Cognition
What is the code for expression of Ideas & wants? when a brain surgery, patient points to bathroom & with garbled speech says, “Go”. C N A reports to nurse that she often has difficulty understanding the patient.
Code 2, Frequently exhibits difficulty with expressing needs and ideas.
Rationale: patient gets his point across regarding the need to go to bathroom, but staff often has difficulty understanding him.
What is the score for EATING? when Pt eats three-fourths of his meal by himself, then extremely fatigued and requests assistance from helper to feed remainder of the meal.
Coding: GG0130A,1. Eating would be coded 03, Partial/moderate assistance.
Rationale: Helper provides less than half the effort for the patient to complete the activity of eating for all meals.
Patient wears a bra and a sweatshirt most days while in rehabilitation program. Patient requires assistance from helper to initiate threading of her arms into bra. Patient completes placement of bra over her chest. Helper hooks the bra clasps. Patient pulls sweatshirt over her arms, head, and trunk. When undressing, patient removes the sweatshirt with helper assisting her with one sleeve. Patient slides bra off once it has been unclasped by the helper.
Coding2: GG0130F, Upper body dressing would be coded 03, Partial/moderate assistance.
Rationale: The helper provides assistance with threading the patient’s arms into the bra, hooking and unhooking the bra clasps, and assistance with removing one sleeve of the sweatshirt. The patient performs more than half of the effort
What is the score for ROLL LEFT & RIGHT when nurse instructs pt to turn onto his right side, providing step-by-step instructions to use bedrail, bend his left leg, & then roll onto right side. Pt attempts to roll with use of bedrail but indicates he cannot do the task. Nurse then rolls patient onto his right side. Pt is instructed to return to lying on his back, which he successfully completes. Pt then requires physical assistance from nurse to roll onto his left side & to return to lying on his back to complete activity.
Coding1: GG0170A, Roll left and right would be coded 02, Substantial/maximal assistance.
Rationale: Nurse provides more than half of the effort needed for patient to complete activity of rolling left & right. Nurse provides physical assistance to move patient’s body weight to turn onto his right side. Nurse provides same assistance when patient turns to his left side & when he return to his back.Patient is able to return to lying on his back from his right side by himself.
What is the CAR TRANSFER? pt requires verbal reminders for safety and light touching assistance when transferring. Therapist instructs the pt on strategic hand placement while pt transitions to sitting in the car’s passenger seat. Therapist opens & closes the door.
Coding2: GG0170G, Car transfer would be coded 04, Supervision or touching assistance.
Rationale: Therapist provides touching assistance as patient transfers into the passenger seat of the car. Assistance with opening and closing the car door is not included in the definition of this item and is not considered when coding this item
What is the code for expression of ideas & wants? when a TBI patient sometimes has difficulty finding a word & will compensate by using other descriptive words. e.g. patient recently described coffee as “that black, hot stuff that I drink in the morning”
Code 3, Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear.
Rationale: Patient has some difficulty expressing needs and ideas. Specifically, the patient experiences word-finding problems
What is the score for EATING? when Pt has adaptive device on his hand that supports eating. At start of each meal, patient can bring food and liquids to his mouth. Patient then tires, and helper feeds patient more than half of each meal.
Coding: GG0130A, Eating would be coded 02, Substantial/maximal assistance.
Rationale: Helper provides more than half effort for the patient to complete the activity of eating at each meal.
Patient sustained a spinal cord injury that has affected both movement and strength in both upper extremities. The patient places her left hand into one-third of the left sleeve of his shirt with much time and effort and is unable to continue with the activity. A helper then completes the remaining upper body dressing for the patient.
Coding3: GG0130F, Upper body dressing would be coded 02, Substantial/maximal assistance.
Rationale: The patient 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.
What is the score for SIT TO LYING? when Pt requires assistance from a nurse to transfer from sitting at the edge of bed to lying flat on the bed. Nurse lifts & positions patient’s right leg, pt uses his arms to position his upper body & lowers himself to a lying position flat on his back.
Coding1: GG0170B, Sit to lying would be coded 03, Partial/moderate assistance.
Rationale: Nurse lifts the patient’s right leg and helps the patient position it as he move from a seated to a lying position. Nurse performs less than half of the effort.
What is code for WALK 10 FT? when Pt has Parkinson’s disease and walks with a walker. Physical therapist must advance walker for pt with each step. Physical therapist assists pt by physically initiating stepping movement forward, advancing pt’s foot, during activity of walking 10 feet. Physical Therapist assists patient by providing more than half of the effort for the patient to walk the 10-foot distance
Coding1: GG0170I, Walk 10 feet would be coded 02, Substantial/maximal assistance.
Rationale: PT provides more than half the effort as the patient completes the activity
What is the code for C1310? When a Clinician reports that a patient with poor short-term memory - suddenly becomes agitated, calling out to his dead relatives, tearing off his clothes, and being completely disoriented to time, person, and place.
Coding: C1310A,
Acute Onset Mental Status Change would be coded 1, Yes.
Rationale:
The new behaviors represent an acute change in mental status
What is the score for EATING? if pt eats meals without any physical assistance or supervision from a helper. Patient has a gastrostomy tube (G-tube), but it is no longer used & will be removed.
Coding:3 GG0130A, Eating would be coded 06, Independent.
Rationale: 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.
Patient is required to follow hip precautions as a result of recent hip surgery. Occupational therapist in acute care hospital instructed patient in use of adaptive equipment to facilitate lower extremity dressing. Patient requires a helper to retrieve patient’s clothing from closet. Patient uses his adaptive equipment to assist in threading his legs into pants. Because of balance issues, patient needs helper to steady patient when standing to manage pulling on or pulling down patient’s pants/undergarments. Patient also needs some assistance to put on and take off ankle foot orthosis (AFO), socks, and shoes.
Coding1: GG0130G, Lower body dressing would be coded 04, Supervision or touching assistance.
Rationale: A helper steadies patient when patient is standing and performing activity of lower body dressing, which is supervision or touching assistance.
Putting on & taking off socks & shoes is not considered when coding lower body dressing nor is putting on & taking off orthotic(s) associated with foot, for example an AFO. These are considered when coding Putting on & taking off footwear
What is the score for LYING TO SITTING? when Pt pushes up from bed to get himself from a lying to a seated position. C N A provides steadying (touching) assistance as pt scoots himself to edge of bed & lowers his feet onto floor
Coding: GG0170C, Lying to sitting on side of bed would be coded 04, Supervision or touching assistance.
Rationale: C N A provides touching assistance as the patient moves from a lying to sitting position.
What is the code for WAK 50 FT? Pt walks 50 feet with Physical therapist providing trunk support & also requires a second helper, to follow closely behind with a wheelchair for safety. The patient walks 50 feet with two turns with assistance of two helpers.
Coding4: GG0170J, Walk 50 feet with two turns would be coded 01, Dependent.
Rationale: The patient requires two helpers to complete the activity
What is the score for inattention during the BIMS interview, when pt is not able to focus on all questions asked, and his gaze wandered.
However, several notes in patient’s medical record indicate that patient was attentive when staff communicated with them, and family confirmed this.
Coding: C1310B, Inattention would be coded 2,
Behavior present, fluctuates.
Rationale:
Evidence of inattention was found during the BIMS, but medical record documentation and family indicated the patient was attentive.
What is ORAL HYGIENE score? when helper provides pt water & toothpaste to clean his dentures. Pt cleans his upper denture plate & half of his lower denture plate then tires and unable to finish cleaning lower denture plate. Helper finishes cleaning the lower denture plate and the patient inserts dentures in his mouth.
Coding3: GG0130B, Oral hygiene would be coded 03, Partial/moderate assistance
Rationale: The helper provides less than half the effort to complete oral hygiene.
Patient was admitted to rehab for a neurologic condition, experiences visual impairment & fine motor coordination & endurance issues. Patient requires setup for retrieving socks and shoes, which he prefer to keep in his closet. Patient often drops his shoes & socks as he attempt to put them onto his feet or as he takes them off. Often a C N A must first thread patient’s socks or shoes over pt.'s toes, and then patient can complete the task. Patient needs C N A to initiate taking off pt.'s socks & unstrapping Velcro used for fastening his shoes
Coding2: GG0130H, Putting on/taking off footwear would be coded 02, Substantial/maximal assistance.
Rationale: Helper provides patient with assistance in initiating putting on & taking off patient’s footwear because of limitations regarding fine motor coordination. Helper completes more than half of effort with this activity
What is the score for SIT TO STAND? Pt has complete tetraplegia & is currently unable to stand when getting out of bed. Pt transfers from bed into a wheelchair with assistance. Activity of sit to stand is not attempted due to pt’s medical condition. Pt did complete activity of sit to stand prior to recent injury.
Coding3: GG0170D, Sit to stand would be coded 88, Not attempted due to medical condition or safety concerns.
Rationale: The activity is not attempted due to the patient’s diagnosis of complete tetraplegia.
What is the code for WALK 150 ft? Pt walks down the hall 150 feet using his walker and C N A provides touching assistance to patient, who intermittently loses his balance while he uses walker
Coding1: GG0170K, Walk 150 feet would be coded 04, Supervision or touching assistance.
Rationale: C N A provides touching assistance intermittently throughout the activity.
What is the score for disorganized thinking when patient was able to tell the interviewer his name, year & where he was. Patient was able to talk about activity he just attended & patients & staff that also attended. Then patient suddenly asked the interviewer, “Who are you? What are you doing in my daughter’s home?”
Coding: C1310C,
Disorganized thinking would be coded 2, Behavior present, fluctuates.
Rationale: The patient’s thinking fluctuated between coherent and incoherent at least once. If as few as one source notes fluctuation, then the behavior should be coded 2.
What is the ORAL HYGIENE score? when pt has Parkinson’s disease, resulting in tremors and incoordination. Helper applies toothpaste on the toothbrush. Pt requires assistance to guide toothbrush into his mouth & to steady his elbow while pt brushes his teeth. Pt starts by brushing his upper & lower front teeth & helper completes activity by brushing rest of pt’s teeth.
Coding5: GG0130B, Oral hygiene would be coded 02, Substantial/maximal assistance.
Rationale: The helper provides more than half the effort for the patient to complete the activity of oral hygiene.
What is the score for TOILET TRANSFER? when Pt is anxious & asks C N A to stay with him as he gets on and off the toilet. C N A stays with pt and provides verbal cues to pt.
Coding3: GG0170F, Toilet transfer would be coded 04, Supervision or touching assistance.
Rationale: The helper provides supervision/verbal cues as the patient transfers onto and off the toilet
What is the score for BED TO CHAIR TRANSFER? when pt has metastatic bone cancer, severely affecting his ability to use his lower & upper extremities during daily activities. Pt is motivated to assist with transfers from side of his bed to wheelchair. Pt pushes himself up from bed to begin transfer while therapist provides trunk support with weight-bearing assistance. Once standing, pt shuffles his feet, turns, & slowly sits down into wheelchair with therapist providing steadying support. Overall, therapist provides less than half of effort
Coding: GG0170E, Chair/bed-to-chair transfer would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half of the effort for the patient to complete the activity of chair/bed-to-chair transfer
What is the code for 4 STEPs? Patient has lower body weakness, and Physical therapist provides steadying assistance when patient ascends 4 steps. While descending 4 steps, Physical therapist provides trunk support (more than touching assistance) as the patient holds stair railing
Coding: GG0170N, 4 steps, would be coded 03, Partial/moderate assistance.
Rationale: Therapist provides touching assistance as the patient ascends 4 steps. Therapist provides trunk support (more than touching assistance) when the patient descends the 4 steps.