Step-by-Step Coding Guide for Item Set: GG0170SS5. Type Wheelchair/Scooter Used (OBRA/Interim Performance)

1. Review of Medical Records

   • Start with a thorough examination of the resident's medical records, focusing on documentation related to mobility aids used, including notes from physical therapy evaluations, physician's orders regarding mobility devices, and nursing assessments. Look for any changes or adaptations made since the last evaluation.

2. Understanding Definitions

   • Type Wheelchair/Scooter Used: Identifies whether the resident is using a manual wheelchair, powered wheelchair, scooter, or other specialized mobility devices at the OBRA/Interim assessment period.
   • OBRA/Interim Performance: Reflects the assessment performed periodically as required by the Omnibus Budget Reconciliation Act, capturing the resident's current use of a mobility aid.

3. Coding Instructions

   • Determine the type of wheelchair or scooter the resident is currently using based on medical records, direct observation, and consultations with the care team. The main categories for coding might include:
     • Manual Wheelchair
     • Powered Wheelchair
     • Scooter
     • Not Using a Wheelchair/Scooter
     • Other Specialized Mobility Device
   • Select the category that accurately describes the resident's current mobility aid.

4. Coding Tips

   • Ensure accuracy by verifying the type of mobility aid directly with the resident and their care team. Consider the resident's mobility needs and any specific recommendations made by healthcare providers.
   • Be aware of any temporary changes in mobility aid usage due to health status or specific activities.

5. Documentation

   • Document the identified type of wheelchair or scooter in the resident's MDS and care plan. Include a comprehensive description of the device, noting any custom features or modifications that support the resident's mobility.

6. Common Errors to Avoid

   • Misclassifying the type of mobility device by not conducting a thorough review or observation.
   • Overlooking changes in mobility aid usage since the last assessment period.

7. Practical Application

   • Example: Mr. Smith was initially using a manual wheelchair upon admission but has transitioned to a powered scooter for increased independence in mobility. This change was documented in his physical therapy notes, highlighting improved maneuverability and reduced exertion. The correct coding is "Scooter," with detailed notes in his care plan about the reasons for this transition and its impact on his mobility and quality of life.

The Step-by-Step Coding Guide for item GG0170SS5 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.