Understanding and Coding MDS Item GG0130B1, Oral Hygiene (Admission Performance)

Understanding and Coding MDS Item GG0130B1 – Oral Hygiene (Admission Performance)

Introduction:

Purpose: MDS Item GG0130B1 assesses a resident’s oral hygiene performance upon admission. Accurate documentation of this item ensures proper care planning, especially for residents who require assistance with oral care.

What is MDS Item GG0130B1?

Explanation: This item captures the resident's ability to complete oral hygiene tasks independently or with assistance during the first three days of admission.

Guidelines for Coding GG0130B1:

Coding Instructions:

1. Medical Record Review: Review documentation on the resident’s oral hygiene during the admission period.
2. Consultation: Speak with staff who assist the resident with oral care.
3. Observation: Observe the resident’s ability to perform oral hygiene tasks, such as brushing teeth or cleaning dentures.

Example Scenario:

• A resident requires setup assistance to apply toothpaste to the toothbrush but can complete the task independently afterward. GG0130B1 would be coded as 05, Setup or Clean-Up Assistance.

Best Practices for Accurate Coding:

• Documentation: Ensure that the resident’s usual oral hygiene performance is consistently recorded in the care plan.
• Communication: Collaborate with nursing staff and caregivers to document oral hygiene accurately.
• Training: Train staff to assess oral hygiene performance thoroughly and document the level of assistance provided.

Conclusion:

Accurate coding of GG0130B1 is essential for creating appropriate care plans and ensuring that residents receive the necessary oral hygiene assistance.

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

Reference:

Please refer to CMS’s Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Page GG-25​.

Disclaimer:

Please note that the information provided in this guide for MDS 3.0 Item GG0130B1 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.