Welcome back to the Section GG training. This is segment three.
We are now going to discuss GG0170: Mobility. Consistent with the
self-care items that I discussed earlier, on the admission assessment
you will see that there is a column for admission performance and a
second column that has a discharge goal. The assessment period for the
admission performance is day one through three of the SNF PPS Stay,
starting with the date in A2400B, the Start Date of the Most Recent
Medicare Stay.
Also, I did want to highlight that on the mobility section, there are
some, what we call gateway questions or screening questions. These are
positioned to the right of the admission performance and discharge goal
on the item set and they have their own coding response options that I
will describe shortly. On the discharge assessment, only the discharge
performance is coded - there are no goals captured. You will again note
that there are gateway questions that are positioned to the right of the
performance items. The assessment period for these items is the last 3
days of the SNF PPS stay ending on A2400C which is the End Date of the
Most Recent Medicare Stay. The rationale for the mobility items in
Section GG is that residents in Medicare Part A SNF stays may have
mobility limitations on admission. In addition, residents may be at risk
of further functional decline during their stay in the SNF. The steps
for assessment in GG0170 are very similar to the steps for assessment
for the self-care items.
Assess the resident's mobility abilities based on direct observation,
the resident's self-report, and reports from the clinician, facility
staff, or family as documented in the medical record during the 3-day
assessment period, which is days 1 through 3, starting with the date in
A2400B, Start Date of most recent Medicare stay.
Residents should be allowed to perform activities as independently as
possible, as long as they are safe.
If helper assistance is required because the resident's performance is
unsafe or of poor quality, score the resident's performance according to
amount of assistance provided. Remember, helpers include facility staff
who are direct employees and facility-contracted employees and do not
include individuals hired, compensated or not, by individuals outside of
the facility's management and administration. Family members are not
included as helpers. Activities may be completed with or without
assistive device(s). Use of assistive device(s) to complete an activity
should not affect coding of the activity.
If the resident's mobility performance varies during the assessment
period, report the resident's usual status, not the resident's most
independent performance and not the resident's most dependent episode.
Remember, that CMS does not require specific staff to complete
particular portions of the RAI - rather, facility staff is advised to
refer to facility, Federal, and State policies and procedures to
determine which SNF staff members may complete an assessment. Resident
assessments are to be done in compliance with facility, Federal, and
State requirements. Physical therapists, occupational therapists, speech
language pathologists, and nurses are the typical staff involved in the
assessment of self-care and mobility items. The items in GG0170 are
assessed at admission and again at discharge. They are completed on
admission only if A0310B is coded 01 indicating that the assessment is a
PPS 5-Day assessment or on discharge if A0310G and A0310H are both coded
1, indicating a planned Part A PPS Discharge.
You will note that the item response codes are identical to those used
in GG0130 so I will review these briefly. Code 06, Independent is used
if the resident completes the activity by him or herself, with no
assistance from a helper. Code 05, Setup or clean-up assistance is
chosen if the helper SETS UP or CLEANS UP but the resident completes
activity. With a code of 05, the helper assists only prior to or
following the activity, but not during the activity. Code 04,
Supervision or touching assistance is used when the helper provides
VERBAL CUES or TOUCHING/STEADYING assistance as resident completes
activity. Assistance may be provided throughout the activity or
intermittently. Code 03, Partial/moderate assistance is used if the
helper does LESS THAN HALF the effort. The helper lifts, holds, or
supports trunk or limbs, but provides less than half the effort to do
so. Code 02, Substantial/maximal assistance is coded if the helper does
MORE THAN HALF the effort. The helper lifts or holds trunk or limbs and
provides more than half the effort to do so. Code 01, Dependent is when
the helper does ALL of the effort and the resident does none of the
effort to complete the activity. Or the assistance of two or more
helpers is required for the resident to complete an activity. Code 07 is
used if the resident refuses to complete the activity. Code 09, Not
Applicable is used if the resident did not perform this activity prior
to the current illness, exacerbation, or injury. And Code 88, is used
when the activity was not attempted due to medical condition or safety
concerns. For GG0170, there are several coding tips.
The 5-Day PPS assessment is the first Medicare-required assessment to be
completed when the resident is admitted for an SNF Part A stay.
On the Part A PPS Discharge assessment, the Mobility items in GG0170 are
completed only if the Type of Discharge is Planned.
When reviewing the health records, interviewing staff, and observing the
resident, assessors should be familiar with the definition of each
activity. For example, when assessing Walk 50 feet with 2 turns in item
GG0170J, the assessor will determine the level of assistance required to
walk 50 feet while making 2 turns. Be sure to use probing questions as
needed to identify the resident's status related to each specific
activity. On the 5-Day PPS assessment, code the resident's usual
performance using the 6-point scale or code the reason an activity was
not attempted, as well as the resident's discharge goal(s) using the
6-point scale. Instructions related to coding Discharge Goals for the
mobility items (GG0170) are the same as those for coding Discharge Goals
for the self-care items (GG0130).
On the Part A PPS Discharge assessment, code the resident's usual
performance using the 6-point scale or code the reason an activity was
not attempted.
Record the resident's usual ability to perform each activity. Do not
record the resident's best performance and do not record the resident's
worst performance, but rather record the resident's usual performance.
Do not record the staff's assessment of the resident's potential
capability to perform the activity - be sure to record their usual
performance during the assessment period.
If the resident does not attempt the activity and a helper does not
complete the activity for the resident, code the reason the activity was
not attempted. For example, code 07 if the resident refused to attempt
the activity, code 09 if the activity is not applicable for the
resident, or code 88 if the resident was not able to attempt the
activity due to medical condition or safety concerns.
If two or more helpers are required to assist the resident to complete
the activity, code as 01, Dependent even if the resident participated in
the activity. 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. Examples of
probing questions are available in the RAI User's Manual and I will
review some with you shortly.
As was stated earlier in the presentation, coding a dash indicates "No
information." CMS expects dash use for SNF quality reporting program
items to be a rare occurrence. Use of dashes for these items may result
in a 2% reduction in the annual payment update (or APU). If the reason
that the activity was not attempted is that the resident refused, the
item is not applicable, or the activity was not attempted due to medical
condition or safety concerns, use codes 07, 09 or 88, respectively,
instead of a dash. There are some key coding questions to help you code
GG0170 that I'll review. Using these when interviewing direct care staff
can help to ensure the assessment accurately reflects the resident's
status.
Begin by asking if the resident needs assistance (physical,
verbal/non-verbal cueing, or setup/clean-up) to complete the mobility
activity? If no, Code 06, Independent. If yes continue questioning in
order to determine if the resident needs only setup or clean-up
assistance. If yes, Code 05, Setup or clean-up If no, continue with more
probing questions. Next, ask if the resident needs only
verbal/non-verbal cueing, or steadying/touching assistance. If yes, Code
04, Supervision or touching assistance. If no, continue questioning to
determine whether or not the resident needs lifting assistance or trunk
support with the helper providing less than half of the effort. If yes,
Code 03, Partial/moderate assistance. If no, continue questioning. Ask
if the resident needs lifting assistance or trunk support with the
helper providing more than half of the effort? If yes, Code 02,
Substantial/maximal assistance. If no, determine if the helper provides
all of the effort to complete the activity, or the assistance of two or
more helpers is required. If yes, Code 01, Dependent If the activity was
not attempted, indicate whether they refused (with Code 07), resident
did not perform this activity prior to the current illness,
exacerbation, or injury (with Code 09 indicating not applicable), or the
activity was not attempted due to a medical condition or safety concerns
(with Code 88). At this point, I'll review the specific activities
included in GG0170 - beginning with item GG0170B. Sit to lying. This
item captures the resident's ability to move from sitting on the side of
the bed to lying flat on the bed. You will notice that, like the
self-care items that I reviewed earlier, the mobility items include very
specific activities and only these activities should be considered when
coding the items. Let's look at some coding examples for GG0170B. The
first one involves Mrs. H. She requires assistance from a nurse to
transfer from sitting at the edge of the bed to lying flat on the bed
because of paralysis on her right side. The nurse lifts and positions
Mrs. H's right leg. Mrs. H uses her arms to position her upper body.
Overall, Mrs. H performs more than half of the effort. How would you
code GG0170B. Sit to lying for Mrs. H? GG0170B. Sit to lying would be
coded 03, Partial/moderate assistance because a helper (the nurse) lifts
Mrs. H's right leg and helps her position it as she moves from a seated
to a lying position; Mrs. H does more than half of the effort. Here is
another example. Mrs. H 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 her right side, obesity, and cognitive limitations. One of
the CNAs explains to Mrs. H each step of the sitting to lying activity.
Mrs. H is then fully assisted to get from sitting to a lying position on
the bed. Mrs. H makes no attempt to assist while asked to perform the
incremental steps of the activity. The assessor would code GG0170B. Sit
to lying as 01, Dependent for Mrs. H. The assistance of two CNAs was
needed to complete the activity of sit to lying. If two or more helpers
are required to assist the resident to complete an activity, code as 01,
Dependent. The next mobility item, GG0170C, captures lying to sitting on
the side of the bed. This includes the resident's ability to safely move
from lying on the back to sitting on the side of the bed with feet flat
on the floor, and with no back support. Consider this example involving
Ms. P. She is being treated for sepsis and has multiple infected wounds
on her lower extremities. Full assistance from the CNA is needed to move
Ms. P from a lying position to sitting on the side of her bed because
she usually has pain in her lower extremities upon movement. How would
you code GG0170C for Ms. P? GG0170C. Lying to sitting on the side of bed
would be coded 01, Dependent for Ms. P because the CNA fully completed
the activity of lying to sitting on the side of the bed for her. The
second example of coding GG0170C involves Mr. B who pushes up on the bed
to attempt to get himself from a lying to a seated position as the
occupational therapist provides much of the lifting assistance necessary
for him to sit upright. The occupational therapist provides assistance
as Mr. B scoots himself to the edge of the bed and lowers his feet to
the floor. Overall, the occupational therapist performs more than half
of the effort. How would you code GG0170C for Mr. B? 02,
Substantial/maximal assistance would be the correct coding of GG0170C.
Lying to sitting on the side of the bed. The occupational therapist
provides lifting assistance (more than half the effort) as the resident
moves from a lying to sitting position.
This is the end of segment three of the training. With segment four, the
final segment of the training, I will continue with GG0170, Mobility.