Step-by-Step Coding Guide for Item Set: GG0170S1. Wheel 150 Feet (Admission Performance)

1. Review of Medical Records

   • Begin with a comprehensive examination of the resident's medical and therapy records, focusing on information relevant to mobility and wheelchair use. Look for physical therapy evaluations, physician orders, and nursing assessments that document the resident's ability or challenges with wheeling themselves over a distance of 150 feet.

2. Understanding Definitions

   • Wheel 150 Feet: This item assesses the resident's capability to self-propel in a wheelchair for a distance of 150 feet, which is roughly equivalent to the length of a standard bowling alley. This task evaluates endurance, upper body strength, and maneuverability.
   • Admission Performance: Refers to the resident's ability to perform the wheeling task at the time of admission to the facility, providing a baseline for care planning and future evaluations.

3. Coding Instructions

   • Observe the resident's performance or consult with caregiving staff to accurately determine the resident's ability to wheel 150 feet. Utilize the following coding scale:
     • 06: Independent - Resident completes the task without any type of assistance.
     • 05: Setup or clean-up assistance - Resident completes the task but requires help before or after.
     • 04: Supervision or touching assistance - Resident needs verbal cues or light touch assistance.
     • 03: Partial/moderate assistance - Staff provides less than half the effort.
     • 02: Substantial/maximal assistance - Staff provides more than half the effort.
     • 01: Dependent - Staff provides all the effort.
     • 88: Not attempted due to medical condition or safety concerns.

4. Coding Tips

   • Ensure accurate observation or consultation with staff to assess the resident's performance. Pay particular attention to the resident's endurance throughout the distance and their ability to navigate the wheelchair without physical support.

5. Documentation

   • Document the chosen code in the resident's MDS and care plan. Provide detailed notes in the medical record regarding the resident's ability, any observed challenges, and the type of assistance required during the task.

6. Common Errors to Avoid

   • Overlooking the need for supervision or verbal cues that might change the coding level.
   • Failing to document the reason for not attempting the task if coded as 88.

7. Practical Application

   • Example: Ms. Davis, upon admission, is able to self-propel in her manual wheelchair for 150 feet but requires verbal encouragement to maintain her pace due to mild anxiety in new environments. The appropriate code would be 04 (Supervision or touching assistance), with a note detailing the support needed.

The Step-by-Step Coding Guide for item GG0170S1 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.