Section GG: Functional Abilities and Goals


Good morning, everyone. I’m going to be presenting this today in partnership
with my colleague Anne, who will join us about half-way through the presentation. So as with all the presentations we have the
acronyms in the beginning. I’m sure you’re familiar with these. So I’m going to kind of zip through these
slides. It is our hope that after this training you’ll
be able to demonstrate an understanding of the standardized items in Section GG, Functional
Abilities and Goals, describe the intent, coding instructions and definitions for Section
GG items, and apply coding instructions to accurately code practice scenarios in the
Case Study. So as with Terri’s presentation and the ice
breaker activity that you guys did this morning, we are going to be using Slido pretty heavily. So if you haven’t yet logged in, I strongly
encourage you all to do so in order to gain the maximum benefit of this presentation. So in 2014 the IMPACT Act was passed, and
that’s the Improving Medicare Post-Acute Care Transformation Act. And in 2016 Section GG was developed in an
effort to sort of result in uniformity, which as you can see on this diagram here, across
all four PAC settings. So that’s IRFs, SNFs, LTCHs and home health
agencies. And the intent specifically for IRFs is that
patients in IRFs have self-care and mobility limitations and are at risk for further functional
decline and complications due to limited mobility. So with Section GG there’s really four items
we focus on. Prior Functioning and Everyday Activities,
which is assessed on admission, prior Device Use, which is also assessed on admission,
and then GG0130, Self-Care and GG0170, Mobility, which address the need for assistance with
self-care and mobility activities and are assessed on admission and discharge. So with GG0100, Prior Functioning, the rationale
for this is that it gives the clinicians knowledge of the patient’s functioning existing prior to
the current illness, exacerbation or injury, and may inform treatment goals. And this item is used in the risk adjustment
for the quality measures. You’ll see here, this is what it looks like
on the item set. On the right-hand side you have different
groups of activities, which we’ll go through in detail and the definitions of those. And then on the left-hand side you have the
coding. So often clinicians won’t have a lot of detail
in terms of what the patient’s ability was immediately prior to the illness that occurred,
and we’ll talk about the steps to obtain the information in just a few moments, so what
you would do in that scenario. So GG0100A is Self Care, which is defined
as, code the patient’s need for assistance with bathing, dressing, using the toilet or
eating prior to the current illness, exacerbation, or injury. GG0100B is Indoor Mobility or Ambulation,
and this is coding the patient’s need for assistance with walking from room to room,
with or without an assistive device, such as a cane, crutch or walker, again, prior
to the current illness, exacerbation, or injury. GG0100C, Stairs, is code the patient’s need
for assistance with internal/external stairs, with or without an assistive device, such
as a cane, crutch or walker, again, prior to the current illness, exacerbation or injury. Then GG0100D, Functional Cognition. You would code the patient’s need for assistance
with planning regular tasks, such as shopping or remembering to take medication prior to
the current illness, exacerbation, or injury. So the steps for assessment when you’re coding
those four activities is, interviewing the patient or their family members and reviewing
the patient’s medical records for details describing the patient’s prior functioning
with everyday activities. It’s mostly self-report by the patient and
family, but of course, you can always look at the medical record to gain additional insight
and check if it’s been documented. In terms of coding instructions, you would
record the patient’s usual ability to perform self-care, indoor mobility ambulation, stairs
and functional cognition prior to the current illness, exacerbation, or injury. And just a quick note that these coding responses
do differ from the 6-point scale and the activity not attempted codes. So they are listed here on this slide. Code 3, Independent, if the patient completed
the activities by him or herself with or without an assistive device, with no assistance from
a helper. So if a patient needed a walker or a cane,
you would still code 3, independent. Code 2, Needed Some Help, if the patient
needed partial assistance from another person to complete the activities. Code 1, Dependent, if the helper completed
the activities for the patient, or the assistance of two or more helpers was required for the
patient to complete the activities. You would code 8, Unknown, if the patient’s
usual ability prior to the current illness, exacerbation, or injury is unknown. And Code 9, Not Applicable, if the activity
was not applicable to the patient prior to the current illness, exacerbation, or injury. Again, as I just said, if you don’t have information
about the patient’s ability, even after attempts to interview the patient and his or her family,
and after reviewing the medical record, you have that 8, Unknown, option. Okay. We’re going to move on to Prior Device Use
now. So again, the rationale for this item is it
gives the clinicians knowledge of the patient’s routine use of devices and aids immediately
prior to the current illness, exacerbation, or injury, and may inform treatment goals. And this item is also used in the risk adjustment
of the Quality Measures. So for Prior Device Use, we have a limited
list of mobility devices and they are, manual wheelchair, motorized wheelchair and/or scooter,
mechanical lift, walker, orthotics or prosthetics, or Z, None of the above. And the steps for assessment, again, interviewing
the patient and the family, reviewing the patient’s medical records describing the patient’s
use of prior devices and aids. And again, you would only report devices and
aids used immediately prior to the current illness, exacerbation, or injury for this
section as well. For coding instructions, you would check all
the devices that apply, so listed here, A-E. If you do check Z, None of the above, this
means that none of the devices listed, A-E, were used. GG0110C, Mechanical Lift. This is any device a patient or caregiver
requires for lifting or supporting the patient’s body weight. A limited list of examples are on this slide,
and they are stair lift, Hoyer lift or bathtub lift. For GG0110D, Walker, we do include all walker
types. And the examples are, again, listed here. But this is not an exhaustive list, we’ll
say. So there are pick-up walkers, hemi-walkers,
rolling walkers, platform walkers, four-wheel walkers, rollator walkers, knee walkers and
walkers for mobilizing while seated in a walker. So one question we got from the last training
we did in May, and several times in the help desk we’ve gotten this question too, so we
decided to include it here for you all. Why is a cane not included in the list of
prior devices? And our answer is, the devices listed in the
item GG0110, Prior Device Use, are included on the Inpatient Rehab Facility Patient Assessment
Instrument because they are risk adjusters for the Functional Outcome Measures. During the development of the Functional Outcome
Measures, testing was conducted to determine if prior use of a cane or crutches affected
either self-care or mobility outcomes. CMS found that these devices did not affect
Functional Outcomes. For that reason, CMS did not include these
items on the list of devices if the patient was using a cane or crutches prior to the
current illness, exacerbation, or injury and none of the devices listed, you would code
GG0110, Prior Device Use, as Z, None of the above. We are going to go through a Practice Coding
Scenario. And this video that you’re going to watch
is actually occurring in an ADL suite in an IRF. So you might notice that the environment appears
more home-like for that reason. Let’s watch a scenario
of an assessing clinician collecting information
from multiple sources, to code GG0110, prior device use. – I noticed you have a
few different devices here Mr. Smith, which of these were you using
to help you walk just before you went to the hospital? – I wasn’t using anything,
I was walking on my own. – How’s it going? Can I help answer anything? – I was just asking your husband
which of these devices he used to help him walk
before he went to the hospital. – Oh he was using that cane over there
to help him get around. – Oh yeah I guess I was using that. – Okay, good. It also says here in your
hospital discharge paperwork, that you were using a
walker before you admitted, is that right? – Yeah I guess I used
that when I went outside. – Okay, and I see a wheelchair over there,
were you also using that? – No that’s mine, I
was using it when I had chemotherapy last year. – Okay thank you for clarifying. And were you using anything else
like a shoe insert, or a chair lift in another room
anything like that? – Nope, that’s all just what I told you. So you guys will now have the opportunity
to practice this on Slido. So how would you code GG0110, Prior Device Use? Your choices are, A, manual wheelchair. B, check D, walker. C., check both A, manual wheelchair, and D,
walker. And D., check Z, none of the above. I’ll give you guys just a few more seconds
to get those responses coming in. We’ll go ahead and take a look at the correct
answer now. It is in fact, D, walker. The rationale behind that is the clinician
used multiple sources of information to determine that Mr. Smith was using a walker and a cane
prior to his recent hospitalization. So if the clinician hadn’t asked Mrs. Smith
about, you know, what the patient was using before, there’s a chance that he may have
gotten inaccurate information and would have coded that incorrectly. So prior use of the cane, as we mentioned
earlier, is not captured in GG0110, so only option D, walker, should be checked. And devices coded for Prior Device Use may be
used indoors and/or outdoors. We’re going to go ahead and get started with
GG0130, Self-Care, and then Anne’s going to take over for Mobility. So I’ll talk quickly through the intent. So GG0130, Self-Care, identifies the patient’s
ability to perform the listed self-care activities and Discharge Goals. And GG0170 identifies the patient’s abilities
to perform the listed mobility activities and Discharge Goals. So for the steps for assessment for both of
these sections, you would assess the patient’s self-care and mobility performance based on
direct observation, the patient’s self-report, and reports from clinicians, care staff or
family reports documented in the patient’s medical record during the 3-day assessment
period. And there is an emphasis placed on 3-day assessment
period. You’re going to hear me say that over and
over again in my presentation. So patients should be allowed to perform activities
as independently as possible, as long as they are safe. And it is important to give patients the time
they need to complete the activity on their own to accurately code their abilities. If helper assistance is required because a
patient’s performance is unsafe or of poor quality, you would score based on the type
and amount of assistance provided. Activities can be completed with or without
an assistive device, and use of the assistive device to complete the activity should not
affect coding of the activity. Continuing with the steps for assessment,
we ask clinicians to refer to facility, Federal and State policies and procedures to determine
which IRF staff members may complete an assessment. Patient assessments are to be done in compliance
with facility, Federal and State requirements. So as promised, I’m going to talk again about
the 3-day assessment period. So the Admission Assessment Period is the
day of admission, the following two days, ending in 11:59 officially on Day 3. Let’s say for example somebody came into your
facility today. They’d have the balance of today, tomorrow
and then officially until 11:59:00 p.m. the day after tomorrow. For the Discharge Assessment period, it’s
the day of discharge and the two calendar days prior to the day of discharge. I’d like to discuss Usual Status next. So for admission, the patient’s functional
status should be based on a clinical assessment of the patient’s performance that occurs soon
after the patient’s admission. The admission function scores are to reflect
the patient’s admission baseline status prior to any benefit from therapeutic interventions. For discharge you want to code the patient’s
discharge functional status based on a clinical assessment that occurs close to the time of
discharge. And one thing, just really quick with the
admission, you don’t want to withhold treatment in order to conduct the Functional Assessment. It is important to continue with that. So a patient’s functional status can be impacted
by the environment or situations encountered at the facility. Observing the patient’s interactions with
others in different locations and circumstances is important for a comprehensive understanding
of the patient’s functional status. If the patient’s status varies, record the
patient’s usual ability to perform each activity. You would not record the patient’s best performance
and worst performance, instead record the patient’s usual performance. And usual performance does require some degree
of clinical judgment. So that’s important to remember when you’re
coding for that. So GG0130 and GG0170 have the same coding
instructions in the 6-point scale. They’re listed here. Code 06 is Independent. 05 is Setup or clean-up assistance. 04, Supervision or touching assistance, and
that does include contact guard as well. 03, being Partial/moderate assistance. 02, Substantial/maximal assistance. 01, Dependent. We are going to watch a video now on the Decision
Tree which will review each coding option in the 6-point scale in greater detail. It’s going to go through using an example
of a patient, Mrs. Jones, completing GG0170D, Sit to Stand. We will walk through the decision tree
for coding GG0130. Self-Care and GG0170. Mobility,
highlighting each coding level using an example
of a patient, Mrs. Jones, completing GG0170 D,
sit to stand. The decision tree presents a
series of yes, no questions represented by diamonds that
guide you to the correct code for your patient or resident. Accurate coding is
important to capture patient and resident safety,
appropriate goal setting, and accurate evaluation of the patient’s
or resident’s functional ability at discharge. The first question in
the decision tree asks does the patient or resident
complete the activity with or without assistive
devices by him or herself and with no assistance,
including physical, verbal or nonverbal cueing, setup, or clean up? If the answer to this question is yes,
the correct code for this patient or resident
is 06 independent. Let’s view an example
of Mrs. Jones completing the sit to stand activity independently. In this scenario, Mrs. Jones is sitting up
on the side of the bed. She retrieves her walker and
places it in front of her. Then she safely rises
to a standing position. Once standing, she holds onto
the walker to steady herself. There is no assistance
provided by a helper. If, however, the answer to
this first question is no the patient or resident
is not able to complete the activity by him or
herself without assistance, proceed to the next question. The second question in
the decision tree asks does the patient or
resident need only setup or clean-up assistance from one helper? If the answer to this question is yes,
the correct code for this patient or resident is 05,
setup or clean-up assistance. Let’s review an example
of the same patient, Mrs. Jones, completing
the sit to stand activity, but this time with setup
or clean-up assistance. In this scenario, Mrs. Jones is sitting up
on the side of the bed. She retrieves her walker and
places it in front of her. Then, a helper raises the bed rail. (women chattering)
Mrs. Jones grasps the bed rail and safely rises
to a standing position. Once standing she holds onto
the walker to steady herself. In this example, the patient
completes the activity by herself with setup assistance. Setup assistance is
demonstrated by the helper raising the bed rail. So, you would code this 05,
setup or clean-up assistance. If however the answer
to this question is no, the patient or resident
requires more than setup or clean-up assistance
to complete the activity, proceed to the next question. The third question in
the decision tree asks does the patient or
resident need only verbal or nonverbal cueing or
steadying, touching, or contact guard assistance from one helper? If the answer to this question is yes,
the correct code for this patient or resident is 04,
supervision or touching assistance. Let’s review an example
of the same patient, Mrs. Jones, completing
the sit to stand activity, but this time with supervision
or touching assistance. In this scene, Mrs. Jones is sitting up
on the side of the bed. She retrieves her walker and
places it in front of her. Then, a helper raises the
bed rail and provides cues for hand placement. – I’m gonna tell you how to do it safely. – [Narrator] The helper
also provides instructions to help Mrs. Jones safely
rise to a standing position. Once standing, Mrs. Jones
holds onto the walker to steady herself. In this scenario, Mrs. Jones needs verbal
and nonverbal cueing from one helper, so you would use code 04
supervision or touching assistance. If however the answer
to this question is no, the patient or resident
requires more than supervision or touching assistance
to complete the activity, proceed to the next question. The fourth question in
the decision tree asks does the patient or resident
need physical assistance, for example, lifting or trunk support,
from one helper with the helper providing less
than half of the effort? If the answer to this question is yes,
the correct code for this patient or resident
is 03 Partial/moderate assistance. Let’s review an example
of Mrs. Jones completing the sit to stand activity, but this time
with Partial/moderate assistance. In this scene, Mrs. Jones is sitting up
on the side of the bed. She retrieves her walker and
places it in front of her. – Hey Mrs. Jones. – Oh, good morning. – [Narrator] The helper
raises the bed rail, secures a gait belt around her waist,
and provides instructions regarding the transfer. – One hand on the rail. You’re gonna put one hand on the bed. We’re gonna go on the
count of three, all right? – [Narrator] Then, while
holding Mrs. Jones, the helper provides a slight upward boost
using the gait belt. Mrs. Jones, who is bearing
most of the weight, rises safely to a standing position. In this example, Mrs. Jones
needs physical assistance with the helper providing
less than half of the effort, so you would code this 03
Partial/moderate assistance. If however the answer
to this question is no, the patient or resident
requires more than partial moderate assistance to
complete the activity, proceed to the next question. The fifth question in
the decision tree asks does the patient or resident
need physical assistance, for example, lifting or trunk
support from one helper, with the helper providing
more than half of the effort? If the answer to this question is yes,
the correct code for this patient or resident is 02,
Substantial/maximal assistance. Let’s review an example of
the same patient, Mrs. Jones, completing the sit to stand activity,
but this time with Substantial/maximal assistance In this scene, Mrs. Jones is sitting up
on the side of the bed. She retrieves her walker and
places it in front of her. A helper raises the bed
rail, secures a gait belt around Mrs. Jones’ waist,
and provides instruction regarding the transfer. – We’re gonna work together. – Okay. – [Woman] Okay, on the count of three. – Three. – Okay. – [Narrator] Using the
gate belt, the helper lifts Mrs. Jones bearing most of her
weight during the transfer. – One, two. – Two. – Three. – [Narrator] The helper
provides continual assistance as she moves Mrs. Jones
to a standing position. In this scenario, Mrs. Jones
needs physical assistance with the helper providing
more than half of the effort. So, you would code this 02
Substantial/maximal assistance. If however the answer
to this question is no, the patient or resident requires more than Substantial/maximal assistance from one helper to complete the activity, proceed
to the next question. The sixth and final question
in the decision tree asks does the helper provide
all the effort to complete the activity, or is the
assistance of two or more helpers required to complete the activity? If the answer to this question is yes,
the correct code for this patient or resident
is 01 dependent. Let’s review a final
example of the same patient, Mrs. Jones, completing
the sit to stand activity, but this time the patient is dependent
on two helpers to complete the activity. – So, she’s gonna help me today. – [Narrator] In this scene, two helpers
are assisting Mrs. Jones. One helper secures a gait
belt around Mrs. Jones’ waist, while the other helper
provides instructions about the transfer. – On three, we’re gonna stand up. One, two, three, all the way up. – [Mrs. Jones] Okay. – [Narrator] Both helpers
provide continual assistance as they move Mrs. Jones
to a standing position using the gate belt to
fully support her weight. Once standing, Mrs. Jones
holds onto the walker to steady herself. In this scenario, Mrs. Jones
needs the physical assistance of two or more helpers to
complete this activity, so you would code this 01 dependent. This video provided you with an overview
of the decision tree for coding GG0130, self-care,
and GG0170, mobility. We reviewed a series
of key coding questions to help you identify the correct code
for your patient or resident. Accurate coding is
important to capture patient and resident safety,
appropriate goal setting, and accurate evaluation of the patient’s
or resident’s functional ability at discharge. We hope you found this video helpful
For more information on coding section GG, refer to your setting
specific guidance manual that can be found on the CMS website. Great. And just a quick note. For those of you in the room, in your folders,
you do have a Decision Tree. It’s Handout Number 7 and it will probably
be useful to have as we go through some of the practice coding scenarios. So if you want to, go ahead and pull that
out while I talk through these next few slides. In the situation that an activity was not
attempted, and that is during the entire 3-day assessment period, if the patient does not
attempt the activity and a helper does not complete the activity for the patient, you
would code the reason the activity was not attempted. And the four activity not attempted codes
are listed here on this slide. They are 07, patient refused. So in this situation the patient refused to
complete the activity. 09, not applicable, which means it’s not attempted
and the patient did not perform this activity prior to the current illness, exacerbation,
or injury. Code 10, which is, not attempted due
to environmental limitations. So for example, lack of equipment or weather
constraints. Or Code 88, not attempted due to medical condition
or safety concerns. And this implies that the activity was not
attempted due to medical conditions or safety concerns. So one of the provider Q&As that came in is,
can you provide scenarios in which a patient would be scored 10 for an item? This is again based on help desk questions
and prior training questions. So our answer is, we do not expect Code 10,
not attempted due to environmental limitations to be used often. If a patient is unable to go outside due to
inclement weather, such as snow or cold temperatures, and no indoor option for uneven surface is
available, Code GG0170L, Walk 10 feet on Uneven Surfaces, with Code 10, not attempted due
to environmental limitations. For GG0170R, Wheel 50 feet with Two Turns,
if the patient is obese and you do not have a wheelchair that is the appropriate size
for the patient, you would code 10, not attempted due to environmental limitations, due to the
lack of equipment. Just some general coding tips when assessing
GG0130 and GG0170. When you’re reviewing the patient’s medical
record, interviewing staff and observing the patient, be familiar with the definition of
each activity. So you’ll notice when we go through the coding
scenarios, I will read the definition to you all just to get into that practice mode. It’s very helpful when you’re assessing the
activity if you know what the definition is. Code based on the patient’s performance. Do not record the staff’s assessment of the
patient’s potential capability to perform the activity. And to clarify your own understanding of the
patient’s performance of an activity, ask probing questions to the care staff about
the patient, beginning with the general and proceeding to the more specific. Continuing with coding tips for GG0130 and
GG0170. Documentation used in the medical record to
support assessment coding of Section GG. Data entered should be consistent with the
clinical assessment documentation in the patient’s medical record. Use of assistive devices to complete an activity
should not affect coding of the activity. So if a patient uses adaptive equipment and
uses the device independently when performing an activity, you would enter Code 06, independent. If the only help that a patient needs is to
complete an activity is for a helper to retrieve an assistive device or adaptive equipment,
such as a cane for walking, then enter Code 05, setup or clean-up assistance. And if two or more helpers are required to
assist the patient in completing the activity, you can automatically skip to Code 01, dependent. Anytime two or more helpers are required,
you do go straight to 01, dependent. So for patients with incomplete stays, such
as a patient with an emergency discharge, the self-care and mobility items are skipped. Patients with incomplete stays include, patients
who unexpectedly discharge to an acute care setting, and that is a short-stay acute care
hospital, critical access hospital, inpatient psychiatric facility or a long-term care hospital,
patients who die or leave the IRF against medical advice, and patients with a length
of stay of less than three days. So another opportunity for Slido. Which example below best demonstrates allowing
the patient to function as independently as possible? Is it A, feeding a patient who can feed himself
in order to expedite mealtime? B, allowing the patient to brush her teeth
as much as possible, assisting only if she becomes fatigued? C, providing the patient with a bedside commode
when he is capable of walking to the bathroom with assistance. Or D, all of the above? We are seeing a lot of people entering in
B. Let’s go ahead and take a look at what the correct answer is. And it is, in fact, B, allowing the patient
to brush her teeth as much as possible, assisting only if she becomes fatigued. The reason for this is it allows the patients
to achieve their goal toward independence. It also allows her to participate in the activity
to the fullest extent possible, only receiving assistance from the caregiver as needed. Patients should be allowed to perform activities
as independently as possible, again, as long as they are safe. And facility staff and/or family should allow
independence whenever possible to promote quality of life and a sense of well-being. We’re going to do a true/false question now
on Slido. Since Mr. W uses a quad cane he cannot be
considered independent for the Section GG walking items. Is this A, true? Or B, false? A lot of rapid movements towards false. Let’s take a look at what the correct answer
is. And it is in fact, B, false. And the rationale behind this is activities,
again, can be completed with or without assistive devices. Use of assistive devices to complete an activity
should not affect the coding of an activity. All right. So we’re going to get started with Self-Care. We’ll start with GG0130A. This is what it looks like again on the item
set. You have two columns, Admission Performance
and Discharge Goal. So the definition of GG0130A, Eating, is the
ability to use suitable utensils to bring food and/or liquid to the mouth and swallow
food and/or liquid once the meal is placed before the patient. Some Coding Tips. If a patient receives tube feeding or parenteral
nutrition, assistance with tube feedings or PN is not considered when coding the item
Eating. If the patient does not eat or drink by mouth
and relies solely on nutrition and liquids through tube feedings or PN due to a new — and
that is a recent onset medical condition — you would code GG0130A as 88, not attempted due
to medical conditions or safety concerns. So continuing with Coding Tips for Eating. If the patient does not eat or drink by mouth
at the time of the assessment and the patient did not eat or drink by mouth prior to the
current illness, injury, or exacerbation, you would code GG0130A as 09, not applicable. And if the patient eats and drinks by mouth
and relies partially on obtaining nutrition and liquids via tube feedings or PN, you
would code Eating based on the type and amount of assistance the patient requires to eat
and drink by mouth. Our practice scenario is, for the past two
years Ms. T has been unable to eat or drink by mouth due to a swallowing disorder and
a history of aspiration pneumonia. She uses a gastrostomy tube, G-Tube, to obtain
nutrition. Ms. T had a stroke 8 days ago and her IRF
admission orders include nothing by mouth, NPO, and G-Tube feedings. How would you code GG0130A? Is it A, 01, dependent? B, 02, substantial/maximal assistance? C, 09, not applicable. Or D, 88, not attempted due to medical condition
or safety concerns. I’m hearing the answer. I’m seeing it on Slido. Let’s go ahead and take a look at what the
correct answer is. And it is 09, not applicable. The rationale behind this, as I mentioned
during the Coding Tips, Ms. T does not eat or drink by mouth at the time of the Admission
Assessment. And she did not eat or drink by mouth prior
to the current illness, injury, or exacerbation. Eating includes only eating by mouth and assistance
with G-Tube feedings or PN are not considered when coding this item. We’re going to move now to Oral Hygiene. The definition for this activity is the ability
to use suitable items to clean teeth, dentures, if applicable, the ability to insert or remove
dentures into and from the mouth and manage denture soaking and rinsing with the use of
equipment. So we have a video here in which we’re going
to talk through the Practice Coding Scenario on Oral Hygiene. – [Narrator] Here you
see the helper providing steadying assistance to Mr. Smith
as he walks to the bathroom using his walker. Once in front of the bathroom sink,
the helper applies toothpaste to Mr. Smith’s toothbrush
and leaves the room. Mr. Smith then brushes his
teeth without supervision. Once Mr. Smith is done brushing his teeth,
the helper reengages by cleaning and putting away the oral hygiene items. The helper then provides
steadying assistance to Mr. Smith as he walks back to bed. In this situation, oral hygiene would be coded
05, setup or clean-up assistance. And the reason being, the helper provided
setup assistance by putting toothpaste on the patient’s toothbrush and clean-up assistance
by putting away the supplies after the patient completed the activity. We wouldn’t consider the assistance getting
to and from the bathroom because we’re coding Oral Hygiene. So we’ll watch another video on this. This is a little different, even though it’s
the same patient. And we are going to have a Slido question
following this to see how you guys do. Here you see the helper
providing assistance to Mr. Smith as he walks to the bathroom. Once in front of the bathroom sink,
the helper retrieves and puts toothpaste on Mr. Smith’s toothbrush
and hands it to him. The helper then steadies Mr. Smith’s arm
as he brushes his teeth. Once Mr. Smith is finished
brushing his teeth, the helper rinses his
toothbrush and puts it away. The helper then provides
steadying assistance as Mr. Smith walks back to bed. So based on what you guys just saw, how would
you code GG0130B? Would it be A, 05, setup or clean-up assistance? B, 04, supervision or touching assistance? C, 03, partial/moderate assistance? D, 02, substantial/maximal assistance. You guys are doing really well. Let’s take a look at what the correct answer
is now. And it is B, supervision or touching assistance. So again, Mr. Smith required the helper to
provide supervision or touching assistance in order to complete the activity of oral
hygiene. We wouldn’t consider the assistance getting
to and from the bathroom. Next we have GG0130C, Toileting Hygiene. This is the ability to maintain perineal hygiene,
adjust clothes before or after voiding or having a bowel movement, and if managing an
ostomy, include wiping the opening but not managing the equipment. So our Practice Coding Scenario for GG0130C. Mr. W uses a urinal when voiding and completes
toileting hygiene tasks without assistance while sitting on the side of the bed. He uses a toilet with a raised toilet seat
when moving his bowels and requires contact-guard assistance from the helper as he holds onto
a grab bar with one hand, lowers his underwear and pants, performs perianal hygiene, and
then pulls up his underwear and pants. So based on that information, how would you
code GG0130C? Your options are A, 02, substantial/maximal
assistance. B, 03, partial/moderate assistance. C, 04, supervision or touching assistance. Or D, 06, independent. And the answer is, 04, supervision or touching
assistance. The reasoning being, the helper provides contact-guard
assistance as the patient completes the activity. Next we have GG0130E, Shower/Bathe Self. This is defined as the ability to bathe self,
including washing, rinsing and drying self, it excludes washing of the back and hair. And it does not include transferring into
or out of the tub or shower. So some more Coding Tips here for GG0130E. Assessment can take place in a shower or bath
or at a sink. So that would be a full-body sponge bath. If the patient bathes himself or herself and
a helper sets up materials for bathing or showering, you would code 05, setup or clean-up
assistance. If the patient cannot bathe his or her entire
body because of a medical condition you would code based on the type and amount of assistance
needed to complete the activity. Now we have our Practice Coding Scenario for
GG0130E. Ms. N declines to shower herself when the
occupational therapist attempts to complete the assessment. The therapist asks Ms. N’s CNA detailed questions
about Ms. N’s ability to shower/bathe herself and considers this input when coding the activity. The therapist learns that Ms. N takes a shower
and initiates washing her face, arms, chest, part of her legs and perineal area. She requires assistance to wash, rinse and
dry her lower extremities below the knees. Ms. N rinses and dries most of her body. So based on this, how would you code GG0130E? Your options are A, 04, supervision or touching
assistance. B, 03, partial/moderate assistance. C, 02, substantial/maximal assistance. Or D, 01, dependent. Again, you guys are doing really well. Let’s look at the correct answer. It is B, 03, partial/moderate assistance. This is because the helper provides less than
half the effort for Ms. N to complete the activity of shower/bathe self. During the 3-day assessment period, the therapist
does not observe the patient bathing and asks other clinicians and care staff of Ms. N’s
abilities. Next we have GG0130F, Upper Body Dressing. This is the ability to dress and undress above
the waist, including fasteners if applicable. So on this slide here we have some examples
of Upper Body Dressing items. You could assess the patient based on the
clothing the patient routinely wears. And this is not an exhaustive list. There are definitely more Upper Body Dressing
items than what’s listed here. This is just to give you guys an idea. Practice Coding Scenario for GG0130F, Upper
Body Dressing. Mr. T has reduced strength and range of motion
in both upper extremities following spinal surgery and he wears a cervical collar. The nurse puts on the cervical collar. Once Mr. T is sitting at the side of the bed,
he threads his hand into the sleeve of his shirt and due to his no-twisting precautions
the nurse pulls the shirt across his back and threads his other hand into the shirt
sleeve. The nurse also pulls up the shirt over both
shoulders. Mr. T buttons two of his shirt buttons and
the nurse buttons the last three. So based on this, how would you code GG0130F? Your options are A, 04, supervision or touching
assistance. B, 03, partial/moderate assistance. C, 02, substantial/maximal assistance. Or D, 01, dependent. I know we’re going through these relatively
quickly but I hope you are getting the opportunity to use the Decision Tree too if you’re stuck. We’ll go ahead and look at the correct answer,
and it is C, 02, substantial/maximal assistance. The reason being Mr. T threads one arm into
his shirt sleeve and buttons up some of his buttons. The nurse assists Mr. T by applying the cervical
collar and helping him to pull his shirt around his back, threading his other arm and pulling
it over his shoulder and buttoning some of the buttons. So the nurse clearly does a lot in this situation. And for dressing items, you consider donning
and/or doffing an orthosis or prosthesis or other device as a piece of the clothing when
dressing or undressing. All right. We’ll move now to Lower Body Dressing. The definition for Lower Body Dressing is
the ability to dress and undress below the waist, including fasteners and it does not
include footwear. So as with Upper Body Dressing, we’ve got
some Lower Body Dressing examples on here. Again, please note these are some examples
and you would assess the patient based on the clothing they routinely wear. So here’s a Practice Coding Scenario for GG0130G. So Mrs. R has peripheral neuropathy in her
upper and lower extremities. She needs assistance from a helper to place
her lower limb into and take it out of her lower-limb prosthesis. She needs no assistance to put on and remove
her underwear or slacks. So based on this information, how would you
code GG0130G? Your options are A, 02, substantial/maximal
assistance. B, 03, partial/moderate assistance. C, 04, supervision or touching assistance. Or D, 06, independent. We’ll go ahead and take a look at the correct
answer now. And it is in fact B, 03, partial/moderate
assistance. The reason being, a helper performs less than
half the effort of lower body dressing. And again, just as I mentioned with Upper
Body Dressing assistance, the lower extremity prosthesis is considered when assessing lower
body dressing. So we do have another provider Q&A. This one says, if a patient does not have
clothing on the day of admission, do you code 10, not applicable due to environmental limitations;
i.e., lack of equipment for dressing? So if a patient does not have clothing then
we have a couple of scenarios that we can go through. The intent for this item is to assess the
patient’s dressing ability with clothing that would be worn in the community. If clothing is available by Day 3, you would
code based on the assessment conducted on that day. So if the patient doesn’t have clothing on
Day 1, but they get it on Day 2 or Day 3, you can code it then. If clothing is not available by Day 3, paper
scrubs could be used to assess the activities of upper and lower body dressing if no other
clothing is available. And if a patient does not have upper body
clothing, other than a hospital gown during the entire 3-day assessment period, in this
scenario you would use Code 10, not attempted due to environmental limitations for GG0130F,
Upper Body Dressing. So coding based on a gown is not — a gown,
only I should say, is not allowed, because it would not represent what the patient’s
abilities are for dressing with the clothes that would be normally worn in the community. And reports from the patient or family could
not be used alone when coding this item. The reports of the family should be incorporated
along with observation. So the goal for this item is to assess the
patient’s current abilities. And if a patient was dressing differently
before they got to the hospital than how they were when this item was assessed, that needs
to be taken into consideration. Next we have GG0130H, Putting On/Taking Off
Footwear. This is defined as the ability to put on and
take off socks and shoes or other footwear that is appropriate for safe mobility, including
fasteners if applicable. So, again, we have some examples of footwear
items. For this item you would assess the patient
based on the footwear that the patient routinely wears. And again, this is not an exhaustive list
of footwear items. So our Practice Coding Scenario for GG0130H,
Putting On/Taking Off Footwear. Mr. Q underwent bilateral below-the-knee amputations
three years ago. He uses bilateral limb prostheses with attached
shoes and socks that he never changes. Prior to the current episode of care at the
acute care hospital and during his IRF stay, he does not perform the activity of putting
on and taking off footwear. So based on this information, how would you
code GG0130H? Your options are A, 01, dependent. B, 09, not applicable. C, 88, not attempted due to medical condition
or safety concerns. Or D, 07, patient refused. We’ll take a look at the correct answer now. And it is 09, not applicable. The rationale for this is that patients with
bilateral lower extremity amputations, with or without use of prostheses, the activity
of putting on and taking off footwear may not occur. Mr. Q’s socks and shoes were attached to his
prostheses, as I told you guys. So Mr. Q did not perform putting on and taking
off footwear prior to the current illness, exacerbation, or injury. And the activity was not performed during
the assessment period. And just a quick note here. If a patient has recent bilateral leg amputations
and completes putting on and taking off footwear immediately prior to the current illness,
exacerbation, or injury, then here the applicable code would be 88, not attempted due to medical
condition or safety concerns. Now we’ll go through the Self-Care Discharge
Goal columns quickly. So this is what it looks like again on the
item set. You have the Admission Performance on the
left-hand side and the Self-Care Discharge Goal on the right. Some coding tips for Discharge Goal. You would code the patient’s Discharge Goals
using the 6-point scale that we went through at the beginning that you guys saw at the
Decision Tree and that I’m sure you all are very familiar with, or one of the activity
not attempted codes, that is, 07, 09, 10 or 88. This is updated guidance of course, effective
October of last year. For the IRF QRP, at least one goal must be
indicated for either self-care or mobility. And you can use a dash to indicate that a
specific activity is not a goal. Using the dash in this allowed instance does
not affect APU determination. So licensed clinicians can establish a patient’s
Discharge Goals at the time of admission, based on the following, patient’s prior medical
conditions, prior and current self-care and mobility status, discussions with patients and family
members concerning their discharge goals, the professional’s standard of practice, expected
treatments that the patient should be undergoing in the IRF, patient motivation to improve,
and anticipated length of stay. And goals should be co-created and established
as a part of the patient’s care plan. Finishing up on Discharge Goal Coding Tips. They may be coded the same as admission performance,
higher than the admission performance or lower than the admission performance. And if the admission performance of an activity
was coded using one of the activity not attempted codes, so 07, 09, 10 or 88, a discharge goal
may be submitted using the 6-point scale if the patient is expected to be able to perform
the activity by discharge. Let’s say a patient came in, they weren’t
able to do an activity. But after coming to your IRF and going through
the treatments they were able to, you can use that 6-point scale. And I know I mentioned this, although I know
it’s not typical for IRF patients for the discharge goal to be lower than the admission
performance, it can be the case in some cases. And so again, I’m going to turn it over to
Anne, who’s going to take over and go through GG0170, Mobility, at this time. Thank you all. (Applause)
»» Thank you so much. Does anyone want to stand up and stretch or
put their arms up? We’re going to be covering the Section GG,
Mobility section next, so we have quite a few more slides. But feel free to stand up. And those who are online are welcome to do
that, too. All right. So moving onto the Mobility section, So we’ll
be similar to what Manisha did. We’ll be covering the item definitions. Because as Manisha mentioned, that’s really
important. That will definitely help you in terms of
thinking about coding. And then we’ll go through a few coding tips,
throw in some Q&As that we’ve gotten that we think will be helpful to cover, and then
we’ll go through some Slido questions and go over the answers. So in the area of mobility, as you are aware,
there are quite a few mobility activities covering things like bed mobility, transfers,
walking, stairs and picking up an object. Similar to what you saw on the Self-Care area,
on the Admission Assessment, you will see two columns, the first being Admission Performance,
the second column being a Discharge Goal. On this slide we have the walking items, the
stairs items, also the wheelchair items, and as you may know, for the wheelchair items
there’s a gateway question. So we’ll talk a little bit about skip patterns
related to that gateway question. Then for the wheelchair items, there’s also
follow-up questions related to the type of wheelchair. So starting off with the Bed Mobility Items. So the first activity is rolling left and
right. And this refers to the ability to roll from
lying on the back to left and right side and returning to the back on the person’s bed. One of the questions that we get about this
particular topic that’s fairly common these days from the inpatient rehab facility providers, as
well as the skilled nursing facility, what if somebody doesn’t sleep on a bed? So if somebody uses an alternative sleeping
surface, please assess them on that alternative sleeping surface. So if they sleep on a mattress on the floor
or, you know, whatever they sleep on can be done for the assessment for the bed mobility
items that talk about a bed. Another topic that we get questions about
is, if the person cannot lay flat on the bed, how do you code bed mobility activities where
you talk about lying on a bed? So if the clinician determines that bed mobility
cannot be assessed because of the degree to which the head of the bed must be elevated
due to a recent onset medical condition, you would code the bed mobility activities, including
GG0170A, Roll left and Right; GG0170B, Sit to Lying; and GG0170C, Lying to Sitting on
Side of Bed, as 88, not attempted due to medical condition or safety concern. If the person has a longstanding condition
where they’ve not been able to lie flat for a long time, and so that meets the criteria
of Code 09 that Manisha covered. So Code 09, just as a reminder, means the
activity did not occur at the time of the assessment and the patient was not able to
do that activity prior to the current illness, exacerbation, or injury. So the difference between Codes 88 and 09
is that for Code 88, in addition to the — well, so for Code 88, the activity didn’t occur
at the time of assessment, so admission or discharge. But the person did do that activity prior
to the current illness, exacerbation, or injury. For Code 09, it means the person did not perform
the activity prior to the current illness, exacerbation, or injury. So the example here, we coded it 88 because
we talked about it being a recent onset condition. I hope that makes sense. For GG0170A-C, those bed mobility activities,
you would use clinical judgment to determine what is considered a “lying” position. So for example, the clinician would determine
that a patient’s preferred slightly elevated resting position is considered lying, and
that’s adequate. So you would be using your clinician judgment
if you can do the assessment. If the head of the bed is elevated so high
that you don’t really feel the person is lying flat, you may make the judgment that the activity
would be coded one of the activity not attempted codes. We do have another practice scenario. And just a reminder, again, you do have all
of these examples in your packet. So this is material Number 5 and we are on
Scenario 9. So that’s actually on Page 7 of that packet. It started off with DRR. It has the Self-Care Activities, and now we’re
moving to the Mobility Activities. So if you wanted to follow along here, you
can do that. The other thing that I want to encourage you
to do is look at the Decision Tree. I’ll actually use it as part of going through
scenarios to help you to see how it can be helpful for you. In this particular example we have Ms. W.
Ms. W’s head of the bed must remain slightly elevated at all times due to aspiration precautions,
so maybe she had a stroke. Although the head of the bed is slightly elevated,
the therapist determines that she can assess Ms. W’s ability to roll left and right. The therapist provides verbal instructions
as Ms. W completes the activity. If you were new to this and were trying to
figure out how to code it, you would look at the Decision Tree and say, okay, the first
question basically asks whether the patient was able to complete the activity, with or
without assistive devices, by him or herself with no physical or verbal, or cueing assistance
or setup. So does that apply here? No. She did need some help. So then we would go down to the next question
on the Decision Tree. Does the patient need only setup/clean-up
assistance from one helper? Or she needs more? She needs more, yeah. So we go down to the next question, which
basically says, does the patient need only verbal/non-verbal cueing or steadying/touching
assistance or contact-guard assistance from one helper? What do you think? Are we there? Okay. All right. So now you can help me with the answer here. So would you code Ms. W as 05, Setup or clean-up
assistance? 04, supervision or touching assistance? Or 09, not applicable? Or 88, not attempted due to medical condition
or safety concern. Okay. I’ll wait for a few more people to answer. We’ll wait until it gets to 100. Great most people coded 04. I do agree with that. That is indeed, the right answer. So as you correctly indicated, Ms. W requires
verbal instructions while rolling left and right in bed. And the assessment definition includes “lying
on the back.” In this example the clinician used clinical
judgment to determine that the assessment can be conducted with the head of the bed
slightly elevated. The next activity again, another bed mobility
activity, is Sit to Lying. For Sit to Lying, the definition is, the ability
to move from sitting on the side of the bed to lying flat on the bed. So for the practice scenario here — this
is Number 10. We have Mr. P. So Mr. P has peripheral vascular
disease and recently had a right above-the-knee amputation. Mr. P requires the physical therapist to provide
steadying assistance as he moves from a sitting position to lying down. How would you code Mr. P? So again, if we were going through the Decision
Tree, does Mr. P need help? Yes or no? Yes. So he’s not able to do it independently. So we go down on the Decision Tree. Does he require only setup/clean-up assistance? Okay. So we go down further in the Decision Tree. Does he only need verbal cueing, steadying/touching
assistance, contact-guard assistance from one helper? Yes. Okay. So go ahead and put your answers in. The options that you have for answers on Slido
are 05, setup or clean-up assistance. 04, supervision or touching assistance. 03, partial/moderate assistance. 09, not applicable. Okay. I’ll wait for a few more responses. Great. It looks like most of you are coding 04. I do agree with that. And that is, indeed, the right response. So as you correctly indicated, the helper
provides only steadying assistance as Mr. P performed the activity. The next activity that we’re going to cover
is Lying to Sitting on Side of the Bed. And for this activity it refers to the ability
to 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. So we do have a video scenario here. – [Nurse] Hi Mrs. Brown,
how are you today? – I’m doing a little better, thanks. – Good, can you come sit on
the side of the bed for me? – It’s hard but I’ll try. Oh, could you help with my legs? – Of course. Good job. – [Woman] Thank you. We do have a coding scenario here. So in this case, this was an example of a
Code 03. And the rationale for this answer is that
Mrs. Brown began to move to a seated position and the clinician assisted with pivoting Mrs.
Brown’s legs to the side of the bed. So again, the level 04, as Manisha covered,
is about touching/steadying assistance, perhaps some verbal. But once you provide lifting assistance, the
code will be level 03 or below. So in this case, you know, if you were the
clinician helping the patient, you would be probably in a much better position to judge
the amount of effort. But overall, the judgment was that the patient
did more than half of the effort. The helper did less than half the effort. And so that would be coded 03. So again, Mrs. Brown began to move to a seated
position and the clinician helped move both of her legs. The clinician provided assistance that represents
less than half of the effort. We do have a bit more video here. – [Attendant] Hi, Mrs. Brown. How are you today? – I’m doing a little better, thanks. – Good. Can you come sit on the
side of the bed for me? – It’s hard, but I’ll try. – Looks like you’re struggling a bit. Can I help you? – Yes, thanks. – Okay, first, let me have
you try to lie on your side. Great, now, put your hand on
the bed and push yourself up. As you do that, I’m gonna put my hand
on your upper back and arm and swing your legs until
you’re in a seated position. Is that okay? – Sure, let’s give it a try. – Good job. – [Mrs. Brown] Thanks. In this video there was a little bit more
assistance being provided. So I will let you consider what you saw in
the assistance being provided. The options are 04, supervision or touching
assistance. 03, partial/moderate assistance. 02, substantial/maximal assistance. And 01, dependent. Okay. We’ll wait for a few more. I think sometimes the online takes a little
bit longer so I want to be sure they get to see the answers and select the answer. Okay. It looks like most people coded 02. And I do agree with that response, and that
is the correct response. So in this instance Mrs. Brown required the
clinician to provide lifting and physical assistance that represents more than half
of the effort to complete the activity of moving from lying on her back to sitting on
the side of the bed. So you know in this scenario you had the same
patient demonstrate two different levels. So you saw the level 03 where it was assisting
with the legs, and in this second instance, she needed more help to even get to the sitting
position. So moving to the Transfer Items next. So the first item in this area, first activity,
is Sit to Stand. So this refers to the ability to come to a
standing position from sitting in a chair, wheelchair, or on the side of the bed. So however it’s assessed, it’s acceptable
to do any or all of those. We have Scenario 12 here where Mrs. P is morbidly
obese and has severe arthritis in both knees. She is unable to transition from sit to stand
without the use of a mechanical lift. Mrs. P lifts and places her feet on the standing
lift device to initiate the activity. Assistance from two helpers is required as
Mrs. P is helped to transition from a sitting to a standing position. So let’s walk through the Decision Tree
on this one. So the first question asks if the person was
able to do the activity without help. Clearly she needs help. So the next question down, did she need just
setup assistance? No. Did she need just steadying/verbal cueing? Okay. And by the way, one of the things you’ll notice
on the Decision Tree that I want to be clear to point out is that the Decision Tree talks
about one helper. So was it setup from one helper. Was it steadying/cueing from one helper? So then the next question is, does the patient/resident
need physical assistance? For example, lifting the trunk, lifting or
trunk support from one helper with the helper providing less than half of the effort. Okay? And then does the helper need physical assistance? Could be trunk support or lifting from one
helper with one helper providing more than half the effort. So it doesn’t meet that criteria. And so basically the last question, at the bottom
of the Decision Tree here is, does the helper provide all of the effort to complete the
activity or is the assistance of two or more helpers required to complete the activity? So based on your reading of the example I
will let you pick the answer that you think is the correct response. The options are Code 02, substantial/maximal
assistance. Code 01, dependent code 09, not applicable. Code 88, not attempted due to medical condition
or safety concern. I’ll just wait for a few more responses to
come in. Okay. So you are indeed correct. Code 01 is the correct response. And the rationale is that although Mrs. P
placed her feet on the mechanical lift without assistance, getting from a sitting to a standing
position required the assistance of two helpers. If the assistance of two or more helpers is
required, you would code 01. And just to clarify, because we have had this
question come in through the help desk, so basically, in order — when you are coding
level 01 because two or more helpers are required, it’s because the patient requires the assistance
of two helpers, not that maybe two people happened to be there and both ended up helping. I think one of the important things for coding
the GG items overall, these activities should be assessed, it’s a clinical assessment. And so you should be allowing the person to
perform the activity as independently as possible. Obviously safety is a concern. So if you are very concerned about the person’s
safety during a transfer or walking, if the patient requires the assistance of two or
more people because of safety, absolutely that’s a level 01. But again, please allow the person to do the
activity as independently as possible. And when an activity might occur — and certainly
when I was a nurse and patients had to get off to therapy on time, you know, it was time
to hurry up and get dressed, there were instances where I helped patients more than they may
be needed to. In that instance that’s not a clinical assessment. So that instance of dressing doesn’t count. So again, just pay attention to this idea
that this is a clinical assessment, allowing the person to perform the activity as independently
as possible. Another question that comes up that makes
me think about this answer is, for the coding, as Manisha covered, the Code 01 refers to
the person requiring — the helper performs all of the activity in order for the activity
to occur. So if the patient participates a little bit
in performing an activity, the code goes up to 02. But if you follow the Decision Tree — and
this question came up in, I think, the May training. In the instance that you have two or more
helpers and the person helps a little bit, if you follow the Decision Tree, the Decision
Tree will help you come to the determination that the code would be 01. So basically, in the instance where the person
is participating a little bit and the assistance of two or more helpers is required, the two
or more helpers required kind of becomes the key issue and the code would be a 01. If you only have one helper, so if we had
let’s say this example, and it was one helper and she was helping a little bit and was participating
to perform the activity a little bit, she would get credit for that. Mrs. P would get credit for that. And her code would be a 02. So I hope that clarifies something. I think I might have seen something on the
Slido about that. The next activity is Bed-to-Chair transfer. And this refers to the ability to transfer
to and from a bed or wheelchair. If somebody uses a slide board to transfer
— maybe somebody who had a spinal cord injury, somebody has below-the-knee amputation, so
a transfer board certainly is an acceptable way to do this particular activity. I do want to highlight that the activities
of Sit to Lying and Lying to Sit, which we previously covered, are two separate activities
that are not assessed as part of GG0170E. So the activity of transferring from the bed
to the chair, chair-to-bed, begins with somebody in the sitting position. And when that person is getting out of bed,
if the person is getting back into bed, they would actually end the activity sitting upright
on the side of the bed. If a mechanical lift is used to assist in
transferring a patient for the bed-to-chair transfer and two helpers are needed, required
to assist the patient, the patient needs the assistance of two helpers and they’re using
a mechanical lift, then the code would be 01, dependent. If the patient assists with any part of the
bed-to-chair transfer — and again, the rationale is that if you follow the Decision Tree, if
two or more helpers are required, you’re always going to end up at that level 01, because
of all of the questions prior to that refer to one helper, one helper, one helper. The next coding scenario we have is obviously,
Bed-to-Chair transfer. So this is Scenario Number 13. So here we have Mr. L. He has spinal stenosis
and due to back pain does not fully stand up. He uses a stand pivot style type of transfer
to get from the chair to the bed and from the bed to the chair. And this occurs obviously during the 3-day
assessment period. The occupational therapist uses a gait belt
around Mr. L’s waist, providing initial lifting assistance from the chair/bed as he raises
himself to a stooped-over position. The therapist continues to steady him as he
completes a pivot, turns, and then lowers himself into a chair. Mr. L contributes more than half of the effort. So if we were going through the Decision Tree,
does he need help? Yes. Is it more than just setup assistance? Yes. Is it more than steadying assistance? Okay. And so we’re down to either an 03, 02, or
an 01. So again, you’ll be making a determination
about does the helper provide less than half of the effort, more than half of the effort,
or all of the effort. The options that you have on Slido are 04,
supervision or touching assistance. 03, partial/moderate assistance. 02, substantial/maximal assistance. 01, dependent. Okay. It looks like most people are heading towards
03. I see a couple of 02s. So for the Decision Tree you’ll notice that
level 03, the helper is doing less than half of the effort. The patient is doing more than half of the
effort. At level 02 the helper is doing more effort
than the patient. And in this instance, I believe it said that
Mr. L was doing more than half of the effort. So it looks like we’re at 97 people who have
submitted answer 03. And the correct response. I do agree with what you’ve put, 03, partial/moderate
assistance. So the rationale here is Mr. L requires a
helper to initially provide lifting assistance during the transfer. So that’s more than touching assistance. And the helper provides less than half of
the effort. It is acceptable if the patient is only able
to partially rise, then pivot, turn and sit on the chair, bed or wheelchair. So again, it can be a slide board transfer. It can be a stand-pivot. It could be this partial kind of standing
and pivot. The next activity is Toilet Transfer. So this is very simply getting on and off
a toilet or commode. So it could be a bedside commode right next
to the bed, or the person may be going to the toilet. As Manisha highlighted in the Self-Care activities,
getting to and from the bathroom is not considered in coding. It’s basically just transferring on and off
the toilet or the commode. One of the things I do want to highlight is
that the toileting hygiene item that you heard about earlier today includes activities that
obviously happened around the toilet transfer. But when you’re coding the activity, do pay
attention to the definitions. So the toileting hygiene, just as a reminder,
relates to the person managing clothing. So for most people it’s going to be pants
down, wiping, pants back up. The toilet transfer is going to happen in
between that, but keep those definitions in mind. It’s absolutely possible that somebody for
example may be holding onto a grab bar as they’re pulling their pants down and as they
sit down onto a toilet. So basically that grab bar — or maybe you’re
providing steadying assistance while both the toileting hygiene and the toilet transfer
happens and you’re just holding on to them continuously. But steadying assistance was required in that
example I just made up at the time of coding, toileting hygiene, as well as the toilet transfer. We also have had questions about whether a
bedpan counts, and the answer is no. Transferring on and off a bedpan is not considered
when you’re doing toileting transfer. So if the person — if the patient is not
getting on and off the toilet, not getting on and off the commode, only uses a bedpan,
you would use the appropriate activity not attempted code. But hopefully that’s pretty rare. Just a reminder that the activity not attempted
codes would indicate that the activity did not occur during the entire 3-day assessment
period. I think there might be some rare exceptions. But if I saw a code of 88, or 09, or 07 for
toilet transfer, I’m going to — when I look at the data and write an analysis, I’m going
to think, hmm, this person didn’t get on and off a toilet during the first three days of
admission or during the last three days of the stay. So please, be very careful about the coding
of the activity not attempted codes. I wouldn’t expect a Code 10 on this one. That’s another thing. The Code 10, as you may know, was added. And that should mainly probably be used for
things like car transfers, uneven surface. But if I saw a Toilet Transfer, Code 10, I
would wonder if that meant you didn’t have a toilet available. I’m not sure what that would mean. But anyway, please, do pay attention to those
things. You know the activity attempted codes should
not be used a lot on some of these activities that are — you know, especially the Self-Care
activities. These are things that patients would be performing,
especially over a 3-day assessment period. So I think Manisha even brought up the issue
of, you know, somebody not having clothing. Well if somebody had clothing on Day 3, code
it based on Day 3. So I think she emphasized, you know, think
about that whole 3-day assessment period. The next activity is Toilet Transfer. So here Mrs. M had a total hip replacement
following a hip fracture and was in an acute care hospital prior to being transferred into
an inpatient rehabilitation hospital. While in the acute care hospital she used
a raised toilet seat. When Mrs. M needs to void, the certified nursing
assistant provides steadying assistance as Mrs. M transfers safely from the wheelchair
onto the raised toilet seat. So I will let you think through the Decision
Tree on this one. And again, if you want to look at the handout
to look at the example a little bit more, the options for coding this activity are 05,
setup or clean-up assistance. 04, supervision or touching assistance 03,
partial/moderate assistance. 09, not applicable. All right. A few more answers. Okay. It looks like actually everybody coded 04. Awesome. I agree with you on that one. Oh, somebody put in another answer. Most of you put in 04, supervision and touching
assistance. So indeed, that is the correct response. The certified nursing assistant provides only
steadying assistance during the activity. The raised toilet seat is used during the
initial assessment and was previously used in the acute care hospital. I do want to highlight — because we do get
a lot of questions about this — are patients allowed to be assessed on the Admission Assessment
with a new device? The answer is yes. So if somebody, let’s say, is — looks like
theoretically, this woman had not used a raised toilet seat prior. Maybe she used a bedpan, I guess, in acute
care. So she’s brought over to the rehab unit. You want to, you know, make sure that she’s
using the toilet and all that, and so a raised toilet seat is used. You can assess her with that raised toilet
seat code, based on the amount, type and amount of assistance required. If it’s a new device you might be providing
maybe more steadying assistance. And you can definitely code based on that
initial assessment. The next activity is Car Transfer. Car Transfer refers to the ability to transfer
in and out of a car or a van on the passenger side. It does not include the ability to open and
close the door or the ability to fasten seatbelts. We’ve also had questions recently about getting
to and from the car. That’s not considered — again, it’s just
really once the person is close to the car or the car simulator, and the person’s ability
to get into the car on the passenger side and to exit the car on the passenger side. So we do have a fair number of coding tips
in the manual related to car transfer, so I just wanted to go over some of those. So use of an indoor car can be used to simulate
outdoor car transfers. These half or full cars would need to have
similar features of a real car. I know some people have Easy Street or different
options. You’ll be using your clinical judgment if
you don’t have an actual car to practice with or a partial car available. We get all kinds of questions about whether
a golf cart can count or this or that. (laughter) Please use your judgment. You know, the idea is that, especially at
discharge, somebody should be able to transfer in and out of the car safely at discharge. And I will tell you we have had questions
on help desk where — you know, instances where they said the patient was being discharged
with a family member, was transferring into the car and fell and ended up in the emergency
room. So the question came in asking, what’s the
discharge destination? Because, in this case, the person ended up
going to the emergency department. But it just is a reinforcement of how important
it is to make sure that something like a car transfer is being assessed for patients before
they are discharged. It’s something we do all the time, getting
in and out of cars. And it’s, you know, kind of hard after a stroke
maybe, or a spinal cord injury. Car transfers do not include transfers to
the driver’s seat, opening or closing the car door, or fastening or unfastening the
seatbelt. Please use your clinical judgment again about
what simulation can be done. In the event of inclement weather, so perhaps
you have an outdoor parking lot, and you usually would take somebody to practice car transfers
outside, maybe when the family’s visiting, and maybe, like me, you live in Chicago and
it gets cold — it was, like, minus-50 one day last year. And so you would not do it on that day, probably. So if you’re not able to practice a car transfer
because it was a cold spell for a week and this person was being discharged, so you could
code the Code 10, not attempted due to environmental limitations in those instances when you only
have access to the outside parking lot and you didn’t have, let’s say, a simulator
inside your facility. But in general, you know, if there is an ability
to transfer in and out of a car when family’s visiting or you have a car available to transfer
in your garage, please do try and do those assessments. We do have a practice scenario here. This is Number 15. So this is when performing car transfers,
Mr. T, who recently had hip surgery requires significant support from the physical therapist
as he transitions into the passenger’s seat of the car to maintain his hip precautions. Once seated, Mr. T places his left leg in
the car and requires assistance to lift his right leg into the car. So the helper is lifting a leg. So think about the Decision Tree. When transferring out of the car, Mr. T requires
significant physical lifting assistance from the therapist and the therapist lifts his
right leg out of the car. Mr. T lifts his left leg out of the car. So as you’re thinking through the Decision
Tree, let’s look at that last bullet there. So he’s transferring out of the car. The helper is providing significant lifting
assistance. So think about who’s probably doing more of
the effort there. And the therapist lifts the right leg out;
but an important part here is the last part. Mr. T lifts his left leg out of the car. So he is contributing effort. And so that’s really important as you think
through the Decision Tree. Because as I mentioned before, Code 01 means
that the helper did all of the effort. So I will let you think through the Decision
Tree and let you put in an answer here. So the options are 05, setup or clean-up assistance. 04, supervision or touching assistance. 03, partial/moderate assistance. 02, substantial/maximal assistance. Okay. We’re getting close to 100. Yes, we’re at 100. It looks like most of you coded 02. I do agree with that answer. And let’s see what the correct response is. And it is indeed a 02. So here the rationale is that the helper provides
more than half of the effort but Mr. T did contribute by lifting his leg and so he does
get credit for contributing to the effort. Next we’re moving to the Walking Items. And we’re going to start off with the Walk
10 Feet. So the definition of Walk 10 Feet refers to,
once standing, the ability to walk at least 10 feet in a room, corridor or similar space. One of the things that I do want to highlight
is that if admission performance is coded one of the activity not attempted codes, so
that’s 07, 09 or 88, you will actually skip over the next few items. The assumption is that if the patient cannot
walk 10 feet, that the patient would not be walking 50 feet with two turns or 150 feet. So in your system it’s probably grayed out. You won’t be able to enter anything. Again just reinforcement, if the patient is
unable to walk the 10 feet, you would skip to the 1 Step curb. The skip does go to the 1 Step or curb because
it’s possible somebody’s in a wheelchair. So they are not walking 10 feet, but they
are able to go up one step or the curb in their wheelchair. So that’s why it’s skipping you to the step,
because it is possible somebody is not walking but they’re able to go up and down that 1
step. So the little post-it note on the slide, if
the admission performance of the activity was coded using one of the activity not attempted
codes, so it triggers the skip pattern for the performance, but you may still code a
goal for that activity. So perhaps on admission the person is not
able to walk 10 feet. Maybe they walk 8 feet. But by discharge they will be able to accomplish
walking 10 feet, then you would actually be able to enter a goal if that’s something that
you wanted to code as a goal. When assessing the patient for the walking
items, do not consider walking in parallel bars. Part of the rationale is that parallel bars
are not portable. So if the person’s in their bedroom and they
need to go to the bathroom, it’s not like they can use the parallel bars to get to the
bathroom. So in general, as Manisha kind of indicated
before, CMS doesn’t provide an exhaustive or comprehensive list of devices that do or
don’t count. But in general, devices that would be used
in therapy and only therapy and can’t be used outside of therapy, so parallel bars is one
example, you would not consider those. So if the person was only able to walk in
parallel bars during therapy and when they were in their room, needing to go to the bathroom
or to the sink to brush their teeth, you may be coding one of the activity not attempted
codes if that’s true for the entire 3-day assessment period. So we have an example. If the patient cannot walk without the use
of parallel bars due to a recent onset condition, you would code 88. Obviously, as I described before, if somebody
had a longstanding — perhaps somebody had a spinal cord injury 20 years ago and so the
person is not able to walk 10 feet, were not able to do it prior to the current illness,
exacerbation, or injury. So maybe they’re admitted with a new condition
but the person was not able to walk 10 feet prior to the current illness, exacerbation
or injury. It would be coded 09. That would be the appropriate activity not
attempted code for that patient. We’ve had questions in the past about whether
a patient is allowed to take a break when walking, and so you would be using your clinical
judgment. But in general, CMS has said that a patient
may take a standing brief break, a breather, if you will, while walking any of the distances. This question mostly comes up with 150 feet. But a breather is allowed. And I guess the other issue about this is
that we mentioned standing. Somebody cannot walk part of a distance, sit
down and walk the rest of the distance. That wouldn’t count. Actually we did the SNF training the last
couple of days and somebody asked if somebody can take a breather break during wheelchair,
traveling wheelchair, self-mobilizing 150 feet. The answer is, yes, a breather is okay. But you’d be using your clinical judgment
about how long a person could actually take that break for. So again, clinical judgment. We have Practice Case Scenario 16 here for
Walk 10 feet. Mr. S has an open reduction internal fixation
on his left lower leg after a fall. So it’s a recent onset condition and is non-weight
bearing on his left lower extremity. Mr. S walks 10 feet in the parallel bars with
the physical therapist providing more than half of the effort to support his trunk. How would you code this example? The options are 01, dependent. 02, substantial/maximal assistance. 03, partial/moderate assistance. 88, not attempted due to medical condition
or safety concern. So what was the key thing that most of you
are coding 88? Parallel bars. Thank you. You can change your answers. I know there was a bit of a distractor there
that, you know, more than half the effort. But the bottom line is that it was parallel
bars. You’re exactly right. So the correct response is indeed, 88, again,
parallel bars. The next activity is Walking, so walking 50
feet with two turns. Again, this is going to begin with the person
standing. And it refers to the ability to go 50 feet
and make two turns. A common question we get about this activity
is, what is a turn? So CMS has determined a turn, for this particular
activity, refers to 90-degree turns. The turns can occur in the same direction,
so two left turns or two right turns, or it could be the person is able to turn once to
the left and once to the right. The 90-degree turns should occur at the person’s
ability level and can include the use of an assistive device, if appropriate for that
individual, so a cane or a walker, without affecting the code. So I think Manisha covered this earlier, that
you would code patients on an activity with or without assistive devices, whatever is
appropriate for that individual. We do have a coding scenario here also. Mr. R has a chronic neurologic condition and
has poor balance as a result of that. He has used a walker for many years. He ambulates 50 feet with two 90-degree turns,
requiring contact-guard when he makes two turns. How would you code Mr. R for 50-feet walking
with two turns? The options are 05, setup or clean-up assistance. 04, supervision or touching assistance. 03, partial/moderate assistance. 09, not applicable. Okay. Wait for a few more answers. When you’re thinking about turns of course,
somebody who is wheeling down a hallway and then goes into their room, they’re making
a turn. Or if somebody is wheeling in their room and
they turn into the bathroom, they’re making a turn or walking. Definitely, as you’re thinking about the walking
and the wheelchair items, those turns are definitely things that happen. Actually, if you look at research where they’ve
tracked people, people turn a lot every day, all the time. So you should be able to assess this, because
turns are something we do all the time. Okay. So it looks like 04. I do agree with that response. That is the correct response. Again, the rationale was contact-guard assistance
is 04. The last walking item here is Walk 150 Feet. So again, starting once in a standing position,
the ability to walk 150 feet in a corridor or similar space. We do get questions by the way in relation
to these walking items. Can you basically assess them simultaneously? So I think our only caution is that, with
the 50 feet with two turns, you’ve got the turn in there. There’s no turn with the 150 feet. So just pay attention again to the definitions. But let’s say you have somebody who is independent. Let’s say this person had an excellent rehab
program, is independent, walking 150 feet by discharge. You can certainly determine, using your clinical
judgment, if the 10 feet was also independent or with supervision or touching assistance. But again, use your judgment in terms of overlapping
or sequential coding related to walking. We’ve also had the question about whether
these activities all need to be assessed during the same therapy session. And the answer is, no. They can be assessed together, but they do
not need to be. So you can assess perhaps 10 feet during one
therapy session and maybe a longer distance the next day. We have another practice scenario here. Mrs. T walks with her walker 150 feet independently
as long as she takes very brief standing-rest breaks halfway through the walk. How would you code Mrs. T? Your options are that she is 06, independent. 05, she requires setup or clean-up assistance. 04, supervision or touching assistance. 09, not applicable for this individual. All right. Somebody coded 09. Did you press a wrong button? Okay. Most of you coded independent and that is
correct. That person’s online. Okay. All right. So I agree the correct response is 06. And again, you’re allowed to take a breather
break, and it was standing. So it’s totally appropriate to code that as
independent. The next activity is Walking 10 Feet on Uneven
Surfaces. For this particular activity it refers to
the ability to walk 10 feet on an uneven or sloping surface. It could be indoor or outdoor. Examples that we have in the manual are things
like turf or gravel. In some instances I know some facilities may
have an outside garden. They can take somebody walking on grass. I know some IRFs have set up obstacle courses
and they have people walk through the obstacle course a little bit. Those are all appropriate. Again, you would be using your clinical judgment. Sometimes we get questions about whether going
from, let’s say, a wood floor to carpet counts. That could be part of it, but that probably
doesn’t last 10 feet. So it is a 10-feet distance. We have another practice scenario here, Number
19. Mr. B sustained an incomplete spinal cord
injury after a car accident. He ambulates outside on grass and negotiates
the turf with the therapist providing more than half the effort to support his trunk. How would you support Mr. B? The options that you have on Slido are 05,
setup or clean-up assistance. 04, supervision or touching assistance. 03, partial/moderate assistance. 02, substantial/maximal assistance. It looks like most people are coding 02. We’ve got one person who coded 04, but otherwise,
02. I think 02 sounds right to me. Let’s see what the correct response is. 02, that’s right. The therapist provides more than half of the
effort in order for the patient to ambulate 10 feet on an uneven surface. Again, it could also be a sloping surface
if you looked at the definition. Now we’re moving to the stairs activities
and pick up object. So the step, it refers to the ability to go
up and down a curb or up and down 1 step. There is a skip pattern here. Again, the logic being that if an individual
is not able to go up and down 1 step, the person is probably not able to manage going
up and down 4 steps or 12 steps. So the skip pattern actually is to go to Pick
up object, GG0170P. As I mentioned before, somebody can certainly
go up and down in a wheelchair. I think we’ve also had questions about somebody
going up and down on their behind, totally fine. The wording is that the person “goes” up and
down, it’s not the person “steps” up and down. So it is truly going up and down. On the little sticky note there’s a coding
tip here. If the admission performance of the activity
was coded one of the activity not attempted codes, 07, 88, 09 or 10, the discharge goal
may be submitted using the 6-point rating scale. So again, the skip relates to the actual performance
column. You may still enter a goal. We have another Practice Coding Scenario here. So we have Mrs. A. She has ataxia due to a
neurologic condition. She uses a quad cane while walking. While stepping down an outdoor curb, Mrs.
A steps down with the physical therapist providing significant trunk support to help Mrs. A maintain
her balance. When stepping up the curb, Mrs. A requires
a significant amount of trunk support from the therapist. Mrs. A contributes effort; the helper provides
more than half the effort. So, again, if you think through the Decision
Tree, you’ll probably end up near the end there and you’ll have to think through who’s
providing more than half of the effort and whether the patient contributes any effort. That last bullet, obviously, is important. The options for the answers here are 04, supervision
or touching assistance. 03, partial/moderate assistance. 02, substantial/maximal assistance. 01, dependent. It looks like most people are coding 02. That seems right to me. So let’s see what the correct response is. It is indeed, 02. Mrs. A requires a helper to provide significant
trunk support while Mrs. A steps down a curb. The same amount of assistance is required
if Mrs. A steps up the curb resulting in the helper providing more than half of the effort. Going up and down the curb does not have to
occur back to back, but both are considered when coding this activity. The next activity is 4 Steps. So again, going up and down 4 steps. Somebody may certainly use a railing if that’s
available, or an assistive device, or both a railing and an assistive device. Again, similar to the skip pattern related
to 1 step, if somebody’s not able to go up and down 4 steps, we believe they probably
are not able to go up and down 12 steps, so you’ll skip over that one 12-step activity. You may still enter a goal for 4 steps, even
if that 4 Steps item gets coded one of the activity not attempted codes. The practice scenario here, Mr. F is recovering
from multiple lower extremity fractures and wears a walking boot and uses a quad cane. Mr. F slowly ascends the stairs, grasping
the stair railing with one hand and his quad cane on the other hand. The therapist provides intermittent steadying
assistance as he climbs up the 4 steps. He then turns around and requires steadying
assistance throughout the activity as he goes up and down the 4 steps. So I’ll let you code this. The options are 05, setup or clean-up assistance. 04, supervision or touching assistance. 03, partial/moderate assistance. 02, substantial/maximal assistance. Now everybody’s coded 04, and I do agree with
that. One thing I would like to highlight about
the steadying assistance that’s brought up in this example is that going up the stairs,
it was intermittent steadying assistance. On the way back it was steadying assistance
throughout. Either throughout an activity or if there’s
intermittent steadying, either of those scenarios would be coded 04. In this case it didn’t make a difference,
both were 04. The rationale here, Mr. F requires steadying
assistance intermittently going up stairs and throughout going down the stairs. If steadying assistance is intermittent or
throughout the activity, the code would be 04. He does not require weight-bearing or lifting
assistance, and that’s why it wasn’t coded a lower level. For 12 Steps, obviously, going up and down
12 steps is the activity. The scenario here is Mr. B, he’s receiving
rehabilitation following a hip fracture — or Ms. B, sorry. And her home has 12 steps from the entry level
to the second floor. During the discharge assessment, Ms. B uses
a cane and stair railing to ascend 12 steps. She goes one at a time. The physical therapist provides contact guard
assistance following behind Ms. B. When Ms. B descends the stairs, the therapist provides
contact guard assistance and holds Ms. B’s gait belt to steady her. How would you code this activity? Your options are 05, setup or clean-up assistance. 04, supervision or touching assistance. 03, partial/moderate assistance. 02, substantial/maximal assistance. It looks like most people will code 04. Let’s see what the correct response is. It is indeed, Code 04. The rationale being that she requires contact guard
assistance, which is required touching assistance. She does not require weight-bearing, lifting
assistance. We do get some questions about stairs on a
regular basis. So this is just an example of one of the ones
actually from the May training. If a patient cannot complete an activity because
he or she states that he or she is simply tired, fatigued or exhausted, should we code
this as a refusal or 88, safety concern? For example, a patient completes 8 out of
12 steps and then says he or she is done. So you’ve probably heard that, right? So we would say, in that instance, please,
use your clinical judgment. Obviously after somebody’s experienced a stroke
or a brain injury, or maybe somebody with a neurologic condition like MS, fatigue is
a significant issue for those patients. So if it’s your determination, or the patient
expresses that there is a safety concern or that they are fatigued, you may certainly
use your judgment to say that this is an 88, activity not attempted code. If in the instance you believe that the patient
is refusing to perform the activity and there’s really no underlying medical or safety issue,
you may code 07. But my guess is, most of the instances, there’s
probably a legitimate underlying issue going on. And you may certainly code that an 88, or
perhaps even — yeah, probably an 88 would be most instances. If the patient completes the activity once
during the assessment period, code based on the amount of assistance provided. One of the things that I do want to be sure
to highlight, because we have had questions about this recently and some discussions. For activities, like walking and stairs — so
let me start actually with walking. So if a patient is able to walk, let’s say,
100 feet but not 150 feet, if I’m the helper, I’m not in a position to actually walk the
remaining distance for the patient. And so in the instance where the activity
cannot be completed, so let’s say the person could only walk 100 feet, we would say the
activity was not attempted, or one of the activity not attempted codes would be used
because the activity wasn’t completed. So if an activity wasn’t completed, I’m not
in a position to know who did more than half of the effort. So for the walking items, the person needs
to be able to walk the entire distance. So if somebody goes 100 feet, obviously you
would be able to code the 10 feet. Hopefully you would be able to code the 50
feet with two turns if there’s turns. But please, for the walking activities, the
full distance does need to be traveled. They may not be able to do it on Day 1 — let’s
say they go 100 feet on Day 1 but maybe on Day 2 they go 160 feet, then you can code
based on the Day 2 assessment. So for stairs, it is possible that somebody
lifts somebody up the stairs, so somebody could be dependent; but it’s probably not
the case. I could be wrong. But it’s probably not typical that somebody
would walk up let’s say 8 steps and you carry the person the rest of the way in your facility. So again, if somebody goes up 8 steps but
not 12 steps, like in this example, you would use one of the activity not attempted codes. Again you’ve got that 3-day assessment period. So if this is discharge and they do it on
the day of discharge or the day before discharge, but they couldn’t do it a week before discharge,
you would code based on what happened during the last 3 days. But for the walking item and the stairs item,
the patient does need to be able to do the activity. And we are actually going to move to the wheelchair
items, which is different. With wheelchair, if a patient is able to wheel,
self-mobilize, 10 feet or 20 feet, but not the 50 feet, I can actually help them the
rest of the way. And I will probably make turns because turns
happen all the time during the day, into a room, into therapy, into the bathroom. So please, keep in mind that the activity
needs to be completed in order for you to be able to determine the assistance required
to complete the activity. For walking in stairs, the activity must be
completed. And because as a helper I cannot walk or go
up remaining stairs generally for a patient. Stairs and walking again, you may be using
those activity not attempted codes for those activities. So the last activity is pick up object. So this is the ability to bend, stoop from
a standing position to pick up a small object, such as a spoon from the floor. We have an example here. Mr. M has Parkinson’s disease and is deconditioned
following a recent acute care illness and an acute care stay. He has tremors and he drops stuff on the floor
frequently. He is highly motivated to perform the activity
of picking up a spoon from the floor safely. The spoon is on the floor next to the chair. Mr. M bends to pick up the spoon from the
floor and the helper provides steadying support to prevent him from falling as he completes
the activity. So how would you code this activity? 03, 04,
09, 88? It looks like most people have coded 04 here. That sounds right to me, steadying assistance. The correct response is indeed, 04, helper
provides steadying assistance. Moving on to the wheelchair items. So the first question related to wheelchair
is actually what we call a gateway question. And it basically asks if the person uses a
wheelchair or scooter. If the answer is no, then you actually will
be skipping through. You don’t need to answer the wheelchair questions
because the person doesn’t use a wheelchair or scooter. If you answer yes, you’ll go on to the next
activity. I want to highlight we do get questions about
this gateway question. Please use clinical judgment to determine
whether the person uses a wheelchair. They may be using it for learning how to self-mobilize
as a result of a medical condition or safety concern. If a patient walks and is not learning how
to use a wheelchair and basically the staff are pushing the person in the wheelchair for
transport purposes only, that doesn’t count as wheelchair use. Again, this is all about doing a clinical
assessment. So just think, if a transport person is taking
somebody to therapy in a wheelchair because it’s on a different floor or needs to go on
an elevator, that’s not a clinical assessment. So in that case if it’s just for staff convenience,
just transport, you can code no, skip out of the items. If the person is learning how to use a wheelchair,
certainly you would be assessing them. 50 feet with two turns starts with the person
seated in the wheelchair. Of course it includes those two turns. We’ve already covered the turns. So again, it could be two turns to the left,
two turns to the right, one left, one right, whatever. We have an example here. Ms. T uses an electric scooter to self-mobilize. In Ms. T’s medical record multiple clinicians
note that she needs supervision and verbal instructions to redirect her using her scooter,
so she seems to have some trouble with it. The physical therapist observes that Ms. T’s
scooter becomes wedged in a corner as she self-mobilizes 60 feet with two turns and
requires instructions. How would you code Ms. T? The options are 06, independent. 05, setup or clean-up assistance. 04, supervision or touching assistance. Or 03, partial/moderate assistance. All right. It looks like most people coded 04. That seems right to me. And that is indeed the correct response, supervision
and instructions in this case. As I mentioned before, there are follow-up
questions related to both wheelchair activities. So if you indicate somebody traveled 150 feet
with a wheelchair, please indicate whether it was a manual or motorized wheelchair or
scooter. There is a follow-up question for each distance
because it’s possible someone uses a different type of wheelchair, depending on the distance. 150 feet is, once seated, the person’s ability
to travel 150 in a corridor or similar space. The example that we have here, Mr. W is recovering
from a stroke. He has right-sided weakness that affects his
balance and a chronic respiratory condition that affects his walking endurance. By discharge he’s had a wonderful rehab program. And so he wheels slowly a manual wheelchair
160 feet down the hall without any assistance. He’s about ready to go home. How would you code him? Your options are 04, supervision or touching
assistance. 07, patient refused. 88, not attempted due to medical condition
or safety concern. 06, independent. All right. You’ve got it. That’s our last example. We wanted to have a good example for a successful
rehab program. So the rationale is he’s independent. He didn’t need assistance. Manisha covered the goals under Self-Care. So as you know, as part of the Quality Measures,
which we’ll be covering after the lunch period, at least one goal does need to be coded, one
of the self-care or mobility goals. So you can code any of the mobility goals
here. There are links to the videos available. I believe, Brigitte covered this a little
bit. And actually, I know I’ve already seen questions
about this. So if you download these slides, you can get
the links directly, or you can go on to the website and find the videos available that
you saw earlier today. There is also online web training on demand
available. It is cross-setting. So you would select and indicate your facility
and you would get these four lessons available. In summary, Manisha and I covered the Section
GG, Self-Care/Mobility activities. I think one of the important things is these
are based on assessments. You’ve got a 3-day assessment period. If you code one of the activity not attempted
codes, that means the activity didn’t occur. We covered the item definitions. We coded the instructions. We talked about some key coding points. We did a lot of practice scenarios. It seems like you did really well. There was just a few questions here and there
that a few people didn’t get correct. So at this point I think I’m going to turn
it over to Brigitte because I think we have a lunch break coming up. (Applause)

Leave a Reply

Your email address will not be published. Required fields are marked *