GG0170J3: Walk 50 Feet with Two Turns (Discharge Performance), Step-by-Step
Step-by-Step Coding Guide for Item Set GG0170J3: Walk 50 Feet with Two Turns (Discharge Performance)
1. Review of Medical Records
The first step in coding for item GG0170J3 involves a thorough review of the resident’s medical records. This includes:
- Physician’s Notes: Examine progress notes, history, and physical examination records for any mention of mobility and walking abilities.
- Nursing Notes: Check nursing notes for observations and documentation of assistance required for walking and turning.
- Therapy Records: Review records from physical and occupational therapy sessions for any documented assistance or equipment used during walking activities.
- Discharge Summaries and Transfer Documents: Look for any information related to walking abilities at discharge.
- Interdisciplinary Notes: Check notes from all members of the care team, including social workers and therapists, for any documentation of walking activities.
2. Understanding Definitions
Understanding the key definitions related to this item is crucial:
- Walk 50 Feet with Two Turns: This activity involves the resident walking at least 50 feet and making two 90-degree turns during the walk. The turns can be in the same or different directions.
3. Coding Instructions
Follow these steps for accurate coding:
- Observe Performance: Assess the resident’s performance of walking 50 feet with two turns as soon after discharge as possible to capture the resident’s discharge performance.
- Determine Assistance Level: Identify the level of assistance required by the resident to complete the activity, using the six-point scale provided in the MDS manual:
- Code 06 (Independent): The resident completes the activity by themselves with no assistance.
- Code 05 (Setup or Clean-up Assistance): The resident requires setup or clean-up assistance only.
- Code 04 (Supervision or Touching Assistance): The resident requires supervision or touching assistance.
- Code 03 (Partial/Moderate Assistance): The helper does less than half the effort.
- Code 02 (Substantial/Maximal Assistance): The helper does more than half the effort.
- Code 01 (Dependent): The helper does all of the effort, or two or more helpers are required.
4. Coding Tips
- Accurate Observation: Ensure the observation is accurate and reflects the resident’s usual performance at discharge. This may require multiple observations.
- Consistent Documentation: Ensure consistency between the coding and the documentation in the medical record.
- Clear Definitions: Be clear about what constitutes each level of assistance to ensure accurate coding.
5. Documentation
Accurate documentation is critical for compliance and effective care planning:
- Daily Records: Maintain thorough daily records of the resident’s walking activities and any changes.
- Care Plans: Update care plans to reflect the resident’s ability to walk 50 feet with two turns and any assistance required.
- Interdisciplinary Communication: Ensure all team members are informed of and document any findings related to walking and its impact on the resident’s functioning.
6. Common Errors to Avoid
- Inconsistent Documentation: Avoid discrepancies between the MDS data and other medical records.
- Outdated Assessments: Ensure the assessment reflects the resident’s current ability at the time of discharge, not earlier in their stay.
- Incorrect Coding: Double-check coding entries for accuracy, especially the level of assistance required.
7. Practical Application
Use case studies and scenarios to apply your knowledge:
- Example 1: A resident requires substantial assistance from a nurse to walk 50 feet and make two turns due to severe weakness. The nurse provides physical assistance with more than half the effort.
- Coding: GG0170J3 would be coded 02 (Substantial/Maximal Assistance).
- Rationale: The nurse provides more than half of the effort needed for the resident to complete the activity of walking 50 feet with two turns.
- Example 2: A resident is able to walk 50 feet and make two turns with only verbal cues from the therapist, who provides no physical assistance.
- Coding: GG0170J3 would be coded 04 (Supervision or Touching Assistance).
- Rationale: The therapist provides verbal cues, but no physical assistance is needed for the resident to complete the activity.
Please note that the information provided in this guide for MDS 3.0 Item set GG0170J3 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.
