By Debbie Duhaime, Quality Improvement Consultant and Robin A. Bleier, President/Healthcare Consultant
Ready or not, here comes change. As of October 1, 2018, Minimum Data Set (MDS) Section GG will be one of the most important areas of SNF documentation. Section GG will be an important factor in the proposed Patient Driven Payment Model (PDPM) for Medicare Part A reimbursement.
This process is geared to help Centers of Medicare Medicaid Services (CMS) to determine which setting has better functional outcomes for short-term rehab patients built on evidence-based practice. With the expansion of Section GG, we will be able to compare functional outcomes to those patients with similar data in the inpatient rehab facilities.
The Quality Reporting Program (QRP) has added four new Quality Measures (QMs) similar to what is currently in place. This includes score changes for mobility, discharge mobility, changes in self-care, and discharge self-care score. These measures will address functional status, cognitive function and changes in functional status and cognitive function. CMS will then be able to compare the functional improvements by the changes in the Section GG documentation.
Changes in Section GG include:
- Added Item GG0100 – Prior Functioning: Everyday Activities
- Added item GG0110 – Prior device used. Complete only at the start of the SNF PPS stay. (5-day assessment). Only code devices used immediately prior to current illness, exacerbation or injury. This includes a manual wheelchair, motorized wheelchair, scooter, mechanical lift, walker, orthotics/prosthetics, or none of above.
- Added a New Code – Code 10: Not attempted due to environmental limitations i.e.: lack of equipment, weather constraints.
- Goals: Coding goals with “activity not attempted codes” is now permissible. These coding goals are:
- 07 – Resident refused.
- 09 – Not applicable. Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
- 10 – Not attempted due to environmental limitations (ie: lack of equipment, weather constraints).
- 88 – Not attempted due to medical condition or safety concern.
- Contact guard assist has now been added to 04 code of supervision or touching assistance.
- It is assumed that all scoring guidance addresses safety. Therefore, the word safe has been removed.
- Eating includes food and liquid. It is the ability to bring food and liquid to the mouth and swallow once the meal is placed before the resident. Tube feedings and TPN are not considered when coding for eating.
- Oral hygiene has been revised to read: an ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with the use of equipment.
- Toilet hygiene has been revised to include adjusting clothes before and after voiding and having a BM.
- Sit to stand has been revised to include the wheelchair and scooter.
- Section GG looks at the resident’s usual ability. Not his/her most dependent and not his/her most independent.
Section GG0100 – Prior Functioning Everyday Activities
This section looks at the resident’s usual ability with everyday activities prior to the current illness, exacerbation, or injury.
- GG0100A: Self-care. Code the resident’s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury.
- GG0100B: Indoor mobility (ambulation). Code the resident’s need for assistance with walking from room to room (with or without a device such as a cane, crutch, or walker) prior to the current illness, exacerbation, or injury.
- GG0100C: Stairs. Code the resident’s need for assistance with the internal or external stairs (with or without a device such as a cane, crutch, or walker) prior to the current illness, exacerbation, or injury.
- GG0100D: Functional cognition. Code the resident’s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.
Code 3. Independent. Resident completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.
Code 2. Needed some help. Resident needed partial assistance from another person to complete activities.
Code 1. Dependent. A Helper completed the activities for the resident or the resident required the assistance of two helpers.
Code 8. Unknown.
Code 9. Not Applicable.
Steps for Assessment of Prior Function
- Ask the resident or his/her family about prior function with everyday activities.
- Review the medical record describing prior activity.
Functional abilities and goals-admission (start of SNF PPS stay)
The admission functional score reflects the baseline status prior to therapeutic benefits.
Section GG0130A through GG0130H: addresses self-care.
Section GG0130. Self-care now has new items: shower/bathe self; upper body dressing, lower body dressing and putting on and taking off footwear.
- Eating. Ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.
- Oral hygiene. Ability to use suitable items to clean teeth. Dentures (if applicable). The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
- Toileting hygiene. Ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bm. If managing an ostomy, including wiping the opening but not managing equipment.
- Shower/bathe self: (new item) ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.
- Upper body dressing. (new item) ability to dress and undress above the waist; including fasteners, if applicable.
- Lower body dressing. (new item) ability to dress and undress below the waist, including fasteners; does not include footwear.
- Putting on/taking off footwear. (new item) ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners, if applicable.
Functional Abilities and Goals-Admission (Start of SNF PPS Stay)
Section GG0170A through GG0170SS1 addresses mobility
The new items are: Roll left and right; Car transfers; Walk 10 feet on even surface; Walk 10 feet on uneven surface; 1-Step Curb; 4 Steps; 12 Steps; picking up an object.
- Roll left and right. Ability to roll from lying on back to left and right side and return to lying on back on the bed. Would code 88 if resident unable to lie flat.
- Sit to lying. Ability to move from sitting on side of bed to lying flat on bed.
- Lying to sitting on side of bed. Ability to move from lying on back to sitting on the side of the bed with feet flat on the floor, and with no back support.
- Sit to stand. Ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
- Chair/bed-to-chair transfer. Ability to transfer to and from a bed to a chair or wheelchair.
- Toilet transfer. Ability to get on and off a toilet or commode
- Car transfer. Ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.
- Walk 10 feet. Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This is a skip pattern to 1-step curb if admission performance is coded 07-09-10-88
- Walk 50 feet with two turns. Once standing, the ability to walk at least 50 feet and make two turns.
- Walk 150 feet. Once standing, the ability to walk at least 150 feet in a corridor or similar space.
- Walk 10 feet on uneven surface or sloping surface (indoor or outdoor). Does not include walking in parallel bars.
- 1-step curb. Ability to go up and down 1 step.
- 4-steps. Ability to go up and down 4 steps.
- 12 steps. Ability to go up and down 12 steps with or without a rail.
- Picking up an object. Ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor.
- Does the resident use a wheelchair/scooter? Wheelchair use is for self-mobility and not transport only.
No = skip to H0100, appliances; Yes = continue to FF0170R
- Wheel 50 feet with two turns. Identify manual or motorized wheelchair.
- Wheel 150 feet in a corridor or similar space. Identify manual or motorized wheelchair.
Section GG Discharge
Should be completed within the last three days of the part an SNF stay. It can be combined with an OBRA assessment or completed as a stand-alone end of Medicare Part A stay assessment when the resident is going to remain in the facility.
It is permissible to use the 07 (refused), 09 (not applicable), 10 (not attempted due to environmental limitations), or the 88 (not attempted due to medical condition or safety) codes when coding the discharge goals.
A minimum of one self-care or mobility goal must be coded. You may code more discharge goals if you want to.
The use of a dash (-) is permissible when coding discharge goals if you have coded at least one discharge goal. This will not affect the annual payment update (APU) determination.
Goals should be established as part of the resident’s care plan based on resident’s prior level of function, discussion with resident and family, professional’s standard of practice, resident’s motivation, anticipated length of stay, and planned discharge setting/home.
A discharge goal can be higher than the admission 5-day SNF PPS assessment performance code if the clinician and resident determine the resident is expected to make gains in function by discharge.
A discharge goal could be the same as the 5-day admission SNF PPS assessment performance code if the clinician and resident determine the resident is expected to maintain function and not progress to a higher level. It should be noted that a discharge goal could be lower than the 5-day admission SNF PPS assessment performance code if the clinician determines a resident with a progressive condition is expected to rapidly decline and that receiving skilled therapy may slow the decline of function.
In summary, change in in the air. The Centers of Medicare Medicaid Services (CMS) seeks to use this data to help direct improved clinical outcomes and to determine which setting has better functional outcomes for short-term rehab patients built on evidence-based practice. With the expansion of Section GG, we will be able to compare functional outcomes to those patients with similar data in the inpatient rehab facilities. Information in this is from the public domain to include CMS.
For questions, please contact Debbie Duhaime, Robin A. Bleier, and Nathan Shaw, Vice President of Clinical Reimbursement & Analytics with RB Health Partners, Inc. and can be reached at 727.786.3032 or [email protected], [email protected], and [email protected].