PDPM Coding Question – Our IDT team writes a progress note for section GG collaboration. Can the note generally state, “Section GG codes vary but IDT team have collaborated to decide on appropriate GG coding for MDS?”

Our IDT team writes a progress note for section GG collaboration. Can the note generally state, “Section GG codes vary but IDT team have collaborated to decide on appropriate GG coding for MDS?”

A:

This statement may need to be more detailed for usual performance determination to clearly validate the MDS coding. RAI manual instructs to assess the resident’s mobility performance based on direct observation, 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, pp. GG-10 & GG-37. Therefore, the IDT note could include documentation such as nurses or direct care staff were interviewed in the assessment period.

Reference

Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html