Understanding and Coding MDS 3.0 Item GG0115B: ROM Limitation, Lower Extremity

Understanding and Coding MDS 3.0 Item GG0115B: ROM Limitation, Lower Extremity

Introduction

Purpose:
Range of Motion (ROM) limitations in the lower extremities can significantly affect residents' mobility and ability to perform daily activities such as walking and transfers. Proper coding of ROM limitations in the lower extremities ensures that healthcare teams can develop effective care plans and interventions. This article offers detailed instructions for accurately coding MDS Item GG0115B.

What is MDS Item GG0115B?

Explanation:
MDS Item GG0115B captures any functional limitations in the range of motion (ROM) of the lower extremities, including the hip, knee, ankle, and foot. These limitations may interfere with activities of daily living (ADLs) or increase the risk of injury. It is crucial to assess whether the ROM limitation affects the resident's ability to perform ADLs like walking and transferring or puts them at risk of falls or other injuries.

Guidelines for Coding GG0115B

Coding Instructions:

1. Code 0, No impairment: If the resident has full functional ROM in both lower extremities (right and left sides).
2. Code 1, Impairment on one side: If the resident has a ROM impairment on one side of the lower extremities that impacts daily functioning or increases the risk of injury.
3. Code 2, Impairment on both sides: If the resident has ROM limitations in both lower extremities that interfere with function or increase the risk of injury.

Example Scenario:
Resident T experienced a stroke and has hemiparesis, which limits movement in their left leg, making it difficult to walk without assistance. They still have full functional ROM in their right leg. For this resident, GG0115B should be coded 1, indicating impairment on one side.

Best Practices for Accurate Coding

Documentation:
Thoroughly document the resident's ROM limitations based on medical records and staff observations. Regularly evaluate how ROM limitations impact the resident’s mobility and ability to complete daily tasks.

Communication:
Collaborate with physical therapists, nursing staff, and caregivers to gather detailed information on the resident’s lower extremity ROM limitations. This will ensure accurate coding and help plan interventions that address these limitations.

Training:
It is crucial for MDS coordinators and staff to receive ongoing training on ROM assessments and coding practices. Regularly reviewing the MDS manual helps ensure accuracy and compliance with updated guidelines.

Conclusion

Accurate coding of MDS Item GG0115B is vital for capturing lower extremity ROM limitations and planning appropriate care. By following the coding instructions and best practices provided, healthcare teams can develop care plans that support the resident's mobility and functional independence.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference:

CMS’s Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Chapter 3, Page GG-8​.

Disclaimer:

Please note that the information provided in this guide for MDS 3.0 Item GG0115B: ROM Limitation, Lower Extremity was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.