L0200G: Unable to Examine (Dental), Step-by-Step

Step-by-Step Coding Guide for L0200G: Unable to Examine (Dental)

1. Review of Medical Records

Objective: Confirm if the resident’s mouth could not be examined due to certain barriers or refusal during the assessment.
Actions:

• Access the resident’s medical records and review any notes indicating refusal or inability to complete an oral examination.
• Identify if the resident was uncooperative, unresponsive, or physically unable to undergo the examination during the 7-day look-back period.
• Check if there is documentation of attempts to perform the examination and the reasons why it could not be completed (e.g., the resident refusing or being non-compliant).

2. Understanding Definitions

L0200G: Unable to Examine: This item is coded when the assessor is unable to perform a proper dental or oral examination due to factors like resident refusal or uncooperative behavior.

• Examples:
  • A resident refuses to open their mouth for an examination.
  • The resident’s physical or cognitive condition prevents them from cooperating with the examination.

Illustration 1:

Scenario: A resident with advanced dementia refuses to cooperate and clench their mouth shut during the attempted examination.

Result: L0200G is coded "Yes" as the resident's mouth could not be examined.

3. Coding Instructions

Step-by-Step:

• Step 1: Review the resident’s medical records to check if there were any attempts to perform an oral or dental examination within the past 7 days.
• Step 2: If the exam could not be completed due to resident refusal, physical inability, or uncooperativeness, code L0200G as "Yes".
• Step 3: If the examination was completed, code "No" and assess other dental conditions in L0200.

Illustration 2:

Scenario: A resident with severe pain following oral surgery is unable to open their mouth for the assessment due to discomfort.

Result: L0200G is coded "Yes", as the resident's condition prevented the examination.

4. Coding Tips

• Document Attempts: Ensure that there is a documented attempt to examine the resident and the reason why the examination could not be completed.
• Consider Referrals: If an oral examination cannot be performed due to the resident’s condition, consider referring the resident for a dental evaluation.

5. Documentation

Objective: Ensure the reasons for being unable to perform the oral examination are clearly documented in the medical records.
Actions:

• Document the attempt to perform the examination and the reason it could not be completed (e.g., uncooperativeness or refusal).
• Record any referral to a dentist or follow-up actions needed for the resident.

Illustration 3:

Scenario: A resident with advanced Parkinson’s disease is physically unable to open their mouth wide enough for a full dental examination.

Documentation: The assessor notes this limitation and marks L0200G as "Yes".

6. Common Errors to Avoid

• Failing to Document Refusal: Do not code L0200G as "Yes" unless there is a clear reason documented for why the exam could not be completed.
• Inconsistent Documentation: Ensure the medical records consistently reflect the resident’s refusal or inability across different shifts and assessments.

7. Practical Application

• Example 1: A resident refuses the dental examination due to fear of pain after a recent dental procedure. L0200G is coded "Yes".
• Example 2: A resident with physical limitations from a stroke is unable to open their mouth for examination. L0200G is coded "Yes".

Please note that the information provided in this guide for MDS 3.0 Item set L0200G 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.