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PDPM Corner: Mastering Section GG: Part 2

By Lori O’Hara, CCC-SLP, Skilled Reimbursement Resource

In Part 1, we focused on scoring Section GG items. In Part 2, we’ll focus on best practices for coding section GG. As a refresher, two Section GG areas impact PDPM: Self Care (Section GG0130) and Mobility (Section GG0170). These two areas impact the final category for the Nursing and Physical and Occupational Therapy case mix categories.

Information captured in the lookback period (days one to three for a five-day MDS, the ARD and two days prior for an IPA, and the discharge date and two days prior for a discharge assessment) is used by the IDT to establish a “usual performance” value that gets recorded into the MDS.

It is absolutely essential to use an interdisciplinary process to identify what constitutes the “usual performance.”

An interdisciplinary team is far more likely to land on an accurate value than someone scoring Section GG alone. Quality measures, quality reporting processes, and publicly available data analyze how effective we are at making short-stay patients better and keeping long-term patients from declining. Teams with a good interdisciplinary process consistently outperform teams who try to do this with one person in showing the impact of our care and hard work.

Also, between therapy data, nursing data, and CNA data, there are a lot of values to choose from, but only one can make it into the MDS. When the record suggests that a value other than the one that is chosen might be reasonably assessed as “usual,” then the why of the decision must be documented. Without documentation explaining that reasoning, the value is vulnerable on review.

The optimal process is two steps:

1. During the assessment window, multiple care providers record the values they get through delivering care, providing therapy, performing direct observation, or conducting interviews.

2. Near the end of the assessment window, the IDT meets. They review all the data, discuss the patient, consider their own information and observations, identify what value best represents "usual performance," and record those values along with their reasoning in the IDT UDA.

It sounds straightforward enough, but day-to-day facility life sometimes complicates things that seem simple, and processes can go a little sideways.

The grid below shows the various scenarios for Section GG source documentation and MDS values commonly seen in our operations. You’ll then see the anticipated risk (how likely a repayment might occur).

Scenario Risk Assessment

1 IDT meets and establishes values by day 3. Low when the values selected are well represented in the record. Low when explanations accompany values that are under-represented in the record. Moderate when under-represented values are chosen with no explanation.

2 IDT meets after day three but only uses data/information recorded during the lookback period. Low when the values selected are well-represented in the record. Low when explanations accompany values that are under-represented in the record. Moderate when under-represented values are chosen with no explanation.

3 No IDT meeting, but coding in MDS includes only values that are recorded and signed by qualified clinicians during the lookback period. Moderate. CMS expects an IDT process for coding Section GG. Lack of an IDT process to explain why some values were chosen over others may result in negative review findings.

4 MDS uses information/data that was recorded and signed after the lookback. Moderate, see info below on Interviews and late entries.

5 IDT meets after day three and uses values that are not present in the record during the lookback period. High

6 MDS Section GG completed after day 3 with no source documentation of any kind High

Interviews and Late Entries

CMS encourages the use of interviews to assist with the assessment of Section GG items. There is no risk to using interviews when they are conducted and recorded during the assessment window, and interviews recorded within a couple of days of the event are likely fine. However, if the interview is recorded significantly after the lookback window — even when the entry states that the information was based on performance during the lookback window — the information loses its validity. It becomes increasingly difficult to make a case for accuracy as time goes on.

The same is true for late entries. Late entries simply must happen on occasion, and when they are infrequent and recorded within a few days of the event, the risk with using them is low. However, CMS frowns on excessive use of late entries, and if they are written many days after the event occurred, they will have very little validity and can be disallowed.

Discharge Section GG Assessment

So your team worked diligently to help your patient recover, and now they can perform many tasks they couldn’t do when they arrived. That’s awesome! But are you telling CMS about it? The outcome Section GG is incredibly important because those improvements are visible to the public and are part of our quality metrics. And just like with the five-day assessment, an interdisciplinary team must be involved! Facilities that use solo clinicians to score Section GG consistently underreport the gains their patients make. Wrangle that IDT back to the table for the discharge assessments so you can get credit for all the good you do with people on the outside.

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