Get the right ADL code every time

Ask The Expert, November 1, 2004

Every time CMS or some other entity studies MDS coding inaccuracies, the ADLs in Section G wind up on the top of the errors list. Now with the Data Accuracy and Verification (DAVE) project taking long look at this MDS section, you can't afford to make multiple errors.

One of CMS' missions through the DAVE project is to provide material to help skilled nursing facilities (SNF) correctly code. That's why this summer the agency ran a Web cast about improving MDS accuracy, especially in the area of ADLs.

Section G, physical functioning and structural problems, has the fifth highest discrepancy rate on the MDS, says Michelle McDonald, RN, MPH, a consultant for Joint Commission Resources in Oak Brook, IL. It's hands-down the most challenging section of the MDS, she conceded when she spoke during CMS' Web cast. According to McDonald, the top five miscoded items of Section G are

1. transfers, self-performance, G1bA

2. bed mobility, self-performance, G1aA

3. toilet use, self-performance, G1iA

4. walk in room, self-performance, G1cA

5. bed mobility, support provided, G1aB

It's good to know where things are going wrong with your MDS coding-but it's also good to know why. There are various reasons staff make ADL coding errors, but here are the top tricksters that McDonald listed:

Staff don't use the full seven-day lookback period.

The documentation doesn't include all three shifts per 24 hours.

Staff don't take credit for all the assistance they give residents when they code ADLs.

Staff code what they believe the resident is capable of doing, rather than what the resident actually does. This often results in a facility not acknowledging all the help it gives residents in ADLs-and cheats that facility out of reimbursement.

Different disciplines contradict each other in the documentation. For instance, the nurses note they assisted a resident, while the certified nursing assistant (CNA) flowsheets show the resident as independent.

There is a lack of documentation to back up the answers on the MDS.

But you can clarify these gaffes with a few tweaks to your system. The keys to Section G, as McDonald related, are to correctly identify what the resident can do without assistance and then to note when the resident requires help. Finally, document how much assistance the resident needed. Those steps should be enough to provide you an accurate ADL score.

Clear coding examples

It's one thing to talk about ADLs and study the definitions and problems, but it's another to observe a resident and come up with the correct coding. That's why the experts on CMS' Web cast took many examples of ADLs and spelled out how to code each scenario.

In this article, we'll only cover the late-loss ADLs because those are the activities that affect your reimbursement. In the coding examples to follow, we'll assume for simplicity's sake that each instance of assistance occurred three or more times.

Bed mobility

The MDS defines bed mobility as "how [the] resident moves to and from lying position, turns side to side, and positions body while in bed." For a more detailed description, consult your revised Resident Assessment Instrument (RAI ) User's Manual.

Scenario one: Take the case of a resident who needs to reposition herself in bed. The CNA must use her hand on the resident's back to help push her into a sitting position, and must support the resident while she lies back down as well.

Answer: "That would be coded a '3' [extensive assistance] for self-performance and a '2' [one person physical assist] for support provided," explained Rena Shephard, MHA, RN, FACDONA, RAC-C, president of RRS Healthcare Consulting Services in San Diego. Even if the resident could roll independently from side to side, the assistance the resident requires to sit up would still place her in the '3, 2' category for bed mobility, said Shephard, who is also the chair of the American Association of Nurse Assessment Coordinators.

Scenario two: A different resident cannot sit up in bed at all. The only movement she is capable of for this ADL is bending her knees. It takes two CNAs to sit her up in bed to a more comfortable position.

Answer: This resident is a '3,' or extensive assistance for self-performance, said Mary Pratt, MSN, RN, acting director at the Division of Ambulatory and Post-Acute Care for CMS. In the support-provided category, you would code her as a '3' because she needed two people's physical assistance.

Scenario three: Now let's look at a resident who is able to reposition himself in bed but has a tendency to lie on his left side. Staff remind him to turn over and monitor him to make sure he gives each side equal favor.

Answer: Because staff don't give any physical assistance, you would code the resident a '1' for self-performance, supervision, and a '0' for support provided, no setup or physical help from staff, Pratt said. But had the resident needed nonweight-bearing assistance from the staff and bedrails to turn himself, he would be a '2, 2' for limited assistance in the self-performance category, and one person physical assist in the support-provided category.

Scenario four: Another example of bed mobility is a resident who has right-sided weakness and cannot move himself in bed at all. It takes two CNAs to reposition this resident because they have to lift the resident, and he cannot participate.

Answer: This resident is a '4' for total dependence in self-performance of the ADL, and a '3' representing the physical assistance of two or more people. Remember, said Pratt, a resident who helps in the activity even once cannot be a '4' for total dependence.


The transfer ADL notes how a resident transfers from one surface to another but excludes transferring to the toilet or the bath. Those incidences have their own separate ADL categories.

Scenario five: Here's an example of a resident who wants to get to the bed from his wheelchair. The resident is actively involved in the process and can stand up. The CNA takes his hands to steady him, and she helps him pivot once out of the chair so he can sit down on the bed safely.

Answer: You could code the resident a '3' for extensive assistance in the self-performance category, said Judy Wilhide, RN, BA, CMS' RAI manager for Virginia. That's because the CNA gave the resident weight-bearing support when she helped him pivot. Code a '2' for assistance provided, representing a one-person physical assist.

Scenario six: Now, what about a resident who is mostly independent but needs her walker to move from a sitting to a standing position? In this case, the staff member provides verbal cueing and oversight. The staff member must also hand the resident's walker to her.

Answer: This results in the coding of a '1, 1,' because the resident only needed supervision for ADL self-performance and set-up help only for ADL support provided, said Wilhide. Handing a resident a walker or locking wheels on a wheelchair does not count in the self-performance category, Shephard added. Look at these activities only for the support-provided category.

Scenario seven: A more impaired resident has undergone extensive surgery and has numerous surgical wound sites. The resident's pain is not under control, hence the physician orders bedrest and says that the resident is not to be moved from the bed. Staff carefully reposition the resident within the bed but do not move her out of it.

Answer: Code the resident as an '8, 8,' said Pratt. In this case, transfer did not occur, so use the codes that reflect that.

Scenario eight: Finally, let's look at the example of a resident who needs verbal cueing and reminders to get up and go to meals and activities. Once reminded, he can transfer without the help of staff.

Answer: Here's where the ADLs get confusing-this scenario is a trick of sorts. You would code the resident '0, 0' for independent self-performance and without setup or help from staff, said Pratt. "Cues to attend meals and activities would not be used in coding decisions for ADL ability," she explained.