MDS Insights – March 2024 Edition

MDS Coding Tip of the Month

SECTION GG0115 of the MDS – RAI Manual

Functional Limitation in Range of Motion

Coding Tip

• Do not look at limited ROM in isolation.  You must determine whether the limited ROM has an impact on functional ability or places the resident at risk for injury.  For example, if the resident has an amputation, it does not automatically mean that they are limited in function.  A resident with an amputation may not have a particular joint in which a certain range of motion can be tested, however, that does not mean that the resident necessarily has a limitation in completing activities of daily living, nor does it mean that the resident is automatically at risk of injury.  There are many amputees who function extremely well and can complete all activities of daily living either with or without the use of prosthetics.  If a resident with an amputation does indeed have difficulty completing ADLs and is at risk for injury, the facility should code this item as appropriate.  This item is coded in terms of function and risk of injury, not by diagnosis or lack of a limb or digit.

Symbria is committed to maintaining a high standard and level of communication with our clients and employees regarding clinical education, MDS understanding, patient assessment, and coding efficiency.  As a result, MDS Insights was born.  In this monthly offering, we hope to provide some valuable information that can foster a quality level of care that meets the needs of the patients that we serve.