Step-by-Step Coding Guide for Item Set: GG0170RR5. Type Wheelchair/Scooter Used (OBRA/Interim Performance)

1. Review of Medical Records

   • Initiate the coding process by thoroughly reviewing the resident's medical and therapy records for information related to their mobility and the use of wheelchairs or scooters. Focus on physical therapy evaluations, physician orders, and nursing notes that specify or recommend the type of mobility aid for the resident during their stay.

2. Understanding Definitions

   • Type Wheelchair/Scooter Used: This item identifies the specific category of wheelchair or scooter the resident utilizes, focusing on their OBRA/Interim Performance. Categories might include manual, powered, or specialized wheelchairs, and scooters.
   • OBRA/Interim Performance: Reflects the resident's use of a wheelchair or scooter during their stay, capturing any changes or adaptations made to their mobility aid since admission.

3. Coding Instructions

   • Based on medical records review and direct observation, identify the category that best describes the resident's wheelchair or scooter. Potential categories for coding might include:
     • Manual Wheelchair
     • Powered Wheelchair
     • Scooter
     • Specialized Wheelchair (e.g., bariatric, tilt-in-space)
     • Not Using a Wheelchair/Scooter
   • Document the selected category in the MDS.

4. Coding Tips

   • Verify the type of wheelchair or scooter through direct observation and consultation with the resident, caregiver, or physical therapy notes to ensure accuracy.
   • Understand the functional need behind the choice of mobility aid, as it informs the care plan and potential interventions.

5. Documentation

   • In the resident's medical record and the MDS, document the specific type of wheelchair or scooter used. Include notes on why this particular mobility aid is appropriate for the resident's needs, citing physical therapy assessments or physician recommendations.

6. Common Errors to Avoid

   • Assuming the type of mobility aid without verifying it directly or through comprehensive review of medical documentation.
   • Neglecting to update the MDS and care plan when a resident transitions to a different type of mobility aid during their stay.

7. Practical Application

   • Example: During his interim assessment, Mr. Allen has transitioned from using a manual wheelchair to a powered scooter. This change was made to accommodate his increased upper body weakness and to promote independence. The appropriate documentation would list "Scooter" as the type of mobility aid used, with a detailed note in his care plan about the reason for this transition and how it aligns with his current mobility goals.

The Step-by-Step Coding Guide for item GG0170RR5 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.