MDS Alert

Published on Mon Jul 25, 2016 PDF

When to code GG0130A as Independent, even when the resident has a G-tube.

Studying coding scenarios is a great way to prepare for Section GG — Functional Abilities and Goals, which will become effective in October. Here are six examples to help you learn how to code this new section.

(For more coding examples, see “Get Ahead Of The Curve: Learn From 6 Section GG Coding Scenarios,” MDS Alert, Vol. 14, No. 6, page 61.)

Example 1: Mr. Smith has upper extremity weakness and fine motor impairments. When eating, the occupational therapist places an adaptive device onto Mr. Smith’s hand that supports the eating utensil within his hand. At the start of each meal, Mr. Smith can bring food to his mouth. He then tires and the CNA feeds him more than half of each meal.

How to code: Code GG0130A — Eating as 02 — Substantial/maximal assistance. In this scenario, the helper provided more than half the effort for the resident to complete the activity of eating at each meal.

Example 2: At night, the CNA provides Mrs. Jones water and toothpaste to clean her dentures. Mrs. Jones cleans her upper denture plate and half of her lower denture plate. She then states she’s tired and unable to finish cleaning her lower denture plate. The CNA finishes cleaning the lower denture plate and Mrs. Jones replaces the dentures in her mouth.

How to code: Code GG0130B — Oral hygiene as 03 — Partial/moderate assistance. In this case, the helper provided less than half the effort to complete the oral hygiene activity.

Example 3: Mrs. Davis uses a bedside commode, and the CNA provides steadying assistance as Mrs. Davis pulls down her pants and underwear before sitting down on the commode. When Mrs. Davis is finished voiding or having a bowel movement, the CNA provides steadying assistance as Mrs. Davis wipes her perineal area and pulls up her pants and underwear.

How to code: Code GG0130C — Toileting hygiene as 04 — Supervision or touching assistance. Here, the helper provided steadying (touching) assistance to Mrs. Davis to complete the toileting hygiene activity.

Example 4: Mr. Brown requires assistance from two CNAs to transfer from sitting at the edge of the bed to lying flat on the bed, due to paralysis on his right side, obesity, and cognitive limitations. One of the CNAs explains to Mr. Brown each step of the sitting-to-lying activity. The CNAs then fully assist Mr. Brown to get from sitting to a lying position on the bed. Mr. Brown makes no attempt to assist when asked to perform the incremental steps of the activity.

How to code: Code GG0170B — Sit to lying as 01 — Dependent, because Mr. Brown needed the assistance of two CNAs to complete the sit-to-lying activity. If two or more helpers are required to assist the resident to complete an activity, you must code 01 — Dependent.

Example 5: Mrs. Johnson had a stroke and is currently unable to walk, so she uses a wheelchair for mobility. When Mrs. Johnson gets out of bed, the CNA moves the wheelchair into the correct position and locks the brakes so Mrs. Johnson can transfer into the wheelchair safely. Staff members have observed Mrs. Johnson several other times to determine any safety concerns, and they documented that she transfers safely without the need for supervision. Mrs. Johnson transfers into the wheelchair by herself with no helper after the CNA leaves the room.

How to code: Code GG0170E — Chair/bed-to-chair transfer as 05 — Setup or clean-up assistance. Mrs. Johnson is unable to walk, so she transfers from her bed to a wheelchair when getting out of bed. The helper provides setup assistance only, and Mrs. Johnson transfers safely and doesn’t need supervision or physical assistance during the transfer.

Example 6: Mr. Adams eats all his meals without any physical assistance or supervision from a helper. He has a gastrostomy tube (G-tube), but it is no longer used and will be removed later today.

How to code: Code GG0130A as 06 — Independent, because Mr. Adams can independently complete the activity without assistance from a helper. The presence of a G-tube doesn’t affect the eating score.