MDS Insights – January 2025 Edition

MDS Coding Tip of the Month

SECTION GG0170 of the MDS – RAI Manual
GG0170: Mobility

General Coding Tips

• When reviewing the medical record, interviewing staff, and observing the resident, be familiar with the definition for each activity. For example, when assessing GG0170J, Walk 50 feet with two turns, determine the type and amount of assistance required as the resident walks 50 feet and negotiates two turns.
• Residents with cognitive impairments/limitations may need physical and/or verbal assistance when completing an activity. Code based on the residents’ need for assistance to perform the activity safely (for example, fall risk due to increased mobility activities).
• An activity can be completed independently with or without devices. If the resident has adaptive equipment, retrieves the equipment without assistance, and performs the activity independently using the device, enter code 06, Independent.
• If two or more helpers are required to assist the residents to complete the activity, code as 01, Dependent.
• To clarify your own understanding and observations about a resident’s performance of an activity, ask probing questions, beginning with the general and proceeding to the more specific.
• 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 and 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 local, 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 residents can use to allow them to safely complete the activity as independently as possible.
• Do not code self-care and mobility activities with the use of a device that is restricted to resident use during therapy sessions (e.g., parallel bars, 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.