Step-by-Step Coding Guide for Item Set: GG0170SS1. Type Wheelchair/Scooter Used (Admission Performance)

1. Review of Medical Records

   • Begin by examining the resident's medical and therapy records for mentions of mobility aids. Look for physician's orders, physical and occupational therapy assessments, and nursing notes documenting the type of wheelchair or scooter prescribed or recommended for the resident upon admission.

2. Understanding Definitions

   • Type Wheelchair/Scooter Used: Identifies the specific kind of mobility aid the resident is utilizing at admission, categorizing it into manual wheelchairs, powered wheelchairs, scooters, or specialized wheelchairs.
   • Admission Performance: The status of the resident’s use of a wheelchair or scooter at the time of admission, providing a baseline for care planning.

3. Coding Instructions

   • Determine the type of wheelchair or scooter the resident uses based on medical records and direct observation. Potential categories include:
     • Manual Wheelchair
     • Powered Wheelchair
     • Scooter
     • Specialized Wheelchair
     • Not Using a Wheelchair/Scooter
   • Select the category that best describes the resident's equipment at admission.

4. Coding Tips

   • Verify the type of wheelchair or scooter through direct observation and consultation with the resident or their caregivers. The resident's comfort and ability to operate the device efficiently should align with the chosen category.
   • Consider the mobility aid's role in the resident's care plan, particularly how it aids in their independence and participation in daily activities.

5. Documentation

   • Document the type of wheelchair or scooter in the MDS and in the resident's care plan. Include specific features of the device that support the resident's mobility needs, such as tilt functions, custom cushions, or specialized controls for powered devices.

6. Common Errors to Avoid

   • Misclassifying the type of mobility aid without verifying through observation or consultation.
   • Overlooking updates to the resident's equipment that may occur shortly after admission.

7. Practical Application

   • Example: Mr. Smith is admitted to the facility with a diagnosis that impacts his lower limb mobility. Upon admission, he uses a powered wheelchair equipped with a joystick control, which allows him independence in movement despite his limited upper body strength. The appropriate documentation would list "Powered Wheelchair" as his mobility aid, noting its specific features that cater to his mobility needs.

The Step-by-Step Coding Guide for item GG0170SS1 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.