MDS Alert

When all else fails, coding supervision is your only choice.

With Item G0110 — Activities of Daily Living (ADL) Assistance on surveyors’ radar for the MDS Focused Surveys, your ADL coding accuracy is more important than ever before. And if you’re still foggy on the “Rule of 3,” now is the time to really get a handle on it.

In a Jan. 21 training for the Pennsylvania Association of Nurse Assessment Coordinators, Terry Raser, RN, RAC-CT, C-NE, CIC, senior consultant with LW Consulting Inc., provides the following scenarios that illustrate how to navigate coding ADLs using the Rule of 3:

Nail Down the First Rule

The first rule in the Rule of 3 is: When an activity occurs three or more times at any one level, code that level.

Scenario #1: Twice, Mr. X required guided maneuvering of his arms to don his shirt. Four times, he had pain in his shoulders and required staff to assist him with his shirt by physically lifting each of his arms. This component of the dressing ADL occurred six times in the seven-day lookback period.

How to code: Code this scenario as 3 — Extensive assistance. The episodes of care occurred three or more times at one level, weight bearing, which is consistent with the Rule of 3. You would not code 2 — Limited assistance, because the non-weight-bearing assistance occurred only twice.

Code for Multiple Levels This Way

The second Rule of 3 states: When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times.

Scenario #2: Mrs. C required verbal cueing four times for hand placement during stand-pivot transfers from her wheelchair. She required weight-bearing assistance three times to help her rise from the wheelchair and turn back to the bed. She completed this transfer without assistance in 14 other occurrences during the seven-day lookback period.

How to code: In this scenario, you would code 3 — Extensive assistance, because Rule #2 instructs you to code the most dependent level that occurred three or more times.

How 3^rd Rule Gets More Complicated

The third Rule of 3 is: 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.

b) When there is a combination of full staff performance and weight-bearing assistance that total three or more times, code 3 — Extensive assistance.

c) 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 2 — Limited assistance.

Scenario #3: Mrs. F was in the nursing home for only one day prior to transferring to another facility. Twice, she required weight-bearing assistance to help her lift her fork to her mouth, and one time staff fed Mrs. F.

How to code: In this case, you would code 3 — Extensive assistance. The ADL occurred three times and at multiple levels, but neither of the levels three times. You would convert the one episode of full staff performance (when staff fed Mrs. F) to weight-bearing assistance, giving you three occurrences at the extensive assistance level.

When No Level Occurs 3 Times

Scenario #4: Mr. N transferred to the hospital on the second day of his nursing home stay. For the dressing ADL, staff provided weight-bearing assistance one time, as well as one occurrence of non-weight-bearing assistance and one of full staff performance. Also, Mr. N was able to dress himself without assistance (independent) one time.

How to code: Mr. N completed the dressing ADL a total of four times, but he did so at multiple levels and none of those levels occurred three times. So in this case, you would code 2 — Limited assistance, because the Rule of 3 instructs that when there is a combination of full staff performance/weight-bearing assistance and/or non-weight-bearing assistance that total three or more times, you must code limited assistance.

Give Up and Code Supervision

A final note for the Rule of 3 instructions states: If none of the above are met, code supervision.

Scenario #5: Mr. P performed the toileting ADL 20 times during the lookback period. He was able to toilet independently 18 times. The other two times Mr. P required non-weight-bearing assistance.

How to code: For this scenario, you would code 1 — Supervision, because the RAI Manual states that if none of the Rule of 3 are met, you must code supervision. The activity occurred three or more times but not three times at any one level.

Also, there are no instances of full staff performance to convert to weight-bearing assistance, nor did a combination of full staff performance/weight-bearing assistance and non-weight-bearing assistance add up to at least three occurrences.