Section GG Functional Abilities Flashcards
1
Q
06
A
Independent
2
Q
A patient is independent if they
A
if they can complete the activity by him/herself with
no helper assisting them
3
Q
05
A
Set up or clean up assistance
4
Q
When is a patient considered set up or clean up assistance?
A
if the helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity
5
Q
04
A
supervision or touching assistance
6
Q
When is a patient considered supervision or touching assistance?
A
If the helper provides verbal cues and or touching/steadying assistance and/or contact guard assist, as patient completes activity. Assistance may be provided throughout the activity or intermittently.
7
Q
03
A
partial/moderate assistance
8
Q
Partial/moderate assistance is considered what?
A
When a helper does LESS THAN HALF the effort. Helper lifts or holds the trunk or limbs, but provides less than half of the effort
9
Q
02
A
substantial/maximum assistance
10
Q
substantial/maximum assistance is considered what
A
helper does more than half of the effort
11
Q
01
A
Dependent
12
Q
When is a patient considered to be dependent?
A
when the helper does all of the effort. The patient does none of the effort to compete the task. or the assistance of two or more helpers is required to do the task.
13
Q
07
A
Patient Refused
14
Q
09
A
Not applicable as the activity was not attempted because the patient did not perform this activity prior to the current illness, exacerbation, or injury
15
Q
10
A
Not attempted due to environmental limitations (lack of equipment, weather constraints)
16
Q
88
A
not attempted due to medical condition or safety concern
17
Q
What are the GG codes OT is expected to score upon admission/discharge?
A
Eating, Oral Hygiene, Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/off footwear, toilet transfer
18
Q
Eating Definition
A
the ability to use suitable utensils to bring food and/or liquid to mouth and swallow food and/or liquid once the meal is placed before the patient
administration of tube feedings and parenteral nutrition is not considered
19
Q
Oral Hygiene (& Dentures if applicable)
A
The ability to use suitable items to clean teeth.
Dentures (if applicable) The ability to insert and remove dentures into and from the mouth, manage denture soaking and rinsing with use of equipment
20
Q
Toileting hygiene
A
the ability to maintain perineal hygiene & adjust clothes before and after voiding or having a bowel movement on toilet/commode/bedpan, or urinal
If managing an ostomy, this includes wiping the opening but not managing equipment.
indwelling urinary catheter is not scored with toileting hygiene
21
Q
Shower/bathing self includes:
A
the ability to bathe self; including washing, rinsing, and drying self (excludes washing of back and hair).
22
Q
Showering/bathing does not include what?
A
transferring in/out of the shower/tub and washing of back and hair
23
Q
Upper body dressing includes:
A
the ability to dress and undress above the waist.
includes fasteners,
24
Q
Lower body dressing includes:
A
the ability to dress and undress below the level of the waist
not including footwear
25
Putting on/taking off footwear includes:
the ability to put on and take off socks/shoes
| includes fasteners
26
How long is the assessment period that therapy has to collect scores for patients "usual performance"?
3 days
beginning on day of admit and until 11:59pm 2 days after admission
27
What is considered to be the discharge assessment period?
Day of discharge and 2 calendar days prior to day of discharge
28
What is the correct code?
patient requires assistance to cut up food or opening containers?
05 setup/clean up assistance
29
What is the correct code?
patient requires verbal cues, coaxing, or general supervision for safety to complete activity?
04 supervision
30
What is the correct code?
patient requires incidental help for steadying assist with dressing
04 supervision/contact guard assist
31
How may licensed clinicians assess the patients performance?
direct observation
| reports from patient's self-report, clinicians, care staff, or family during 3 day assessment period
32
What type of performance is scored during assessment period?
usual performance. not best and not worst
33
What is the correct code?
patient does not eat or drink by mouth and relies solely on nutrition and liquids through tube feedings or total parenteral nutrition (TPN) due to a new (recent-onset) medical condition,
88 not attempted due to medical condition or safety concerns
34
What is the correct code?
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
09 not applicable and the patient did not perform this activity prior to the current illness, exacerbation, or injury
35
what is the correct code?
If the patient eats and drinks by mouth, and relies partially on obtaining nutrition and liquids via tube feedings or parenteral nutrition requiring assistance to open containers at breakfast.
05 set up assist
36
What is the correct code?
Ms. S usually becomes extremely fatigued and requests assistance from the certified nursing assistant to feed her the remainder of the meal.
03, Partial/moderate assistance.
Rationale: The certified nursing assistant provides less than half the effort for the patient to complete the activity of eating for all meals.
37
Mr. M has upper extremity weakness and fine motor impairments. The occupational therapist places an adaptive device onto Mr. M’s hand that supports the eating utensil within his hand. At the start of each meal Mr. M can bring food and liquids to his mouth. Mr. M then tires and the certified nursing assistant feeds him more than half of each meal.
02, Substantial/maximal assistance. Rationale: The helper provides more than half the effort for the patient to complete the activity of eating at each meal. 3
38
What is the correct code?
Mr. A eats meals without any physical assistance or supervision from a helper. He has a gastrostomy tube (G-tube), but it is no longer used, and it will be removed later today.
06, Independent. Rationale: The patient can independently complete the activity without any assistance from a helper for this activity. In this scenario, the presence of a G-tube does not affect the eating score. 4
39
What is the correct code?
The nurse opens all of Mr. S’s cartons and containers on his food tray before leaving the room. There are no safety concerns regarding Mr. S’s ability to eat. Mr. S eats the food himself, bringing the food to his mouth using appropriate utensils and swallowing the food safely.
05, Setup or clean-up assistance. Rationale: The helper provides setup assistance only prior to the activity
40
What is the correct code?
Mrs. H does not have any food consistency restrictions, but often needs to swallow two or three times so that the food clears her throat due to difficulty with pharyngeal peristalsis. She requires verbal cues to use the compensatory strategy of extra swallows to clear the food.
04, Supervision or touching assistance. Rationale: Mrs. H swallows all types of food consistencies, and requires verbal cueing (supervision) from the helper. Code based on assistance from the helper. The coding is not based on whether the patient had restrictions related to food consistency
41
What is the correct code?
Mrs. V has had difficulty seeing on her left side since her stroke. During meals, a helper must remind her to view her entire meal tray to ensure she has seen all the food.
04, Supervision or touching assistance. Rationale: The helper provides verbal cueing assistance as Mrs. V completes the activity of eating. Supervision, such as reminders, may be provided throughout the activity or intermittently.
42
Correct code?
Mrs. N is impulsive. While she eats, a helper provides verbal and tactile cueing so that Mrs. N does not lift her fork to her mouth until she has swallowed the food in her mouth
04, Supervision or touching assistance. Rationale: The patient requires supervision and touching assistance to eat safely
43
Correct Code?
Mr. R is unable to eat or drink by mouth since he had a stroke 1 week ago. He receives nutrition and fluids through a G-tube, which is administered by nurses
88, Not attempted due to medical condition or safety concerns. Rationale: The patient does not eat or drink by mouth at this time due to his recent onset stroke. This item includes eating and drinking by mouth only. If eating and drinking do not occur due to a recent-onset medical condition, then the activity is coded as 88, Not attempted due to medical condition. Assistance with G-tube feedings is not considered when coding this item. 9
44
Correct Code?
Mr. F is fed all meals by the certified nursing assistant, because Mr. F has severe arm weakness, and he is unable to assist in the eating activity
01, Dependent Rationale: The helper does all of the effort. The patient does not contribute any effort to complete the activity
45
Correct Code?
In the morning and at night, Mrs. F brushes her teeth while sitting on the side of the bed. Each time, the certified nursing assistant gathers her toothbrush, toothpaste, water, and an empty cup and puts them on the bedside table for her before leaving the room. Once Mrs. F is finished brushing her teeth, which she does without any help, the certified nursing assistant returns to gather her items and dispose of the waste
05, Setup or clean-up assistance. Rationale: The helper provides setup and clean-up assistance. The patient brushes her teeth without any help. 2
46
Correct code?
Before bedtime, the nurse provides steadying assistance to Mr. S as he walks to the bathroom. The nurse applies toothpaste onto Mr. S’s toothbrush. Mr. S then brushes his teeth at the sink in the bathroom without physical assistance or supervision. Once Mr. S is done brushing his teeth and washing his hands and face, the nurse returns provides steadying assistance as the patient walks back to his bed
05, Setup or clean-up assistance.
The helper provides setup assistance (putting toothpaste on the toothbrush) before Mr. S brushes his teeth. Do not consider assistance provided to get to or from the bathroom to score Oral hygiene
47
Correct code?
Before bedtime, the certified nursing assistant provides Mrs. K water and toothpaste to clean her dentures. Mrs. K cleans her upper denture plate. Mrs. K then cleans half of her lower denture plate, but states she is tired and unable to finish cleaning her lower denture plate. The certified nursing assistant finishes cleaning the lower denture plate and Mrs. K replaces the dentures in her mouth.
03, Partial/moderate assistance. Rationale: The helper provides less than half the effort to complete oral hygiene.
48
Correct Code?
Mr. W is edentulous (without teeth) and his dentures no longer fit his gums. Mr. W begins to brush his upper gums after the helper applies toothpaste onto his toothbrush. He brushes his upper gums, but cannot finish due to fatigue. The helper completes the activity of oral hygiene by brushing his back upper gums and his lower gums
02, Substantial/maximal assistance. Rationale: The patient begins the activity. The helper completes the activity by performing more than half the effort. 5
49
Correct code?
Mr. G has Parkinson’s disease, resulting in tremors and incoordination. The certified nursing assistant retrieves all oral hygiene items for Mr. G and applies toothpaste to his toothbrush. Mr. G requires assistance to guide the toothbrush into his mouth and to steady his elbow while he brushes his teeth. Mr. G usually starts by brushing his upper and lower front teeth and the certified nursing assistant completes the activity by brushing the rest of his teeth.
02, Substantial/maximal assistance. Rationale: The helper provides more than half the effort for the patient to complete the activity of oral hygiene
50
Correct Code?
Ms. T is recovering from a severe traumatic brain injury and multiple bone fractures. She does not understand how to use oral hygiene items nor does she understand the process of completing oral hygiene. The certified nursing assistant brushes her teeth and explains each step of the activity to engage cooperation from Ms. T; however, she requires full assistance for the activity of oral hygiene
01, Dependent. Rationale: The helper provides all the effort for the activity to be completed
51
What if patient does not use undergarments in regards to scoring toileting?
assess patient's need for assistance to manage lower body clothing and perineal hygiene
52
correct code?
Mrs. J uses a bedside commode. The certified nursing assistant provides steadying (touching) assistance as Mrs. J pulls down her pants and underwear before sitting down on the toilet. When Mrs. J is finished voiding or having a bowel movement, the certified nursing assistant provides steadying assistance as Mrs. J wipes her perineal area and pulls up her pants and underwear without assistance
04, Supervision or touching assistance. Rationale: The helper provides steadying (touching) assistance to the patient to complete toileting hygiene. 2
53
correct code?
Mrs. L uses the toilet to void and have bowel movements. Mrs. L is unsteady, so the certified nursing assistant walks into the bathroom with her in case she needs help. During the assessment period, a staff member has been present in the bathroom, but has not needed to provide any physical assistance with managing clothes or cleansing
04, Supervision or touching assistance. Rationale: The helper provides supervision as the patient performs the toileting hygiene activity. The patient is unsteady and the staff provide supervision for safety reasons. 3
54
correct code?
Mrs. P has urinary urgency. As soon as she gets in the bathroom, she asks the certified nursing assistant to lift her gown and pull down her underwear due to her balance problems. After voiding, Mrs. P wipes herself, pulls her underwear back up and adjusts her gown
03, Partial/moderate assistance. Rationale: The helper provides more than touching assistance. The patient performs more than half the effort; the helper does less than half the effort. The patient does two of the three toileting hygiene task
55
correct code?
Ms. Q has a progressive neurological disease that affects her fine and gross motor coordination, balance, and activity tolerance. She wears a hospital gown and underwear during the day. Ms. Q uses the bedside commode as she steadies herself in standing with one hand and initiates pulling down her underwear with the other hand but needs assistance to complete this activity owing to her coordination impairment. After voiding, Ms. Q wipes her perineal area without assistance while sitting on the commode. When Ms. Q has a bowel movement, a certified nursing assistant performs perineal hygiene as Ms. Q needs to steady herself with both hands to stand for this activity. Ms. Q is usually too fatigued at this point and requires full assistance to pull up her underwear
02, Substantial/maximal assistance. Rationale: The helper provided more than half the effort needed for the patient to complete the activity of toileting hygiene
56
Correct code?
Mr. J is morbidly obese and has a diagnosis of debility. He requests the use of a bed pan when voiding or having bowel movements and requires two certified nursing assistants to pull down his pants and underwear and to mobilize him onto and off the bedpan Mr. J is unable to complete any of his perineal/perianal hygiene. Both certified nursing assistants help Mr. J pull up his underwear and pants
01, Dependent. Rationale: The assistance of two helpers was needed to complete the activity of toileting hygiene
57
correct code?
Mr. J. sits on a tub bench as he washes, rinses and dries himself. A certified nursing assistant stays with him to ensure his safety, as Mr. J has had instances of losing his sitting balance. The certified nursing assistant also provides lifting assistance as Mr. J gets onto and off of the tub bench
04, Supervision or touching assistance. Rationale: The helper provides supervision as Mr. J. washes, rinses, and dries himself. The transfer onto or off of the tub bench is not considered when coding the Shower/bathe self activity.
58
Correct Code?
Mrs. E has a severe and progressive neurological condition that has affected her endurance as well as her fine and gross motor skills. She is transferred to the shower bench at partial/moderate assistance. When showering she uses a wash mitt that was provided by the acute care facility prior to her admission to the inpatient rehabilitation facility. Mrs. E showers while sitting on a shower bench and washes her arms and chest using a wash mitt. A certified nursing assistant then must help wash the remaining parts of her body, as a result of Mrs. E’s fatigue, to complete the activity. Mrs. E uses a hand-held showerhead to rinse herself but tires half way through the task. The certified nursing assistant dries Mrs. E.’s entire body.
02, Substantial/maximal assistance. Rationale: The helper assists Mrs. E with more than half of the task of showering, which includes bathing, rinsing and drying her body. The transfer onto the shower bench is not considered in coding this activity.
59
Correct Code?
Mr. Y has limited mobility resulting from his multiple and complex medical conditions. He prefers to wash his body while sitting in front of his sink in his bathroom. Mr. Y washes, rinses, and dries his face, chest, and abdomen. A helper assists with washing, rinsing, and drying Mr. Y’s arms/hands, upper legs, lower legs, buttocks, and back
02, Substantial/maximal assistance. Rationale: The helper completed more than half the activity. Bathing may occur at the sink. When coding this activity, do not include assistance provided with washing, rinsing, or drying the patient’s back.
60
When coding upper body dressing and lower body dressing, helper assistance with buttons and/or fasteners is considered __________________
touching assistance 04
61
Do you score don/doffing of elastic bandage, compression stockings, or an orthosis/prosthesis with dressing?
yes.
then count the elastic bandage/compression stocking/orthosis/prosthesis as a piece of clothing when determining the amount of assistance, the patient needs when coding the dressing item
62
Upper body dressing items includes:
bra, undershirt, T-shirt, button-down shirt, pullover shirt, dresses, sweatshirt, sweater, and pajama top.
thoracic-lumbar-sacrum-orthosis (TLSO), abdominal binder, back brace, stump sock/shrinker, upper body support device, neck support, hand or arm prosthetic/orthotic
cannot count hospital gown
63
Lower body dressing items include
underwear, incontinence brief, slacks, shorts, capri pants, pajama bottoms, and skirts, knee brace, elastic bandage, stump sock/shrinker, lower-limb prosthesis
64
Footwear items include
socks, shoes, ankle foot orthosis (AFO), elastic bandages, foot orthotic, orthopedic walking boots, compression stockings (considered footwear because of dressing don/doff over foot)
65
correct code?
patient with recent Bilateral lower extremity amputation performed activity of putting on/taking off footwear but now unable due to current condition.
88 88, Not attempted due to medical condition or safety concern
66
correct code:
patient with history of Bilateral lower extremity amputation and has not been don/doffing footwear
code as 09, Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury
67
What do you need to consider for patient with single limb amputation in regards to don/doffing footwear?
the activity of putting on/taking off footwear could apply to the intact limb or both the limb with the prosthesis and the intact limb.
— If the patient performed the activity of putting on/taking off footwear for the intact limb only, then code based upon the amount of assistance needed to complete the activity.
— If the patient performed the activity of putting on/taking off footwear for both the intact limb and the prosthetic limb then code based upon the amount of assistance needed to complete the activity
68
Correct Code?
Mrs. Y has right-side upper extremity weakness as a result of a stroke and has worked in therapy to re-learn how to dress her upper body. During the day, she requires a certified nursing assistant only to place her clothing next to her bedside. Mrs. Y can now use compensatory strategies to put on her bra and top without any assistance. At night she removes her top and bra independently and puts the clothes on the nightstand and the certified nursing assistant puts them away in her dresser
05, Set-up or clean-up assistance. Rationale: Mrs. Y dresses and undresses her upper body and requires a helper only to retrieve and put away her clothing, that is, setting-up the clothing for her use. The description refers to Mrs. Y as “independent” (when removing clothes), but she needs set-up assistance, so she is not independent with regard to the entire activity of upper body dressing.
69
correct code?
Mr. D has Parkinson’s disease resulting in mild tremors in his upper extremities upon intentional movement. Mr. D has worked hard with an occupational therapist to increase his independence in self-dressing. Mr. D prefers to wear loose undershirts and sweaters with buttons or zippers. He puts on and takes off his undershirt and sweaters without assistance; however, he requires only touching assistance with buttons and zippers by the certified nursing assistant during upper body dressing
04 supervisio
Mr. D needs a helper to provide touching assistance (button or zipper his upper body clothing) to complete the activity. When coding upper body dressing and lower body dressing, helper assistance with buttons and/or fasteners is considered touching assistance
70
correct code?
Mrs. Z wears a bra and a sweatshirt most days while in the rehabilitation program. She requires assistance from a certified nursing assistant to initiate the threading of her arms into her bra. Mrs. Z completes the placement of the bra over her chest. The helper hooks the bra clasps. Mrs. Z pulls the sweatshirt over her arms, head, and trunk. When undressing, Mrs. Z removes the sweatshirt with the helper assisting her with one sleeve. Mrs. Z slides the bra off once it has been unclasped by the helper
03, Partial/moderate assistance. Rationale: The helper provides assistance with threading Mrs. Z’s arms into her bra, hooking and unhooking her bra clasps, and assistance with removing one sleeve of the sweatshirt. Mrs. Z performs more than half of the effort
71
correct code?
Mr. K sustained a spinal cord injury that has affected both movement and strength in both upper extremities. He places his left hand into one-third of his left sleeve of his shirt with much time and effort and is unable to continue with the activity. A certified nursing assistant then completes the remaining upper body dressing for Mr. K.
02, Substantial/maximal assistance. Rationale: Mr. K can perform a small portion of the activity of upper body dressing and requires assistance by a helper for more than half of the effort of upper body dressing
72
correct code?
Mr. D is required to follow hip precautions as a result of recent hip surgery. The occupational therapist in the acute care hospital instructed him in the use of adaptive equipment to facilitate lower extremity dressing. He requires a helper to retrieve his clothing from the closet. Mr. D uses his adaptive equipment to assist in threading his legs into his pants. Because of balance issues, Mr. D needs the helper to steady him when standing to manage pulling on or pulling down his pants/undergarments. Mr. D also needs some assistance to put on and take off his socks and shoes
04, Supervision or touching assistance. Rationale: A helper steadies Mr. D when he is standing and performing the activity of lower body dressing, which is supervision or touching assistance. Putting on and taking off socks and shoes is not considered when coding lower body dressing nor is putting on and taking off adaptive equipment associated with the foot, for example Ankle Foot Orthosis. These are considered when coding putting on and taking off shoes and socks
73
Correct Code?
Mrs. M has severe rheumatoid arthritis and multiple fractures and sprains due to a fall. She has been issued a knee brace, to be worn during the day. Mrs. M threads her legs into her garments, and pulls up and down her clothing to and from just below her hips. Only a little assistance from a helper is needed to pull up her garments over her
CMS IRF-PAI Manual Chapter 2: Section GG
IRF-PAI Version 3.0, Effective October 1, 2019 Page GG-20
hips. Mrs. M requires the helper to fasten her knee brace because of grasp and fine motor weakness
03, Partial/moderate assistance. Rationale: A helper provides only a little assistance when Mrs. M is putting on her lower extremity garments and fastening the knee brace. The helper provides less than half of the effort. Assistance putting on and removing the knee brace she wears is considered when determining the help needed when coding lower body dressing. 3
74
Correct Code?
Mrs. R has peripheral neuropathy in her upper and lower extremities. Each morning, Mrs. R needs assistance from a helper to place her lower limb into, or to take it out of (don/doff), her lower limb prosthesis. She needs no assistance to put on and remove her underwear or slacks
03, Partial/moderate assistance. Rationale: A helper performs less than half the effort of lower body dressing (with a prosthesis considered a piece of clothing). The helper lifts, holds, or supports Mrs. R’s trunk or limbs, but provides less than half the effort for the task of lower body dressing.
75
Correct code?
Mr. M is undergoing rehabilitation for right-side upper and lower body weakness following a stroke. He has made significant progress toward his independence and will be discharged to home tomorrow. Mr. M wears an ankle-foot orthosis that he puts on his foot and ankle after he puts on his socks but before he puts on his shoes. He always places his AFO, socks, and shoes within easy reach of his bed. While sitting on the bed, he needs to bend over to put on and take off his AFO, socks, and shoes, and he occasionally loses his sitting balance, requiring staff to place their hands on him to maintain his balance while performing this task.
04, Supervision or touching assistance. Rationale: Mr. M puts on and takes off his AFO, socks, and shoes by himself; however, because of occasional loss of balance, he needs a helper to provide touching assistance when he is bending over. 2
76
correct code?
Mrs. F was admitted to rehabilitation for a neurologic condition and experiences visual impairment, and fine motor coordination and endurance issues. She requires set-up for retrieving her socks and shoes, which she prefers to keep in the closet. Mrs. F often drops her shoes and socks as she attempts to put them onto her feet or as she takes them off. Often a certified nursing assistant must first thread her socks or shoes over her toes, and then Mrs. F can complete the task. Mrs. F needs the certified nursing assistant to initiate taking off her socks and unstrapping the Velcro used for fasting her shoes
02, Substantial/maximal assistance. Rationale: A helper provides Mrs. F with assistance in initiating putting on and taking off her footwear because of her limitations regarding fine motor coordination putting on/taking off footwear. The helper completes more than half of the effort with this activity.
77
Toilet transfer includes
patient’s ability to get on and off a toilet (with or without a raised toilet seat), or bedside commode. Do not consider or include GG0130C, Toileting hygiene item tasks (managing clothing, undergarments, or perineal hygiene) when assessing the Toilet transfer item. Transferring on and off a bedpan is not included in Toilet transfer.
78
correct code?
patient usually needs a helper to position/set-up the bedside commode before and/or after the patient’s bed to commode transfers (place at an accessible angle/location next to the bed
05 setup or clean up assistance
79
correct code?
The certified nursing assistant moves the wheelchair foot rests up so that Ms. T can transfer from the wheelchair onto the toilet by herself safely. The certified nursing assistant is not present during the transfer, because supervision is not required. Once Mrs. T completes the transfer from the toilet back to the wheelchair, she flips the foot rests back down herself.
05, Setup or clean-up assistance Rationale: The helper provides setup assistance (moving the foot rest out of the way) before Mrs. T can transfer safely onto the toilet
80
correct code?
Mrs. Q transfers on and off the elevated toilet seat with the certified nursing assistant supervising due to her unsteadiness.
04, Supervision or touching assistance. Rationale: The helper provides supervision as the patient transfers on and off the toilet. The patient may use an assistive device
81
Correct code?
Mrs. Y is anxious about getting up to use the bathroom. She asks the certified nursing assistant to stay with her in the bathroom as she gets on and off the toilet. The certified nursing assistant stays with her, as requested, and provides verbal encouragement and instructions (cues) to Mrs. Y.
04, Supervision or touching assistance Rationale: The helper provides supervision/verbal cues as Mrs. Y transfers onto and off the toilet. 4
82
correct code?
The certified nursing assistant provides steadying (touching) assistance as Mrs. Z lowers her underwear and then transfers onto the toilet. After voiding, Mrs. Z cleanses herself. She then stands up as the helper steadies her. Mrs. Z pulls up her underwear as the helper steadies her to ensure Mrs. Z does not lose her balance.
04, Supervision or touching assistance
The helper provides steadying assistance as the patient transfers on and off the toilet. Assistance with managing clothing and cleansing is coded under item GG0130C, Toileting hygiene, and is not considered when rating the Toilet transfer item
83
Correct code?
The therapist supports Mrs. M’s trunk with a gait belt as Mrs. M pivots and lowers herself onto the toilet. The therapist provides less than half the effort during the toilet transfer.
03, Partial/moderate assistance. Rationale: The helper provides less than half the effort to complete the activity. The assistance provided to the patient was physical support or weight bearing assistance
84
correct code?
03, Partial/moderate assistance. Rationale: The helper provides less than half the effort to complete the activity. The assistance provided to the patient was physical support or weight bearing assistance
03, Partial/moderate assistance. Rationale: The helper provides less than half the effort to complete the activity. The assistance provided to the patient was physical support or weight bearing assistance
85
Correct code?
Mr. H has paraplegia incomplete, pneumonia, and COPD. Mr. H prefers to use the bedside commode when having a bowel movement. Due to his severe weakness, history of falls, and dependent transfer status, two certified nursing assistants assist during the toilet transfer.
01, Dependent. Rationale: The activity required the assistance of two or more helpers for the patient to complete the activity.
86
Correct code?
Mrs. S is on bed rest due to a medical complication. She uses a bedpan for bladder and bowel management during the entire 3-day assessment period.
coded 88, Not attempted due to medical condition or safety concerns. Rationale: The patient does not transfer onto or off a toilet due to being on bedrest because of a newly acquired medical condition.
87
Correct code?
a patient can dress her upper body, except for requiring assistance with her bra clasp.
03 partial/moderate assist
If a patient requires assistance with dressing including assistance with any type of fasteners (e.g. with buttons, zippers and/or fastening a bra) code based on the type and amount of assistance required to complete the entire upper body dressing activity. If a patient requires assistance with fasteners and a helper provides less than half the effort code 03-Partial/moderate assistance.
88
Rolling left and right is considered the..
the ability to roll from lying on back to left and right side; and return to lying on back on the bed
89
sit to lying is considered
the ability to move from sitting on side of bed to lying flat in bed
90
lying to sitting on side of bed is considered
the ability to move from lying on the back to sitting on the side of the bed with feet flat on floor
91
sit to stand is considered
the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed
92
chair/bed to chair transfer is considered
the ability to transfer to and from a bed or chair to wheelchair
