GG0170C5: Lying to Sitting on Side of Bed (OBRA/Interim Performance), Step-by-Step
Step-by-Step Coding Guide for GG0170C5: Lying to Sitting on Side of Bed (OBRA/Interim Performance)
1. Review of Medical Records
Objective: Assess the resident’s ability to move from a lying position to sitting on the side of the bed during the OBRA/Interim assessment period.
Actions:
- Review nursing notes, therapy records, and observation reports that document the resident’s mobility.
- Observe the resident transitioning from lying to sitting on the side of the bed, focusing on the amount of assistance they require and any assistive devices used.
2. Understanding Definitions
GG0170C5: Lying to Sitting on Side of Bed (OBRA/Interim Performance): This item captures the resident’s ability to move from lying on their back to sitting on the side of the bed without back support. The assessment should include both the physical assistance required and any equipment used.
Example Scenarios:
- Resident A: The resident pushes up from the bed to sit with only light touch assistance from a nursing assistant. This would be coded as 04: Supervision or touching assistance.
3. Coding Instructions
Step-by-Step:
- Step 1: Assess the resident’s ability to move from lying on their back to sitting on the side of the bed during the OBRA or interim assessment.
- Step 2: Determine the level of assistance needed and select the appropriate code:
- 06: Independent: The resident transitions without any help.
- 05: Setup or clean-up assistance: The resident performs the task independently but needs setup assistance.
- 04: Supervision or touching assistance: A helper provides only verbal cues or light touch.
- 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: Two or more helpers are required.
Illustration:
- Scenario: Resident B requires a nursing assistant to provide significant lifting assistance as they move from lying to sitting.
- Result: GG0170C5 would be coded 02: Substantial/maximal assistance.
4. Coding Tips
- Helper Involvement: Focus on the helper’s effort in assisting the resident. For example, if the resident only needs verbal instructions to complete the task, this is coded as supervision.
- Medical or Safety Exceptions: If the resident cannot perform this activity due to medical or safety concerns, code the activity as 88: Not attempted due to medical condition or safety concern.
5. Documentation
Objective: Clearly document the resident’s ability to move from lying to sitting, including the level of assistance and any equipment used.
Actions:
- Record how much effort the helper provides during the transfer.
- Include any mobility aids or adaptive devices used (e.g., bedrails or grab bars) in the medical record.
6. Common Errors to Avoid
- Misclassifying Assistance Levels: Ensure that the code accurately reflects the amount of physical help provided, not just verbal cues.
- Incomplete Documentation: Do not code GG0170C5 without clear evidence of the resident’s ability and the assistance required.
7. Practical Application
- Example 1: A resident needs touching assistance to sit up from a lying position. GG0170C5 is coded 04: Supervision or touching assistance.
- Example 2: A resident requires a nurse to provide significant physical support to sit up. GG0170C5 is coded 02: Substantial/maximal assistance.
Please note that the information provided in this guide for MDS 3.0 Item set GG0170E1 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.
