MDS Insights – April 2024 Edition

MDS Coding Tip of the Month

SECTION GG0130 of the MDS – RAI Manual
Self-Care

General Coding Tips

• When reviewing the medical record, interviewing staff, and observing the resident, be familiar with the definition for each activity (e.g., eating, oral hygiene). For example, when assessing Eating (item GG0130A), determine the type and amount of assistance required to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.
• Residents with cognitive impairments/limitations may need physical and/or verbal assistance when completing an activity. Code based on the resident’s need for assistance to perform the activity safely (for example, choking risk due to rate of eating, amount of food placed into mouth, risk of falling).
• If the resident does not attempt the activity and a helper does not complete the activity for the resident during the entire assessment period, code the reason the activity was not attempted. For example, code as 07 if the resident refused to attempt the activity; code as 09 if the activity is not applicable for the resident (the activity did not occur at the time of the assessment and prior to the current illness, injury, or exacerbation); code as 10 if the resident was not able to attempt the activity due to environmental limitations; or code as 88 if the resident was not able to attempt the activity due to medical condition or safety concerns.
• An activity can be completed independently with or without devices. If the resident uses adaptive equipment and uses the device independently when performing an activity, enter code 06, Independent.
• If two or more helpers are required to assist the resident to complete the activity, code as 01, Dependent.
• To clarify your own understanding of the resident’s performance of an activity, ask probing questions to the care staff about the resident, beginning with the general and proceeding to the more specific. See examples of probing questions at the end of this section.
• A dash (“-“) indicates “No information.” CMS expects dash use to be a rare occurrence.
• Documentation in the medical record is used to support assessment coding of Section GG. Data entered should be consistent with the clinical assessment documentation in the resident’s medical record. This assessment can be conducted by appropriate healthcare personnel as defined by facility policy and in accordance with State and Federal regulations.
• CMS does not provide an exhaustive list of assistive devices that may be used when coding self-care and mobility activities. Clinical assessments may include any device or equipment that the resident can use to allow them to safely complete the activity as independently as possible.
• Do not code self-care and mobility activities with use of a device that is restricted to resident use during therapy sessions (e.g., parallel, exoskeleton, or overhead track and harness systems).
  

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.