Understanding and Coding MDS Item GG0130B3, Oral Hygiene (Discharge Performance)

Understanding and Coding MDS Item GG0130B3 – Oral Hygiene (Discharge Performance)

Introduction:

Purpose: MDS Item GG0130B3 assesses the resident’s oral hygiene performance at discharge. Proper coding of this item ensures that the resident’s oral care abilities are documented accurately, supporting appropriate post-discharge care planning.

What is MDS Item GG0130B3?

Explanation: This item captures how the resident performs oral hygiene tasks, such as brushing teeth or cleaning dentures, at discharge. It helps determine whether the resident can manage oral care independently or requires assistance.

Guidelines for Coding GG0130B3:

Coding Instructions:

1. Medical Record Review: Review the resident’s oral care performance documented in the final three days before discharge.
2. Consultation: Speak with the nursing team to verify any assistance provided for oral hygiene.
3. Observation: Observe the resident during oral care to assess their level of independence.

Example Scenario:

• A resident can brush their teeth independently but requires assistance with denture care. In this case, GG0130B3 would be coded as 03, Partial/moderate assistance.

Best Practices for Accurate Coding:

• Documentation: Ensure detailed records of the resident’s oral hygiene performance are maintained.
• Communication: Discuss the resident’s oral care routine with staff to ensure accuracy.
• Training: Train staff to accurately assess and document oral hygiene performance.

Conclusion:

Accurately coding GG0130B3 ensures that residents’ oral care needs are properly assessed, aiding in their post-discharge care plan.

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 GG0130B3 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.