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

1. Review of Medical Records

• Objective: To accurately identify and document the type of wheelchair or scooter the resident uses as part of their mobility aid.
• Process:
  • Examine the resident’s care plan, therapy assessments, and equipment issue records to determine the type of wheelchair or scooter provided.
  • Review physical therapy notes that might detail recommendations or adaptations made to the resident’s mobility aid.
  • Consult with the facility's staff who manage or distribute mobility aids to gather specifics about the wheelchair or scooter model and type used by the resident.

2. Understanding Definitions

• Wheelchair/Scooter: Mobility aids used by individuals who require assistance with walking or are unable to walk on their own. Wheelchairs can be manual or powered, while scooters are typically motorized.

3. Coding Instructions

• Code GG0170RR5:
  • 1: Manual - Wheelchair or scooter that requires physical power either by the resident or an assistant to move.
  • 2: Motorized - Wheelchair or scooter that is powered electronically and operated by the resident.
• Example: If a resident uses an electronic wheelchair that they operate themselves, code GG0170RR5 as '2'.

4. Coding Tips

• Verify the type of mobility aid directly from physical inspections or by consulting with physical therapists.
• Differentiate between temporary and permanent use of specific types of wheelchairs or scooters, especially if the resident is undergoing rehabilitation.

5. Documentation

• Required Documentation:
  • Detailed descriptions in the resident’s medical and equipment records about the type of wheelchair or scooter used.
  • Notes from physical therapists or rehabilitation specialists that specify the need for a manual or motorized wheelchair/scooter.
  • Documentation of any training provided to the resident on the use of the mobility aid, especially if it's motorized.
• Ensure that all records clearly justify the type of wheelchair or scooter used to support accurate MDS coding.

6. Common Errors to Avoid

• Misclassifying the type of wheelchair or scooter based on incomplete observations or outdated information.
• Failing to update the resident’s equipment records when changes to the mobility aid type occur.
• Overlooking the resident’s ability or inability to operate a motorized scooter or wheelchair independently.

7. Practical Application

• Scenario: A resident who has recently transitioned from using a manual wheelchair to a motorized scooter due to worsening arthritis, making manual operation difficult. The change is recommended by the physical therapist to enhance the resident's mobility and independence. The therapy notes detail the resident’s training sessions with the motorized scooter and subsequent adaptation to it. Based on these documented changes and the resident's successful use of the scooter, GG0170RR5 is correctly coded as '2' for motorized, reflecting the current and most accurate status of mobility aid usage.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170RR5 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.