GG Code
Client required max A x2 for upper body dressing in bed
1
Dependent
1
Patient performs 0%, 2 helpers required
1
Therapist required OT teach to help complete a task with the client
1
You are evaluating your patient perform lower body dressing. This patient requires the help of 2 people, yourself and a CNA. What is the correct code for LB dressing for this particular patient?
1
Helper does 100% of the task or 2 or more helpers are needed at any time?
1- Dependent
Helper does ALL of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for
1- Dependent
Not attempted due to environmental limitations
10
Client required max A for transfer from toilet to w/c
2
Patient performs 1-49% of activity, substantial assistance, helper does more
2
Substantial/maximal assistance
2
The client needs maximum assistance during the task
2
Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort
2- Substantial/maximal assistance
Helper provides MORE THAN HALF but less than 100% of the effort to complete the task
2- Substantial/maximal assistance
Client required mod A during sit to stand from w/c
3
Example: Client pushes up on the bed to attempt to get himself from a lying to a seated position as the OT provides less than half the lifting effort necessary for the client to sit upright. The OT provides assistance as the client scoots himself to the edge of bed and lowers his feet to the floor. Overall, the OT provided less than half the effort for the patient to complete bed mobility.What code would you score this client using the scale, 1-6 of the GG codes?
3
Partial/moderate assistance
3
Patient performs 50-99% of activity, partial assistance, pt does more
3
The client requires moderate assistance with tasks
3
Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half of the effort.
3- Partial/moderate assistance
Helper provides LESS THAN half the effort to complete the task
3- Partial/moderate assistance
Client required VC during meal preparation to increase use of L hand
4
Stand by, observation, cuing, coaxing, verbal cues, steadying/touching (constant or intermittent), CONTACT GUARD
4
Supervision or touching assistance
4
The therapist provides verbal cue and light touch during task
4
Your client requires supervision by you, the OT, to complete oral hygiene during the initial evaluation. What code is accurate to record on admission?
4
Your patient is transferring on and off the toilet. You (the OT), provide steadying assistance as the patient performs the toilet transfer as pt is experiencing B/L LE weakness due to prolonged hospitalization. How would you code toilet transfer performance for this patient?
4
Helper provides VERBAL CUES or TOUCHING/STEADYING and/or CONTACT GUARD ASSISTANCE as person completes activity. Assistance may be provided throughout the activity or intermittently.
4- Supervision or touching assistance
Helper provides only supervision (verbal cues) or light touch?
4- Supervision or touching assistance
During tx session, client required assistance with setting up grooming equipment (taking off toothpaste lid, pulling brush out of drawer)
5
Set up or clean up assistance
5
Set-up or take-down
5
The client can complete tasks alone after setup
5
You are evaluating a client in their home. You ask the client to perform the activity of bathing. Your client asks you to retrieve his long-handled sponge from the closet to allow him to wash his lower body. He does not need any other assistance to perform the activity. What do you score the client for bathing?
5
Your client is attempting to perform lying to sitting from the side of the bed. You lower the client's bed so her feet can reach the floor to safely perform the activity. The client then moves from lying to sitting on the edge of the bed without any assistance. What is the correct code?
5
Client can be left alone to do the task after setup
5- Setup or cleanup assistance
Helper SETS UP or CLEANS UP; person completes activity. Helper assists only prior to or following the activity. (The helper can walk away and leave the person to complete the task.)
5- Setup or cleanup assistance
100% independent, no assistance, normal time, no touching, no device, no v/c's
6
Assistive device, more than reasonable time
6
Client complete transfer from bed to w/c independently
6
Independent
6
The client is able to complete tasks with no assistance
6
Your client uses a sock aid and shoe horn when putting on and taking off footwear, with no assistance from the OT during his last session before d/c to home from the IRF.What is the correct code to document on this item?
6
Client can complete the task with no assistance (with or without adaptive equiptment)
6- Independent
Person completes the activity by himself/herself with no assistance from a helper.
6- Independent
Patient refuses to perform the activity
7
Refused
7
For a patient at an IRF with an incomplete stay due to an unexpected d/c to the acute care hospital, what code do you utilize for the d/c functional status items?
88
If a resident relies solely on nutrition and liquids through tube feedings and is unable to eat by mouth due to a medical condition, what is the correct code for eating?
88
Not attempted due to medical condition or safety concern
88
Not attempted due to medical reasons or safety concerns
88
You are evaluating a client who is unable to perform a toilet transfer due to MD ordering bed rest due to a recent fall resulting in compression fractures. What is the correct code for this scenario?
88
Not applicable
9
Not applicable, did not perform the activity prior
9
You are evaluating a patient with a history of SCI and was admitted for sepsis. The patient does not perform the activity of sit to stand. Prior to this admission, the patient received total assistance for all transfers and her caregivers used a hoyer lift to transfer her to all surfaces. How would you code Sit to Stand on the admission performance?
9
