GG0170E3: Chair/Bed-to-Chair Transfer (Discharge Performance), Step-by-Step
Step-by-Step Coding Guide for GG0170E3: Chair/Bed-to-Chair Transfer (Discharge Performance)
1. Review of Medical Records
Objective: Assess the resident’s ability to transfer between a chair and bed at the time of discharge.
Actions:
- Review the resident’s nursing notes, therapy assessments, and mobility records.
- Observe the resident during a chair-to-bed or bed-to-chair transfer, focusing on the assistance needed and any equipment used during the discharge assessment period.
2. Understanding Definitions
GG0170E3: Chair/Bed-to-Chair Transfer: This item captures the resident’s ability to transfer from a bed to a chair or wheelchair, or from a chair to a bed, during the discharge assessment period. This includes manual assistance and assistive devices used.
Example Scenarios:
- Resident A: Needs help from a therapist who provides touching assistance as they pivot from the bed to the chair. This requires supervision or touching assistance, coded as 04.
- Resident B: Uses a full-body mechanical lift and requires two helpers for the transfer. This is coded as 01: Dependent.
3. Coding Instructions
Step-by-Step:
- Step 1: Assess the resident’s ability to transfer to and from a chair/bed at discharge.
- Step 2: Determine the level of assistance required and code accordingly:
- 06: Independent: The resident transfers without assistance.
- 05: Setup or clean-up assistance: The resident transfers independently, but the helper sets up equipment (e.g., wheelchair positioning).
- 04: Supervision or touching assistance: The helper provides 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 needed.
Illustration:
- Scenario: A resident requires full assistance from two helpers and a mechanical lift to transfer between bed and wheelchair at discharge.
- Result: Code GG0170E3 as 01: Dependent.
4. Coding Tips
- Mechanical Lifts: If two helpers are required to operate a mechanical lift, always code 01: Dependent, even if the resident assists in some way.
- Exclude Bed Mobility: The transfer must involve the resident moving between sitting positions. Separate activities, like rolling or lying-to-sitting, are coded elsewhere.
5. Documentation
Objective: Document the resident’s performance during transfers, noting the amount of assistance and equipment used.
Actions:
- Record the type of transfer (e.g., stand-pivot or mechanical lift).
- Include information on any assistive devices and how much effort the resident contributes to the transfer.
6. Common Errors to Avoid
- Misclassifying Setup Assistance: If the helper only sets up equipment (e.g., adjusts a wheelchair), but the resident completes the transfer independently, this should be coded as 05: Setup or clean-up assistance.
- Incomplete Documentation: Ensure that all details of the transfer, including the amount of assistance provided, are clearly documented in the medical record.
7. Practical Application
- Example 1: A resident transfers independently from a wheelchair to bed without assistance. Code GG0170E3 as 06: Independent.
- Example 2: A resident requires significant physical support during transfers, with the helper providing more than half of the effort. Code GG0170E3 as 02: Substantial/maximal assistance.
Please note that the information provided in this guide for MDS 3.0 Item set GG0170E3 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.
