GG0170R5. Wheel 50 feet with two turns (OBRA/ Interim Performance)

Step-by-Step Coding Guide for Item Set: GG0170R5. Wheel 50 Feet with Two Turns (OBRA/Interim Performance)

1. Review of Medical Records

   • Begin with a comprehensive review of the resident's medical and therapy records, focusing on notes related to their mobility, specifically their ability to use a wheelchair. Look for details in physical therapy evaluations, occupational therapy notes, nursing assessments, and care plans that provide insight into the resident's current mobility status and any recent changes.

2. Understanding Definitions

   • Wheel 50 Feet with Two Turns: This item measures the resident's ability to self-propel in a wheelchair for 50 feet and successfully navigate two turns. It assesses mobility, coordination, endurance, and spatial awareness in a wheelchair.
   • OBRA/Interim Performance: Refers to the Omnibus Budget Reconciliation Act requirements for ongoing assessment. Interim performance assesses the resident's current level of ability, capturing any changes since the last assessment.

3. Coding Instructions

   • Observe the resident performing the task, or gather accurate and reliable information from staff who have witnessed the resident's performance. Use the following coding scale:
     • 06: Independent - Completes the task without any assistance.
     • 05: Setup or clean-up assistance - Requires help before or after the task.
     • 04: Supervision or touching assistance - Needs verbal cues or light touch support.
     • 03: Partial/moderate assistance - Staff provides less than half the effort.
     • 02: Substantial/maximal assistance - Staff provides more than half the effort.
     • 01: Dependent - Staff provides all the effort.
     • 88: Not attempted due to medical condition or safety concerns.

4. Coding Tips

   • Ensure the assessment reflects the resident's current ability. Consider any temporary factors that may affect performance, such as fatigue or illness.
   • Pay special attention to the resident's ability to initiate and complete the task, including maneuvering the turns.

5. Documentation

   • Document the chosen code in the MDS and detail the observation or staff reports in the resident's medical record. Note the type of wheelchair used, any modifications or adaptations, and the resident's response to the task.

6. Common Errors to Avoid

   • Failing to consider all aspects of the task, including the ability to execute turns.
   • Overlooking the need for verbal cues or supervision that may change the coding level.
   • Not documenting the reason for not attempting the task when coded as 88.

7. Practical Application

   • Example: Mr. Garcia, who has recently shown improvement in upper body strength, is observed to self-propel his manual wheelchair for 50 feet and make two turns. He requires verbal guidance for safely navigating the turns due to cognitive impairments. The appropriate code is 04 (Supervision or touching assistance).

The Step-by-Step Coding Guide for item GG0170R5 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.