MDS Coding Tips of the Month
SECTION GG0170 of the MDS – RAI Manual
GG0170M, 1 step (curb); GG0170N, 4 steps; and GG0170O, 12 steps
Coding Tips
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Completing the stair activities indicates that a resident goes up and down the stairs, by any safe means, with or without any assistive devices (for example, railing or stair lift) and with or without some level of assistance. Getting to and from the stairs is not included when coding the curb or step activities.
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Ascending and descending stairs does not have to occur sequentially or during one session. If the assessment of going up the stairs and then down the stairs occurs sequentially, the resident may take a standing or seated rest break between ascending and descending the 4 steps or 12 steps.
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If a resident requires a helper to provide total assist (for example, the resident requires total assist from a helper to move up and down over a curb in their wheelchair), code as 01, Dependent.
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A resident who uses a wheelchair may be assessed going up and down stairs (including one step or curb) in a wheelchair. Code based on the type and amount of assistance required from the helper.
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If, at the time of the assessment, a resident is unable to complete the activity because of a physician-prescribed restriction of no stair climbing, they may be able to complete the stair activities safely by some other means (e.g., stair lift, bumping/scooting on their buttocks). If so, code based on the type and amount of assistance required to complete the activity.
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If, at the time of assessment, a resident is unable to complete the stair activities because of a physician-prescribed bedrest, code the stair activity using the appropriate “activity not attempted” code.
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Assess the resident going up and down one step or up and down over a curb. If both are assessed, and the resident’s performance going up and down over a curb is different from their performance going up and down one step (e.g., because the step has a railing), code GG0170M, 1 step (curb) based on the activity with which the resident requires the most assistance.
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If a resident’s environment does not have 12 steps, the combination of going up and down 4 stairs three times consecutively in a safe manner is an acceptable alternative to comply with the intention and meet the requirements of this activity.
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While a resident may take a break between ascending or descending the 4 steps or 12 steps, once they start the activity, they must be able to ascend (or descend) all the steps, by any safe means, without taking more than a brief rest break to consider the stair activity completed.
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Getting to/from the stairs is not included when coding the curb/step activities.
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Do not consider the sit-to-stand or stand-to-sit transfer when coding any of the step activities.
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.