Understanding and coding MDS Item GG0130B5, Oral Hygiene (OBRA/Interim Performance)

MDS Item GG0130B5 – Oral Hygiene (OBRA/Interim Performance)

Introduction:

Purpose: MDS Item GG0130B5 captures a resident’s oral hygiene performance during OBRA or Interim Payment Assessments (IPA). This item ensures that the level of assistance required for oral hygiene is recorded accurately for ongoing care adjustments.

What is MDS Item GG0130B5?

Explanation: This item assesses the resident’s ability to manage oral hygiene tasks independently or with assistance during the OBRA or interim assessment period, typically covering tooth brushing and denture care.

Guidelines for Coding GG0130B5:

Coding Instructions:

1. Medical Record Review: Review oral hygiene documentation from the 3-day assessment period.
2. Consultation: Confirm oral care details with caregivers.
3. Observation: Observe the resident’s oral care routine to determine the level of assistance required.

Example Scenario:

• A resident requires verbal cues to complete oral hygiene. GG0130B5 would be coded as 04, Supervision or touching assistance.

Best Practices for Accurate Coding:

• Documentation: Ensure detailed notes on oral care are documented during OBRA or interim assessments.
• Communication: Coordinate with staff to confirm the level of assistance.
• Training: Train caregivers on proper oral care assessment and documentation.

Conclusion:

Accurate coding of GG0130B5 ensures that oral hygiene assistance is documented correctly, contributing to ongoing care planning.

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 GG0130B5 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.