GG codes/quality indicators

• GG/Quality Indicators


  A set of standardized patient assessments used to determine the functional abilities of a patient
• The GG/Quality Indicators can be documented by different members of the multidisciplinary team
• The data is gathered to complete and submit the IRF-PAI (Inpatient Rehabilitation Facility Patient Assessment Instrument) to CMS (Centers for Medicare & Medicaid Services)
• The GG/Quality Indicators is one component of the data that is gathered for submission to CMS
• Importance of GG/Quality Indicators

  • To calculate the estimated length of stay
  • Reimbursement for each patient
• Accurate coding and documentation is key!
• GG (Functional Mobility and Goals)/Quality Indicators

  • Roll Left and Right
  • Sit to Lying
  • Lying to sitting on side of bed
  • Sit to stand
  • Chair/bed-to-chair transfer
  • Toilet transfer
  • Walk 10 feet
  • Walk 50 feet with two turns
  • Walk 150 feet
  • Walking 10 feet on uneven surfaces
  • 1 step(curb)
  • 4 steps
  • 12 steps
  • Picking up object
  • Wheel 50 feet with two turns
  • Wheel 150 feet
  • Eating
  • Oral Hygiene
  • Toileting Hygiene
  • Shower/Bathe Self
  • Upper body dressing
  • Lower body dressing
  • Putting on/taking off footwear
• OT GG (Functional Mobility and Goals)/Quality Indicators


  • Eating
  • Oral Hygiene
  • Toileting Hygiene
  • Shower/Bathe Self
  • Upper body dressing
  • Lower body dressing
  • Putting on/taking off footwear
• GG (Functional Mobility and Goals)/Quality Indicators Coding


  • Code 06 – Independent
  • Code 05 – Setup or Clean Up Assistance
  • Code 04 – Supervision or Touching Assistance
  • Code 03 – Partial/Moderate Assistance
  • Code 02 – Substantial/Maximal Assistance
  • Code 01 – Dependent
• Independent


  Patient completes the activities by him/herself, with or without an assistive device, with no assistance from a helper
• Set or Clean up Assistance


  Helper sets up or cleans up; Patient complete the activity. Helper assists only prior to or following the activity
• Supervision/Touching


  Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as a patient/ resident completes the activity
• Partial/Moderate


  Helper does LESS THAN HALF the effort, Patient does > 50%. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort
• Substantial/Maximal


  Helper does MORE THAN HALF the effort, Patient does < 50%. Helper lifts or holds trunk or limbs and provides more than half the effort
• If the patient just helps even 1%, they are max, not dependent
• Dependent


  Helper does ALL of the effort. Patient does none of the effort to complete the activity or the assistance of 2 OR MORE HELPERS are required for the patient to complete the activity
• When the patient cannot complete the task

  • 07 - Patient refused
  • 09 - Not applicable. Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury
  • 10 - Not attempted due to environmental limitations
  • 88 - Not attempted due to medical condition or safety concerns
• Usual Status


  The patient's functional status should be based on clinical assessment of performance soon after the patient's admission
• Admission


  The admission function scores are to reflect the patient's admission baseline status, prior to any benefit from therapeutic intervention
• Discharge


  Code the patient's discharge functional status based on clinical assessment that occurs close to the time discharge
• Eating


  The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient
• Oral Hygiene


  The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment
• Toileting Hygiene


  The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment
• Shower/Bathe Self


  The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower
• Upper Body Dressing


  The ability to dress and undress above the waist, including fasteners, if applicable
• Lower Body Dressing


  The ability to dress and undress below the waist, including fasteners; does not include footwear
• Putting on/Taking off Footwear


  The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners, if applicable
• eating coding tips for tube or parental nutrition

  • assistance not considered when coding the item eating
  • relies solely on nutrition thru tube or PN due to new medical condition-> code 88: not attempted bc of medical/safety concerns
  • relies solely on nutrition thru tube or PN currently and prior to-> code 09: N/A
  • relies partially on nutrition thru tube or PN-> code eating based on amount of assistance required to eat by mouth
• Mr. R requested his OT to bring his food to him in bed and to open his orange juice. Mr. R was able to feed himself

  Code 5: set up/clean up assistance
• At w/c level, Mr. R was able to propel to his sink and place toothpaste on his toothbrush. He completed oral hygiene without assistance

  code 6: independent
• Mr. R currently receives suppository for his bowel management program and is able to empty his bladder with intermittent catheterization. He requires 2 ppl for clothing and hygiene management

  code 1: dependent
• at rolling shower commode chair level, Mr. R was able to wash hair, face, shoulders, arms and chest with a washcloth. OT assisted with remainder of washing. Mr. R was able to rinse all of his body using a long-handed shower. Mr. R was able to dry all of his upper body and chest. OT assisted with drying lower body, back, and bottom

  code 3: partial/moderate assistance
• Mr. R donned an overhead shirt at w/c level. he was able to thread both sleeves and pull the shirt over his head. the OT provided steadying assistance for pt to lean forward while the pt pulled shirt down

  code 4: supervision or touching assistance
• OT practice lower body dressing with the head of the bed raised. the OT donned pants to bilateral knees and Mr. R can pull his pants up to his hips. The OT assisted with rolling right and left and pulling the pants over the hips

  code 2: substantial/max assist
• at w/c level, Mr. R performed figure 4 to don and doff socks. pt required total assistance to don and doff shoes

  code 3: partial/moderate assistance