The proposed changes to section GG of the Minimum Data Set (MDS) anticipated on October 1, 2018 will require increased collaboration between therapy and nursing to appropriately fulfill coding requirements. Section GG was implemented in response to the IMPACT Act (Improving Medicare Post-Acute Care Transformation Act) with the goal of measuring patient care delivery in response to patient needs. Failure to collect adequate data negatively impacts a facility’s annual reimbursement update by as much as 2%. To encourage appropriate data collection, discharge goals should no longer be “dashed” and a new option has been added to the choices describing why an activity was not attempted.

New Items in Section GG relate to Resident’s Function Prior to Admission:

GG0100. Prior Functioning: Everyday Activities—Indicate the resident’s usual ability with everyday activities prior to the current illness, exacerbation, or injury.

This item includes the following coding set:
3) Independent—Resident completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.
2) Needed Some Help—Resident needed partial assistance from another person to complete activities.
1) Dependent—A helper completed the activities for the resident.
8) Unknown.
9) Not Applicable.

GG0100A. Self-Care
GG0100B. Indoor Mobility (Ambulation)
GG0100C. Stairs
GG0100D. Functional Cognition
GG0110. Prior Device Use. This section includes manual wheelchair, motorized wheelchair and/or scooter, mechanical lift, walker, orthotics/prosthetics, none of the above.
GG0130E. Shower/bathe self: Does not include transferring in/out of tub/shower.
G0130F. Upper body dressing
GG0130G. Lower body dressing: does not include footwear.
GG0130H. Putting on/taking off footwear
GG0170A. Roll left and right
GG0170G. Car transfer: Does not include the ability to open/close door or fasten seat belt.
GG0170I. Walk 10 feet
GG0170L. Walk 10 feet on uneven surfaces
GG0170M. 1 step (curb)
GG0170N. 4 steps
GG0170O. 12 steps
GG0170P. Picking up object

All new item additions focus on patient function and are coded at the admission and discharge assessments. While the “Everyday Activities” focus on the resident’s usual ability prior to the current illness, exacerbation, or injury, the items added to “Self-Care” and “Mobility” should be coded based upon the patient’s “usual performance”, presumably during the first three days of a resident’s SNF stay, which is unchanged from the current instruction.

Fiscal year (FY) 2018 payment determinations under the Skilled Nursing Facility Quality Reporting Program (SNF QRP) hinge on data completion, not accuracy. However, that does not imply that providers can ignore the accuracy of what’s being coded in the new Section GG (Functional Abilities and Goals). In the FY 2017 SNF PPS final rule, the Centers for Medicare & Medicaid Services (CMS) noted that it will propose details on the SNF QRP data validation process, as well as plans for publicly reporting the program’s quality measures (QMs) in future rule-making. In addition, inaccuracy could result in potential survey implications.

Best practices to consider for Section GG coding accuracy:
  • Examine the role of CNAs: Given the difficulty in ensuring thorough training regarding the nuances of section G and GG coding, it may be beneficial to consider a system of reporting to the charge nurse (who would need to be well-trained in section GG) the information needed, and assigning the charge nurse the responsibility of determining the appropriate coding.
  • Examine the role of therapy: Facilities should use caution in using coding information based solely on therapy assessment information, since therapists are not assessing the patient based on a 24-hour period. Also, the patients may perform differently for a therapist than for nursing staff based upon cues provided and expectations presumed.
  • Consider a collaborative process between therapy and nursing services to best determine usual performance. That collaboration should include interviews, as well as direct observation, and it should be across all three shifts because what a resident does on the day shift may not be reflected on the evening shift. Coding may be more challenging for those residents who are not receiving therapy services during the early days of their stay.
  • Continual improvement practices: Training in a classroom setting with discussion of examples to determine thorough understanding of coding is best practice. Re-assessment and re-education should then take place at least quarterly. This helps to determine whether the system put into place is working effectively.
  • Update policies and procedures: If concerns related to the MDS are identified during survey, surveyors may ask to see specific MDS policies and procedures, at a minimum detailing who completes which sections for the facility. Providers should update policies and procedures with ‘who and how’ Section GG is completed.

Final instruction and guidance will be available with the updated RAI User’s Manual which has not yet been released as of the publication of this article.

Section GG accuracy will be an important factor as provider’s transition to the proposed PDPM system in 2019. Contact Proactive for training and systems help to prepare for this significant reimbursement transition.

Proactive Medical Review specializes in MDS Coding Support Services, Documentation Excellence, 5 Star Improvement, and QRP accuracy. Contact Proactive today for assistance with your coding compliance needs.

Click here to access Proactive’s Section GG Webinar Recording