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Complete Guide to:

MDS Section GG Coding

Self Study Guide

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Presented By

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clinical@smkmedical.com�PH: 313-314-8267

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DISCLAIMER

This presentation is an educational resource for long-term care professionals, reflecting current federal regulations and practices as of the publication date. It should not be considered absolute or universally applicable. The information provided must be interpreted in the context of individual organizational and state regulations.

This content aims to offer practical knowledge on the covered subject matter and is provided with the understanding that SMK Medical LLC and MDS Education are not offering legal advice or other professional services.

Please note that it is the responsibility of the student or observer to validate the information, as CMS rules and regulations may change over time.

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Goal: Focused Learning

For: MDS, Staff Nurses, C.N.A.

MDS: Section: GG CODING

The Programming Guide:

I Wish I Had When I Started Learning to Code the ADL’s

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ADL VERBIAGE

POC documentation in PCC – looks like this for CENA charting

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INDEPENDENT

Resident completes the activity by themselves with NO assistance from a helper.

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Helper sets up or Cleans up; resident completes activity.
Helper assists only prior to or following the activity.

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SUPERVISION OR TOUCHING ASSISTANCE

Helper provides VERBAL CUES and/or TOUCHING/STEADYING and or contact guard assistance as resident completes activity.
This is NON WEIGHT BEARING assistance. The resident is the one who is bearing all the weight.

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PARTIAL/MODERATE ASSISTANCE

Helper does LESS THAN HALF of the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.

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SUBSTANTIAL / MAXIMAL ASSISTANCE

Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

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WEIGHT BEARING ASSISTANCE �“EXTENSIVE” ASSIST WILL NOW BE MORE SPECIFIC WITH 2 DEFINITIONS

Partial Moderate Assistance
Helper does LESS THAN HALF the effort.
Helper LIFTS, HOLDS, SUPPORTS trunk or limbs but provides less than half the effort.
Patient is bearing most of the weight
Patient does more = Partial Moderate Assist

Substantial/Maximal Assistance
Helper does MORE THAN HALF the effort.
Helper LIFTS or HOLDS trunk or limbs and provides more than half the effort.
Staff is bearing most of the weight
Staff does more = Substantial/Maximal assistance

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DEPENDENT

Helper does ALL of the effort. Resident does none of the effort to complete the activity. OR, the assistance of 2 or more helpers is required for the resident to complete the activity.

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PCC: ADL TASKS IN POC

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BED MOBILITY

Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support.

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SIT TO STAND

Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.

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TRANSFERS

Toilet transfer: The ability to get on and off a toilet or commode.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).

Tub/shower transfer: The ability to get in and out of a tub/shower.

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EATING

Eating: 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 resident.

Residents who are NPO and do not bring food or liquid to the mouth should be coded as not attempted or not applicable

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TOILETING

Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.

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DRESSING

Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.

Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.

Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.

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HYGIENE

Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment.

Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene).

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LET'S PRACTICE

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QUESTION: EATING

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ANSWER:�� PARTIAL MODERATE ASSISTANCE

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QUESTION: ORAL HYGIENE

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ANSWER: ��SET UP OR CLEAN UP

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QUESTION:�TOILETING HYGIENE

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ANSWER: ��SUPERVISION OR TOUCHING ASSIST

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QUESTION: SHOWER/BATHE

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ANSWER:�� SUPERVISION OR TOUCHING ASSIST

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QUESTION: DRESSING

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ANSWER:�� PARTIAL MODERATE ASSIST

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