Step-by-Step Coding Guide for Item Set: GG0170RR3. Type Wheelchair/Scooter Used (Discharge Performance)

1. Review of Medical Records

   • Begin with a comprehensive examination of the resident's medical and therapy records, focusing on changes in mobility status, physical therapy progress notes, and any physician's orders related to wheelchair or scooter use since admission.

2. Understanding Definitions

   • Type Wheelchair/Scooter Used: This refers to the specific kind of mobility device, including manual, powered wheelchairs, or scooters, that the resident uses at the time of discharge.
   • Discharge Performance: Indicates the resident's mobility device preference and need at the time of discharge, reflecting any progress or changes in mobility status during their stay.

3. Coding Instructions

   • Based on the review of medical records and direct observation or consultation with the resident and care staff, determine the type of wheelchair or scooter the resident uses at discharge. Consider creating distinct categories for coding, such as:
     • Manual Wheelchair
     • Powered Wheelchair
     • Scooter
     • Specialized Wheelchair (e.g., tilt-in-space, standing wheelchair)
     • Not Using a Wheelchair/Scooter
   • Select the category that accurately reflects the resident's equipment at discharge.

4. Coding Tips

   • Verify the type of mobility device directly with the resident or their caregiver, when possible, to ensure accuracy.
   • Take into account any modifications or adaptations made to the wheelchair or scooter to better suit the resident's needs.

5. Documentation

   • Clearly document the type of wheelchair or scooter in the resident's discharge summary and the MDS. Include detailed notes on the device's features or modifications and the rationale for its use based on the resident's current mobility status.

6. Common Errors to Avoid

   • Not updating the resident's mobility device information at discharge if there have been changes during their stay.
   • Failing to document the specific type of wheelchair or scooter and any special features or adaptations that support the resident's mobility needs.

7. Practical Application

   • Example: Mr. Allen arrived at the facility using a manual wheelchair due to lower limb weakness. Over his stay, he received consistent physical therapy and showed significant improvement in upper body strength. At discharge, Mr. Allen transitions to using a power-assist wheelchair, which allows him to navigate longer distances with less effort. The device would be documented as "Power-Assist Wheelchair."

The Step-by-Step Coding Guide for item GG0170RR3 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.