MDS Alert

Beware that sometimes the answer isn’t what you think it will be.

Coding accurately for item G0110 — Activities of Daily Living (ADL) Assistance is no easy task. So the fact that many MDS coders are doing this wrong shouldn’t surprise you. Here are five scenarios that explain why you might be making some common mistakes when coding ADLs.

Pay attention: You should review Section G in the RAI manual, because “we are finding that many are not understanding it correctly,” noted Joan Brundick, RN, BSN, RAC-CT in the July issue of Quality Improvement Program for Missouri’s Long-Term Care Facilities’ (QIPMO’s) MDS Tips and Clinical Pearls.

And you cannot simply rely on the ADL Self-Performance Algorithm in the RAI manual (page G-7) to get the correct coding answers. “CMS made a point to say that the algorithm is only to augment what is in the text of the RAI manual,” Brundick cautioned.

Warning: “It is the responsibility of the facility to be sure that the ADLs are reported accurately,” stressed Angela Gibbs, RN, a healthcare consultant with Myers and Stauffer LC, in the June issue of North Carolina News. 

Think Twice Before Using ‘Exceptions’

Myers and Stauffer offers the following examples to clarify ADL coding using the Rule of 3:

Example 1: The resident ADL self-performance scores are 3, 3, 2, 2, 0, 0, 0, 0.

Under the Rule of 3, the first rule applies because the activity occurred three times as 0 — Independent, but you cannot use 0 because it’s an exception. The second rule does not apply, and the third rule does not apply because the activity did occur at least three times at 0.

Therefore, you would follow the RAI Manual’s instructions: “If none of the above are met, code supervision.” 

Answer: The answer for this example is 1 — Supervision.

Example 2: The resident ADL self-performance scores are 4, 3, 2, 2, 1, 1, 1, 1, 8, 8, 0, 0, 0.

For this example, the applicable Rule of 3 is the second rule: “When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times.” Here the resident scored 1 — Supervision and 0 — Independent three or more times each.

Answer: So if you code the most dependent level that occurred three or more times, the correct coding is 1 — Supervision.

Example 3: The resident ADL self-performance scores are 4, 4, 3, 3, 2, 2, 1, 0, 8, 8.

The applicable Rule of 3 for this example is 3b: “When there is a combination of full staff performance and weight-bearing assistance that total three or more times — code extensive assistance (3).”

Answer: The correct coding here is 3 — Extensive assistance.

Example 4: The resident ADL self-performance scores are 4, 3, 2, 2, 1, 1, 0, and the rest are left blank.

The applicable Rule of 3 is 3c: “When there is a combination of full staff performance/weight-bearing assistance, and/or non-weight-bearing assistance that total three or more times — code limited assistance (2).”

Answer: Therefore, this combination of ADL self-performance values is 2 — Limited assistance.

Be Patient to Find the Answer When Nothing Fits

And Brundick provides this additional example:

Example 5: The resident ADL self-performance scores are 3, 3, 4, 0 (31 times).

For this example, you could not code 0 — Independent because the resident didn’t perform the ADL independently every time.

And to code 3 — Extensive assistance, the resident must perform part of the ADL over the last seven days and receive help of the following type(s) three or more times: weight-bearing support provided three or more times; OR full staff performance of activity three or more times during part, but not all, of the last seven days.

But you could not code 3 — Extensive assistance because weight-bearing assistance occurred only twice and full staff performance occurred only once.

Then, you would likely look to the third Rule of 3: “When an activity occurs three or more times and at multiple levels, but not three times at any one level, apply the following: a) Convert episodes of full staff performance to weight-bearing assistance when applying the third Rule of 3, as long as the full staff performance episodes did not occur every time the ADL was performed in the 7-day look-back period.”

So if the activity did not occur three times at any one level, then you can convert. “However, in this scenario the activity did occur more than three times at any one level (it occurred 31 times at the independent level),” Brundick noted. “So this third rule does not apply.” This means that you cannot code 3 — Extensive assistance (full staff performance) because you cannot convert the one episode of 4 — Total dependence to the two episodes of 3 — Extensive assistance (weight-bearing assistance).

You can also review the four exceptions to the Rule of 3, none of which apply to this scenario. Therefore, you must follow the final instruction for the Rule of 3: “If none of the above are met, code supervision.”

Answer: So for this example, you would code 1 — Supervision.

Don’t forget: Because of all the confusion over the Rule of 3, CMS released an instructional video on Section G, “which is well worth your time to view,” Gibbs noted. The video is available at www.youtube.com/watch?v=t-6e5NV4j6k. And if you still have questions, Gibbs recommended contacting your state RAI coordinator for assistance.