Q&A: Can therapy code section GG based on their clinical judgment of what the resident is capable of doing?

Carol Maher, RN-BC, CPC, RAC-MT

Question: For Section GG items like car transfer, we were using a not attempted code when the resident didn't attempt this task in the first 3 days. Therapy is saying based on their clinical judgment they can code them. For example, coding car transfer as 1-dependent, based on how the resident can complete other tasks.  Can therapy code based on their clinical judgment if it can be compared to another task?

 

Answer: We cannot code any of the GG items based on a clinician’s clinical judgement of the resident’s potential capability to perform the activity. The resident must be assessed for each item where they have been encouraged to complete the task as independently as possible while safe. There will be tasks that the resident cannot complete. Instead of coding as dependent, code one of the activity did not occur choices. For example, most new Medicare residents cannot safely attempt to transfer into a car during the first 3 days of the stay. The correct code would be 88, not attempted due to safety concerns or medical condition. If the resident might have been able to transfer into a car, but no car was available, code 10.

See the coding tip on page GG-13, “Code based on the resident’s performance. Do not record the staff’s assessment of the resident’s potential capability to perform the activity.”


Carol Maher, RN-BC, CPC, RAC-MT

 


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