Functional Assessment Status for Ambulation Section GG

Please clarify the following scenario to better understand MDS coding rationale for Functional Assessment Status for Ambulation Section GG.

Question

Please clarify the following scenario to better understand MDS coding rationale for Functional Assessment Status for Ambulation Section GG.

“A patient is observed to be unable to walk the entire 150 feet, how would we best describe how to accurately code on MDS 3.0 section GG for:

1. Admission status
2. Goal status
3. Discharge status?”

Answer

Admission status: In this case where resident initiated walking however, the resident was unable to complete the task of ambulating 150. The Admission Status item should be coding as “88”

Not attempted due to medical condition or safety concerns.

However, Kris B Harmony (KBH), recommends further investigation of the reason why the resident was unable to walk.  The response to Section GG0170H1 “Does the resident walk?” will assist in assessor response for Goal Status.

Goal Status:  As for the goals please note the gateway question asks the assessor “Does the resident walk?”  The purpose of this question is the establish skip criteria.  Section GG0170H1

Does the resident walk?

1. No, and walking goal is not clinically indicated. And then Skip to GG0170Q1, Does the resident use a wheelchair/scooter?

1. No, and walking goal is clinically indicated Code the resident's discharge goal(s) for items GG0170J and GG0170K.

1. Yes, continue to GG0170J Walk 50 feet with two turns.

When the assessor codes 0, “No” this indicates the resident does not walk and a walking goal for discharge is not clinically indicated.  This would likely be the response for a resident who was unable to ambulate prior to the onset of the current illness (perhaps because he is a longstanding double amputee with no prosthetics) In this case the coder is instructed to skip to the question about whether the resident uses a wheelchair.