MDS Insights – September 2024 Edition

MDS Coding Tip of the Month

SECTION GG0130 of the MDS – RAI Manual
Self-Care – GG0130F, Upper body dressing; GG0130G, Lower body dressing; GG0130H, Putting on/taking off footwear

Coding Tips

• For upper body dressing, lower body dressing, and putting on/taking off footwear, if the resident dresses themselves and a helper retrieves or puts away the resident’s clothing, then code 05, Setup or clean-up assistance.
• If donning and doffing an elastic bandage, elastic stockings, or an orthosis or prosthesis occurs while the resident is dressing/undressing, then count the elastic bandage/elastic stocking/orthotic/prosthesis as a piece of clothing when determining the amount of assistance the resident needs when coding the dressing item.
• The following items are considered a piece of clothing when coding the dressing items:
  
  • Upper body dressing examples: thoracic-lumbar-sacrum orthosis (TLSO), abdominal binder, back brace, stump sock/shrinker, upper body support device, neck support, hand or arm prosthetic/orthotic.
  • Lower body dressing examples: knee brace, elastic bandage, stump sock/shrinker, lower-limb prosthesis.
  • Footwear examples: ankle-foot orthosis (AFO), elastic bandages, foot orthotics, orthopedic walking boots, compression stockings (considered footwear because of dressing don/doff over foot).
• Upper body dressing items used for coding include bra, undershirt, T-shirt, button-down shirt, pullover shirt, dresses, sweatshirt, sweatshirt, sweatshirt, sweater, sweater, nightgown (not hospital gown), and pajama top. Upper body dressing cannot be assessed based solely on donning/doffing a hospital gown.
• If a resident requires assistance with dressing, including assistance with buttons, fasteners and/or fastening a bra, code based on the type and amount of assistance required to complete the entire dressing activity.
• Lower body dressing items used for coding include underwear, incontinence brief, slacks, shorts, capri pants, pajama bottoms, and skirts.
• Footwear dressing items used for coding include socks, shoes, boots, and running shoes.
• For residents with bilateral lower extremity amputations with or without use of prostheses, the activity of putting on/taking off footwear may not occur. For example, the socks and shoes may be attached to the prosthesis associated with the upper or lower leg.
  • If the resident performed the activity of putting on/taking off footwear immediately prior to the current illness, exacerbation, or injury, code as 88, Not attempted due to medical condition or safety concerns.
  • If the resident did not perform the activity of putting on/taking off footwear immediately prior to the current illness, exacerbation, or injury because the resident had bilateral lower-extremity amputations and the activity of putting on/taking off footwear was not performed during the assessment period, code as 09, Not applicable – Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
• For residents with a single lower extremity amputation with or without use of a prosthesis, the activity of putting on/taking off footwear could apply to the intact limb or both the limb with the prosthesis and the intact limb.
  • If the resident performed the activity of putting on/taking off footwear for the intact limb only, then code based upon the amount of assistance needed to complete the activity.
  • If the resident performed the activity of putting on/taking off footwear for both the intact limb and the prosthetic limb, then code based upon the amount of assistance needed to complete the activity.

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.