The ability to exercise clinical judgment to define usual performance in MDS items GG0130 (Self-Care) and GG0170 (Mobility) offers nursing homes unprecedented opportunity to impact quality measures (QMs), says Rosanna Benbow, RN, CCM, ICC, IP, DNS-CT, QCP, RAC-CTA, regional director of operations at Proactive LTC Consulting in Evansville, IN.
“You have a little more control with section GG (Functional Abilities) than you did with section G (Functional Status),” explains Benbow. “You can verify that the documented data is correct through direct assessment and interviews, make an interdisciplinary decision (i.e., a clinical judgment) on the resident’s usual performance, and decide how to code the MDS based on more accurate, consistent documentation.”
However, the coding instructions are incredibly vague, says Benbow. “When section GG first implemented, someone at an AAPACN presentation noted that the Centers for Medicare & Medicaid Services (CMS) is practically the first entity in history to define a word with that same word,” she points out. “The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) actually does define usual performance with the word ‘usual,’ so it’s no surprise that nurse assessment coordinators (NACs) and other interdisciplinary team members may sometimes be confused.”
The following excerpt from the RAI User’s Manual (pages GG-15 and GG-40 in chapter 3) explains:
| Usual Performance A resident’s functional status can be impacted by the environment or situations encountered at the facility. Observing the resident’s interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident’s functional status. If the resident’s functional status varies, record the resident’s usual ability to perform each activity. Do not record the resident’s best performance and do not record the resident’s worst performance, but rather record the resident’s usual performance. |
“Exactly what documentation will support usual performance is unclear, says Benbow. The steps for assessment for GG0130 (page GG-15) and GG0170 (page GG-40) both indicate that section GG coding decisions should be a team decision based on direct observation, documentation, and resident or family interviews:
| Assess the resident’s self-care* 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 assessment period. CMS anticipates that an interdisciplinary** team of qualified clinicians is involved in assessing the resident during the assessment period. * GG0170 assesses mobility performance and uses the word mobility. ** GG0170 uses the word multidisciplinary instead of interdisciplinary. |
“However, if you specifically ask CMS what type of documentation they want, they will say that facilities need to have a documentation policy, and they don’t dictate the documentation,” stresses Benbow.
The result has been inconsistent outcomes with section GG during medical review, says Benbow. “In some buildings where therapy provided the sole documentation to support section GG, auditors have accepted it as long as the documentation was completed and signed during the three-day look-back period. On the flip side, auditors have found that providers didn’t define the resident’s usual performance even though they had three days of section GG documentation and an interdisciplinary note summarizing the resident’s usual performance.”
However, NACs can still be proactive and take the following steps to improve the coding of usual performance:
Don’t try to ‘Rule of 3’ section GG
With G0110 (ADL Assistance), CMS provided the Rule of 3 algorithm with clear instructions on how to determine the appropriate coding based on whether the activity occurred three or more times during the look-back period, notes Benbow. “One common mistake that assessors make now is to try to apply a Rule of 3-style methodology to GG0130 and GG0170.”
CMS does provide a decision tree in the RAI User’s Manual (page GG-18) that applies to both items, acknowledges Benbow. “However, this decision tree basically just re-states the coding instructions. It’s not a true algorithm that defines how many times count toward each level in the six-point coding scale: Independent (06), Setup or Clean-up Assistance (05), Supervision or Touching Assistance (04), Partial/Moderate Assistance (03), Substantial/Maximal Assistance (02), and Dependent (01). So, there is currently nothing as concrete as section G’s Rule of 3 telling assessors how to come to a decision about what the resident’s usual performance is for section GG.”
While clinical judgment is the current standard for coding section GG, it’s important to note one recent sign that more specific Rule of 3-type guidance may be coming in the future, says Beckie Dow, RN, RAC-MT, CPC-A, CHC, a clinical reimbursement specialist in Augusta, ME. “In the finalized v1.19.1 RAI User’s Manual, CMS included a newly edited example for coding personal hygiene in GG0130I. This is the only GG example in the manual that includes counting the number of times that an activity happened as part of the instruction on how to determine usual performance.”
The example, excerpted from p. GG-32 in chapter 3, is as follows:
| Examples for GG0130I (Personal Hygiene) Resident J completed all hygiene tasks independently two out of six times during the observation period. The other four times they were unable to complete brushing and styling their hair and washing and drying their face because of elbow pain after initiating the tasks, so a staff member completed these tasks. Coding: GG0130I would be coded 02, Substantial/maximal assistance. Rationale: Although Resident J was able to complete their personal hygiene tasks independently on two of the six occasions the activity occurred, a staff member had to complete their personal hygiene tasks after the resident initiated them on four of the six occasions. Because the staff had to complete Resident J’s personal hygiene tasks on four of the six occasions the activity occurred during the observation period, the staff provided more than half the effort to complete the personal hygiene tasks. Note: Italicized text indicates v1.19.1 updates. |
“Counting occurrences is very different from using clinical judgment to determine usual function,” points out Dow. “We never used clinical judgment to code section G because there was a prescribed method for determining how to code self-performance. This updated example for section GG seems to hearken back to section G’s Rule of 3.”
So, it will be important to monitor what CMS does with future updates to the coding guidance, says Dow. “Is it the beginning of a trend from CMS? Or, will the agency continue to have assessors use clinical judgment to determine each resident’s usual performance?”
Pay attention to the three-day assessment window to get the right data
“The three-day assessment windows associated with GG0130 and GG0170 for the PPS 5-Day MDS, the Part A PPS Discharge assessment, and OBRA assessments and Interim Payment Assessments (IPAs) are generally well-understood,” says Benbow. “However, assessors who don’t refer back to the steps for assessment in the RAI User’s Manual sometimes get confused when combining a PPS 5-Day assessment with an OBRA assessment.”
For example, assessors may use a look-back period of the ARD plus the two previous calendar days for a combined 5-Day/OBRA Admission assessment because they think the OBRA requirements take precedence, points out Benbow. “However, CMS makes it clear that the assessment period for this combined assessment is still the first three days of the stay.”
The following chart adapted from the RAI User’s Manual (the item set instructions plus pages GG-15 and GG-40) explains how CMS defines these look-back periods:
| Admission | Discharge | OBRA/Interim | |
| Assessment or Look-Back Period | First three days of the stay* * For residents in a Medicare Part A stay (PPS 5-Day), the admission assessment period is the first three days of the Part A stay starting with the date in A2400B (Start of Most Recent Medicare Stay). * For residents who are not in a Medicare Part A stay, the admission assessment period is the first three days of their stay starting with the date in A1600 (Entry Date). Note: If A0310B = 01 and A0310A = 01 – 06 indicating a PPS 5-Day assessment combined with an OBRA assessment, the assessment period is the first three days of the stay beginning on A2400B. In these scenarios, do not complete Column 5 (OBRA/Interim Performance.) | Last three days of the stay* * For residents in a Medicare Part A stay (Part A PPS Discharge), the discharge assessment period is A2400C (End Date of Most Recent Medicare Stay) plus the two previous calendar days. * For all other Discharge assessments, the assessment period is A2000 (Discharge Date) plus the two previous calendar days. | The ARD plus the two previous calendar days* * When the facility chooses to complete an IPA for residents in a Medicare Part A stay, the assessment period for the IPA (A0310B = 08) is the last three days (i.e., the ARD plus the two previous calendar days). * When completing an OBRA-required assessment other than an Admission assessment (i.e., A0310A = 02 – 06), the assessment period is the ARD plus the two previous calendar days. |
Another potential issue related to look-back periods involves the facility process for notifying NACs about changes in the resident’s discharge date, says Dow. “Since our NACs trigger the licensed nurses to complete section GG documentation for the three-day look-back period, they need to keep close track of the date that the resident will discharge from Part A. In some cases, we risked missing data because the NAC was unaware of changes to the discharge date.”
To ensure that NACs are kept updated, Dow’s organization added them to the e-mail list of staff members who receive the revised discharge planning form, she explains. “This way, they don’t have to wait for a weekly team meeting to find out about the change. They know as soon as the change is made, and they can set up the PPS Discharge assessment in time to get the necessary documentation.”
Encourage staff to document occurrences to obtain more comprehensive data
Many staff members who document for section GG do their documentation shift by shift—not per occurrence of the activity, says Dow. “Staff are busy, and it’s easy to go in and do their documentation one time for the entire shift.”
However, documenting per shift vs. per occurrence means that there is less section GG data available, says Dow. “The more information that you have, the better that you can see what that resident’s usual performance actually is.”
So, Dow’s organization stresses per-occurrence documentation, she notes. “We know that it is not necessarily realistic to think that a staff member will come out of a room and go over to the documentation kiosk every time. However, we encourage staff to do that whenever possible. For example, if they have some downtime before lunch and can complete some documentation, that’s really helpful. Our goal is to get staff to work per-occurrence documentation into the everyday fabric of their shift rather than follow the old-school model of sitting down and doing their documentation at the end of their shift.”
Providers can improve compliance with per-occurrence documentation by making it easier to access documentation software, suggests Dow. “For example, some software products offer portable tablets for inputting data. Or, if you have a kiosk system, you can station those kiosks in centralized locations for particular assignments or units so that staff don’t have to go out of their way to reach them. That can be helpful as well.”
Note: For additional insights on getting usual performance right, access two AAPACN resources: the podcast Section GG: Key Insights into Determining Usual Performance and the Section GG Prior Function and Admission Performance Tool.
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