How are reviewers determining PDPM payment accuracy from Section GG coding?



The Function Score calculated from coding responses to certain Section GG items impacts your PDPM rate in the nursing component and the OT/PT component. Not surprisingly, reviewers are focusing on usual performance accuracy as well as documentation to support the IDT collaboration for assessment data. In medical review, discrepancies identified between the final MDS coding decisions and supporting documentation will contribute to your medical review error rate and potentially result in financial recoupment. For providers, this means that inaccurate coding could lead to instances of repayment or lower initial reimbursement due to inappropriate case-mix assignments.

Tips for Section GG Coding Accuracy:

      • Ensure your team consists of qualified clinicians involved in assessing the resident during the appropriate 3-day assessment period. At minimum documentation should be collaborative from nursing and therapy, but the RAI guidance also includes incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the three-day assessment period.
      • The usual performance coded in Section GG must be consistent with the clinical assessment documentation in the resident’s medical record. Be sure your medical review response team knows where to locate the supporting documentation.
      • Document an IDT note to clearly support coding decisions. This may include justification for determining coding decisions when the usual performance is not obvious, as well as noting necessary information such as data determined prior to the patient’s benefit from treatment interventions.

Section GG coding accuracy continues to be a top area of opportunity in Proactive’s PDPM Coding Audits. Our experts offer remote audit solutions for coding and documentation compliance and reimbursement accuracy. Contact us today to learn more about our targeted Section GG audits or for information on Medical Review support services including ADR preparation and Appeals management.

Blog by Stacy Baker, OTR/L, RAC-CT, CHC, Proactive Medical Review

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