in the resident’s condition.
• Be mindful of the resident’s safety and provide assistance as needed to prevent falls or injuries during the assessment.

5. Documentation

Clearly document the assessment process and results in the resident’s medical record, including the date of the assessment, the specific assistance required, and any observations related to the resident's ability to perform the task. Note any environmental or medical reasons why the task was not attempted.

6. Common Errors to Avoid

• Coding based on assumptions about the resident's ability without direct observation.
• Failing to account for temporary factors such as illness or discomfort that may affect performance.
• Not recognizing or documenting the need for occasional assistance for set-up or clean-up.

7. Practical Application

Example: Mr. Brown, a resident, is observed while maneuvering his wheelchair along a designated path in the facility that includes two turns. He completes the task independently but requires a brief rest due to fatigue. Since he did not need physical assistance or supervision, he is coded as 06, Independent.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170R5 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.