Step-by-Step Coding Guide for Item Set: GG0170RR1. Type Wheelchair/Scooter Used (Admission Performance)

1. Review of Medical Records

   • Initiate the process by thoroughly reviewing the resident's medical and therapy records for information related to mobility needs and the use of wheelchairs or scooters. Look for physician's orders, physical therapy assessments, and any notes that specify the type of wheelchair or scooter recommended or prescribed for the resident upon admission.

2. Understanding Definitions

   • Type Wheelchair/Scooter Used: Identifies the specific kind of wheelchair or scooter the resident is using at the time of admission, including distinctions between manual, powered, or specialized models designed for specific mobility limitations.
   • Admission Performance: Refers to the resident's status and assistive device usage at the time of admission to the facility, establishing a baseline for care planning and future assessments.

3. Coding Instructions

   • Based on the information gathered from the medical records and direct observation, categorize the type of wheelchair or scooter the resident uses. While there might not be a predefined coding scale in the RAI Manual for this specific item, consider creating categories such as:
     • Manual Wheelchair
     • Powered Wheelchair
     • Scooter
     • Specialized Wheelchair (e.g., tilt-in-space, reclining)
     • Not Using a Wheelchair/Scooter
   • Select the category that best describes the resident's equipment at admission.

4. Coding Tips

   • Confirm the type of wheelchair or scooter by physical inspection and consultation with the resident or caregiver to ensure accuracy.
   • Consider the resident's functional mobility assessment results to understand why a particular type of wheelchair or scooter is being used.

5. Documentation

   • Record the identified type of wheelchair or scooter in the resident's MDS and care plan, including a description of the device and any customization or adaptations made to meet the resident's needs.

6. Common Errors to Avoid

   • Assuming the type of wheelchair/scooter without verifying against medical records or physical inspection.
   • Overlooking the importance of specifying the type of wheelchair/scooter for accurate care planning and provision.

7. Practical Application

   • Example: Upon admission, Mrs. Thompson is using a powered wheelchair due to severe arthritis and limited upper body strength, as noted in her physical therapy assessment. The powered wheelchair enables her to maintain independence in mobility despite her condition. In this case, the device would be coded as "Powered Wheelchair."

The Step-by-Step Coding Guide for item GG0170RR1 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.