Harmony Healthcare Blog

ADL Coding: The Rule of Three

Posted by Christine Twombly on Thu, Nov 16, 2017

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Photo of patient with walking problem and doctor.jpegWe spend a great deal of time educating the industry on the accurate coding of Activities of Daily Living of the four late loss ADLs which include: 

  • Bed Mobility
  • Transfers
  • Eating
  • Toileting 

And we can never hear enough about the difference between limited and extensive assist (Kris Mastrangelo does not let a speaking engagement pass without refence to this key metric). However, the past year there seems to be a slight memory lapse on the adjustments made to the MDS coding guidelines back in 2013. Specifically, the Rule of Three. 

Staff level understanding of the ADL Coding “Rule of Three” is essential for coding section G of the MD.  The “Rule of 3” steps must be followed in a sequential manner with stopping at the first rule that applies.  This procedure allows for determining the self-performance code for each ADL task in section G of the MDS.  Clarification of this rule was provided in the RAI Manual effective in 2013. 

The manual instructs the assessor to “Use the first instruction encountered that meets the coding scenario (e.g., if #1 applies, stop and code that level).” 

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The Self-Performance Algorithm provided in the manual is a helpful tool particularly when coders utilize step 3 of the “Rule of 3” or when none of the “Rule of 3” steps apply. These important sequential steps are outlined below: 

ADL Scoring Step 1 

When an activity occurs three or more times at any one level, code that level.” 


A resident was Supervision on three occasions, total assistance on two occasions, and Extensive assistance on two occasions. The correct score is Supervision because the first Rule of 3 was met. Note that since the first step applies, the process stops and the episodes of total are not converted to Extensive Assistance. 

The correct score is Supervision. 

ADL Scoring Step 2 

“When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times.” 


A resident was Supervision on six occasions, Limited Assistance on five occasions, Extensive Assistance on two occasions, and Total Assistance on one occasion. The correct score is Limited Assistance since that was the most dependent level at which the activity occurred at least three times. Note that in this example, there are three episodes of Limited assist and fewer than three episodes of either of the two higher levels. This step does not combine Extensive and Total Assistance. 

The correct score is Limited Assistance. 

ADL Scoring Step 3 

When an activity occurs three or more times and at multiple levels, but not three times at any one level, apply the following: 

  • Convert episodes of full staff performance to weight-bearing assistance when applying the third Rule of 3, if the full staff performance episodes did not occur every time the ADL was performed in the 7-day look-back period.
  • When there is a combination of full staff performance and weight-bearing assistance that total three or more times—code extensive assistance (3).
  • When there is a combination of full staff performance/weight-bearing assistance, and/or non-weight-bearing assistance that total three or more times—code limited assistance (2). 


A resident was Extensive Assistance on two occasions and Total Assistance on two occasions. Since none of the coding levels occurred at least three times, apply step 3, by combining the episodes of Extensive and Total Assistance. 

The correct code is Extensive Assistance.

We hope this blog post helps you with coding and care planning.  The MDS process is the foundation for patient care and caregiver communication.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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Tags: ADL Coding

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