GG0130B1: Oral Hygiene (Admission Performance), Step-by-Step

Step-by-Step Coding Guide for GG0130B1: Oral Hygiene (Admission Performance)

1. Review of Medical Records

Objective: Assess the resident’s ability to perform oral hygiene during the first three days of admission.

Actions:

• Review the resident’s nursing notes, oral care plans, and therapy records.
• Directly observe or ask caregivers about the resident’s performance in cleaning their teeth, dentures, or gums (for edentulous residents).

2. Understanding Definitions

GG0130B1: Oral Hygiene: This item captures the resident’s ability to clean their teeth or dentures and manage oral hygiene, including rinsing and spitting. For edentulous residents, the ability to clean gums is assessed.

Example Scenarios:

• Resident A: Brushes their teeth independently but needs help setting up the toothbrush and applying toothpaste. This would be coded as 05: Setup or clean-up assistance​.

3. Coding Instructions

Step-by-Step:

• Step 1: Assess the resident’s ability to clean their teeth, dentures, or gums.
• Step 2: Determine the level of assistance required:
  • 06: Independent: The resident completes oral hygiene without help.
  • 05: Setup or clean-up assistance: The resident performs the task but requires help with setup (e.g., placing toothpaste on the brush).
  • 04: Supervision or touching assistance: The resident needs verbal cues or light physical assistance.
  • 03: Partial/moderate assistance: The helper provides less than half of the effort.
  • 02: Substantial/maximal assistance: The helper provides more than half of the effort.
  • 01: Dependent: The resident requires full assistance from two or more helpers​​.

Illustration:

• Scenario: Resident B starts brushing their teeth but becomes fatigued, requiring a caregiver to finish the task. This should be coded as 02: Substantial/maximal assistance​.

4. Coding Tips

• Include Denture Care: If the resident has dentures, their ability to clean them should be included as part of oral hygiene.
• Edentulous Residents: For residents without teeth, cleaning gums should be assessed similarly to oral hygiene with teeth​.

5. Documentation

Objective: Document the resident’s oral hygiene performance, including the level of assistance and any adaptive equipment used.

Actions:

• Record the type of assistance provided and whether the resident used any adaptive devices, such as a toothbrush holder​.

6. Common Errors to Avoid

• Misclassifying Assistance: Ensure that setup assistance (e.g., placing toothpaste on the brush) is coded as 05: Setup or clean-up assistance, not as 04.
• Incomplete Documentation: Avoid coding GG0130B1 without proper documentation of the resident’s ability and any assistance provided​.

7. Practical Application

• Example 1: A resident brushes their teeth independently but requires help with preparing the toothbrush. Code GG0130B1 as 05: Setup or clean-up assistance.
• Example 2: A resident needs help to clean their dentures due to fatigue. This should be coded as 03: Partial/moderate assistance​.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130B1 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.