Harmony Healthcare Blog

ADL Coding: Where Does the Confusion Begin?

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Wed, May 04, 2016

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Edited by Kris Mastrangelo

Activities-of-Daily-Living.pngADL (Activities of Daily Living) Coding is always a beneficial topic of discussion given the blow incorrect coding can have on reimbursement and quality of care.  Typically, this miscoding starts with a misunderstanding of the definitions on the amount of assistance provided by the caregiver.  Thus, it is imperative that facility staff (inclusive of the nurse assistants, therapists and nurses) fully understands the intent of each level of assist provided on the MDS.  It is extremely common for patients to be erroneously coded into the wrong category.  Of interest, the two levels seemingly with the most confusion are Limited Assistance and Extensive Assistance.

Defining the Difference in the Levels 

Limited Assistance:

The resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight-bearing assistance. 

Guided Maneuvering and Non-weight bearing means that the caregiver did not flex his/her muscle while helping the resident.  Only lightly touched the patient to guide a hand or a shoulder. 

  • Therapy Crosswalk: Contact Guard Assistance

Extensive Assistance:

If the resident performed part of the activity over the last 7 days, help of the following type(s) was provided three or more times: 

  • Weight-bearing support provided
  • Full staff performance of activity during part but not all

Weight bearing assist encompasses the array of physical assistance provided when the caregiver if flexing a muscle and using 25%-75% effort.  

  • Therapy Crosswalk: Minimal, Moderate and Maximum Assistance 

Where do ADL errors come from? 

1.) Confusion typically arises with the coding physical assistance.  The biggest misconception seen across the country lies in the understanding of Limited Assistance.  Many staff perceive this level as "just a little bit of assist."  In other words, when providing some weight bearing assistance, they code the patient as limited assistance when in fact the accurate level is extensive assistance.  In addition, this misunderstanding transcends into the interpretation of Extensive Assistance. Staff also state that Extensive Assistance includes performing "all of care for the patient." This too is a critical mistake that results in an inaccurate representation of the care provided. 

2.) Errors also originate from missed tasks.  Consistently, there are various instances that the CNAs oftentimes forget or exclude tasks completed during ADLs.  Examples included: 

  • providing assist with fluids during off shifts
  • assistance with incontinent care
  • assistance in clothing management as part of the toileting task 

3.) Staff desire to show how well a patient can perform (at times) causes a misrepresentation.   Rehabilitation documents the patient's best performance while the MDS captures the patient's function throughout a 24 hour period.  Countless times, a patient or resident requires less assistance during the day, versus the night time hours, causing the MDS to reflect a completely different level of assistance than documented in the therapy notes. 

Click Here to Request a Free Five-Star Quality Measure Analysis with 5 New Measures


With the implementation of Value Based Purchasing and monetary implications for functional improvement, the accuracy and understanding of coding is more important than ever. Take a moment and validate that the staff in your facility truly have a proper understanding of MDS Coding.  Once you have nailed it, we can then continue our discussion on how does this effectively show patient improvement, decline and the rationalization for skilled nursing and skilled therapy interventions. 

If you have questions about ADL Coding, please contact Harmony Healthcare International by clicking here or calling our office at (800) 530-4413.  If you would like a free Five-Star Quality Analysis with 5 New Measures, click here.  


Tags: ADL Coding, Activities for Daily Living

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