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Section GG: What It Takes to Get the Coding Right

How can nurse assessment coordinators (NACs) lead the interdisciplinary team (IDT) to develop a workable plan to ensure that MDS section GG (Functional Abilities and Goals) is coded accurately per the coding guidelines in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual and that the medical record contains all supporting documentation needed to back up that coding? “There is no magic one-size-fits-all answer to that question,” says Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, director of clinical reimbursement for LeaderStat in Powell, OH. “Even though section GG has been around for years—predating the now two-year-old Patient-Driven Payment Model (PDPM)—accurate coding with strong supporting documentation remains a constant struggle for providers across the country.”

The effects of items GG0130 (Self-Care) and GG0170 (Mobility) are multi-tiered, says Heichel. “They are a huge component of reimbursement under PDPM. In addition, they are used in the Skilled Nursing Facility Quality Reporting Program (SNF QRP), both as publicly reported quality measures (QMs) and as data that needs to be submitted to meet the annual assessment-based data submission threshold.”

Given its widespread impact, the accuracy of section GG should be a high priority, but the pandemic and the staffing shortage have combined to put many facilities in a difficult situation, says Heichel. “Providers have been most concerned about taking care of the residents, and the process for ensuring that section GG is robust has fallen off in some facilities. However, providers have a lot riding on this section of the MDS. You can’t take your eyes off of it, and you should be constantly striving to meet the requirements that CMS has set out in the RAI User’s Manual.”

What are CMS’s expectations?

Many providers still don’t quite understand what to do with section GG, says Heichel. “So, the first step is to learn what the intent behind section GG is and what the RAI User’s Manual actually is asking you to code. Then, you can figure out, ‘How can we get there?’”

The steps for assessment for GG0130 and GG0170 in chapter 3 of the RAI User’s Manual clearly indicate that providers should use an interdisciplinary approach, says Heichel. “CMS wants assessment information coming from multiple data sources throughout a Part A resident’s stay to try to determine what that resident’s ‘usual performance’ was over the required time frames. Specifically, CMS wants a picture of the resident’s usual performance at the beginning of the stay, at the end of the stay, and any time that the facility chooses to complete an Interim Payment Assessment (IPA).” Note: Some states now include section GG on OBRA assessments as well.

From CMS’s perspective, the point of taking a picture during a three-day window upon admission is to have a clear understanding of what this resident’s condition and functional status is before the provider typically intervenes to help the resident get better, says Heichel. “In other words, what is the resident’s starting point in all of these functional areas of self-care and mobility before your team implements interventions?”

Then, that picture of the resident is set aside for their entire medical stay (assuming no IPA is completed), whether that stay is, for example, 27 days, 74 days, or 17 days, says Heichel. “At the end of the stay, you take another picture over another three-day period to try to determine what this resident’s functional status is in these areas following the interventions you provided during the resident’s stay.”

That information paints a very broad picture of the care that the facility delivers, showing the resident’s progress from the beginning to the end of that stay, says Heichel. “Therefore, a consumer can get some sense of how much residents are improving, getting worse, or staying the same during their stay. Looking at those outcomes via the SNF QRP QMs will help them make decisions about whether they want to go to that facility.”

If either the beginning or the ending picture of the resident’s functional status is incorrect due to inaccurate or missing supporting documentation, then the provider will not receive the credit they deserve for the work that they did with the resident, says Heichel. “If, for example, you didn’t get an accurate picture of just how poorly functioning the resident was at the beginning of the stay, that sets the table for an inaccurate comparison at the end of the Medicare stay. You have to be able to compare accurate to accurate to get a true picture of what happened.”

Think twice about using therapy as the only assessment source

Since the implementation of section GG, many providers have leaned on the therapy disciplines to provide the necessary assessment information, says Heichel. “If you read GG0130 and GG0170, the items do seem oriented toward therapy-speak. So, directors of nursing services (DNSs) often said, ‘Let’s have therapy work these items into the therapy evaluations. I’m not going to get my nursing staff involved.’ A process was already set up for the therapy evaluations, so it was easy for providers to meld section GG into that and create no additional work for anyone.”

The decision to make section GG “a therapy thing” isn’t a terrible answer, says Heichel. “However, it certainly isn’t an interdisciplinary approach, and standing behind it is very difficult if someone asks, ‘How do you prove that this was the resident’s usual performance over the three-day assessment period when only the physical therapist or the occupational therapist at one point in time of their evaluation gave you the picture?’”

There are up to 24 hours in a day when this resident is functioning for those three days, he notes.
“If the physical therapist did an evaluation at 2 p.m. on day 2, proving that this physical therapy (PT) evaluation shows the usual performance will be hard to do if it has to stand alone, and there is no family documentation or documentation from the care staff and the other qualified professionals that CMS speaks to in the RAI User’s Manual.”

Another challenge with putting section GG completion solely in the hands of the therapy department is that there is no guarantee that every Part A resident will be evaluated upon admission, says Heichel. “For example, a resident who was recently there may have returned, and therapy determines that they don’t require an evaluation. Now, what will you do?”

The end of the Medicare stay also can present problems, says Heichel. “Sometimes, a resident at the end of their Part A stay may be skilled only for nursing because PT and occupational therapy (OT) have already discontinued their case. Again, how will this be handled?”

These types of issues are why nursing homes typically should avoid processes that are person-based, says Heichel. “You need a process that will occur no matter what happens. If one component falls off, then the other components of the process will back it up. This is especially important when a discipline like therapy is not guaranteed to be in with every resident to provide that documentation.”

Get nursing involved—somehow

Unlike therapy, nursing staff will be involved in the care of every resident who comes into the facility no matter what services they require. As a result, nursing can provide consistent documentation, as well as critical interdisciplinary input, says Heichel. “How that nursing input is obtained and what the documentation looks like may vary because nursing documentation can come from anyone on that clinical side. The best process for incorporating the nursing component will be facility-specific.”

Some options include the following:

* Build section GG into the nursing admission assessment. “The nurse who assesses the resident upon admission might be asked to assess and document the section GG items as part of that assessment,” says Heichel.

* Establish a dedicated section GG assessor. “With a dedicated assessor, you would have one specific nurse in the building (plus their backup) who would do a section GG assessment every time a Part A resident is admitted,” says Heichel. “This dedicated assessor could be, for example, an admission nurse, a unit manager, or the NAC.”

* Ask the floor nurses to document for section GG. “You may want to consider having the nurses document for section GG, while the certified nursing assistants (CNAs) continue documenting on section G (Functional Status),” suggests Melanie Tribe-Scott, BSN, RN, RAC-MT, RAC-MTA, QCP, director of quality initiatives for Zimmet Healthcare Services Group in Manalapan, NJ. “It’s a shorter assessment period for the nurses, and the CNAs get to continue working with the MDS section that they are familiar with. That’s important in states that use case-mix index for Medicaid payment.”

* Consider using CNAs as an interview source, not a documentation source.“Historically, nursing homes struggle enough with getting CNAs to document activities of daily living (ADLs) in section G every shift on a daily basis,” points out Heichel. “Adding 20-plus section GG items to the documentation requirements for CNAs who may or may not have been trained on how to actually perform these tasks may not be the best approach.”

NACs and other nurse managers also should be cautious about assuming that a caregiver who knows how to code section G can just flip those skills over and start answering questions about self-care and mobility for section GG, advises Heichel. “There is no true crosswalk between sections G and GG. The section GG items are very detailed and specific on the tasks that CMS wants the IDT to perform with the resident to see how they function on both the self-care and the mobility sides. For example, bed mobility is broken down into three items that each have a high level of specificity: GG0170A (Roll Left and Right), GG0170B (Sit to Lying), and GG0170C (Lying to Sitting on Side of Bed). It is not one global ‘How is the resident doing in bed mobility?’ question the way it is in section G.”

Instead of having CNAs try to document section GG on their own, providers may want to incorporate them into section GG interviews, says Heichel. “For example, if you as the NAC are handling the interview component, you can go out and ask the CNAs specific, targeted questions: ‘When this resident does X-Y-Z, how much assistance do they need?”

* Do a chart review if other options fall through. “At a minimum, if providers are pulling information from the therapy software to code section GG, a nurse needs to review it and provide input after reviewing the rest of the resident’s documentation in the medical record,” says Tribe-Scott. “It’s not appropriate to import the data from therapy without any interdisciplinary review at all.”

Think outside the box with agency staff

Agency staffing levels can have a huge impact on section GG, says Tribe-Scott. “Agency staff are in your facility to provide direct patient care, and any education they receive in the facility is typically focused on care processes or skills, not documentation. You have to take agency staffing use into account when you set up a structure for section GG.”

For example, if a facility has a high level of agency CNAs, staff nurses would probably be better at documenting section GG, says Tribe-Scott. “However, if you have a high level of agency nurses, it might make more sense to train staff CNAs to document for section GG.”

In some parts of the country, facilities have high levels of both agency nurses and agency CNAs, adds Tribe-Scott. “In that scenario, it may make more sense to have a dedicated assessor, such as the NAC. You need to adjust to the staffing situation in your facility so that you can get more accurate assessment information for section GG.”

Understand how section GG duties can impact NACs

NACs need to realize that they may have to tweak their schedules to do either observations or section GG interviews with CNAs or nurses, says Heichel. “Most NACs are not working on MDS assessments that are yesterday’s assessment reference date (ARD). CMS has built in a specific period of time after each ARD for assessors to actually complete the MDS, so many NACs work a little bit behind the ARD.”

Consider the example of a NAC who is working on a 5-day MDS with an ARD that was 10 – 12 days ago, suggests Heichel. “If you go out on the floor and try to ask a CNA or a nurse how much help one individual resident needed in these particular categories back in the first three days of their stay, you will face a huge barrier. It’s just not possible to get accurate information with that type of delay between the provision of care and the interview, especially when staff have high resident caseloads and often work in multiple facilities. The answers staff give are just a guess at that point—and there is no way that you can prove that it is accurate.”

To interview staff or to observe care in order to pull together section GG information in much more real time, NACs almost have to alter the course of MDS assessments, says Heichel. “You have to constantly be looking ahead for information that you may need in the future. On any given day, you have to consider upcoming MDSs so that you can carve out those assessments and gather the section GG component. Then, you have to set aside that information until you are ready to work on the rest of that particular MDS. There are a lot of challenges that come with revising your approach to MDS assessments in this way.”

Find ways to simplify

“Especially with staffing being what it is right now, you have to look at your systems to ensure not only that section GG is completed accurately but that your systems are simplified as much as possible,” says Tribe-Scott. “If you overwhelm your nurses, CNAs, or even therapy staff with documentation, the quality of that documentation decreases.”

One way to start the simplification process is by looking at the three-day assessment window, suggests Tribe-Scott. “The RAI User’s Manual tells you to ‘Assess the resident’s self-care [or 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.’ The manual goes on to say that ‘This functional assessment must be completed within’ the first three days of the Part A stay, the last three days of the stay, or within the facility-chosen three-day window of an IPA.”

The assessment may take up to three days, but the RAI User’s Manual doesn’t say that providers must document section GG across all three shifts for all three days, says Tribe-Scott. “Remember that you are coding the resident’s usual ability to perform in these items. You don’t necessarily need to have 24-hour documentation covering all three days to capture usual functioning.”

For example, some facilities have staff on the 11 p.m. – 7 a.m. shift documenting for section GG, says Tribe-Scott. “However, if that shift rarely sees these residents perform these items, why require it? Or, if your staff can get the assessments completed so that you have a good idea of the resident’s usual performance in two days, why require all three days to be documented when it’s not necessary? You can make the process a little easier for staff if you understand how usual performance relates to the three-day assessment period.”

Another way to simplify is to divide up some of the questions among disciplines during the staffing shortage, says Tribe-Scott. “CMS wants interdisciplinary input over the whole section, but not necessarily for each question. For example, nursing may be able to document oral hygiene in GG0130B, while therapy and restorative nursing may be better suited to document the resident’s ability to walk 150 feet in GG0170K. Yon don’t always need full interdisciplinary participation on every question to determine usual performance, so you may want to take a look at who is doing what.”

Take advantage of resident/family reports

Sometimes, providers forget that CMS allows MDS assessors to incorporate resident self-reports and family reports into section GG coding, say Tribe-Scott. “You may want to consider, for example, adding a resident interview regarding GG items onto the nursing admission assessment if your resident is alert and oriented so that you can use that information on the 5-day MDS.”

Have a strong process to trigger end-of-stay section GG

Providers are often able to build triggers for day 1 – 3 documentation into the software so that assessments are automatically pushed out to the right staff upon admission, says Heichel. “For example, a SNF may include section GG nursing documentation in nursing admission user-defined assessments, or there may be a tool for nursing staff to use over the first three days.”

However, there also needs to be a strong process for the end of the Medicare stay, says Heichel. “Often, this process has to be more manually driven because the end of the stay obviously is different for every resident. The NAC has to have a process to either trigger those assessments to open up again or to put the forms back out there for that three-day assessment window, and the same would be true if the facility chooses to do an IPA.”

Data gathered? Write a section GG summary note

The best practice at the end of the data-gathering process is for the IDT to pull together a section GG summary progress note, says Heichel. “As a team, you should write a simple note that basically says, ‘Based on these sources of information for this particular resident, this is what we came up with as their usual performance in these items.’ It would be helpful to cite the sources in the note.”

The goal is to build a roadmap so that the summary note will help guide anyone else looking at the same information in the medical record—whether that may be an auditor or a state surveyor—to come up with the same section GG coding conclusion that the IDT did, says Heichel. “When you gather information from various sources, including PT, OT, and nursing interviews and observations, it’s often difficult to find one consistent code for each section GG item. You most likely will see varied coding responses.”

Therefore, a summary note can help make it as clear as possible how the IDT members all agreed upon that ultimate coding decision, says Heichel. “It should be a team note so that it’s not put on the shoulders of one individual in the facility to document and take responsibility for this information.”

As part of the process of making a coding decision, the summary note also needs to clarify any inconsistencies, stresses Tribe-Scott. “Clarifying inconsistencies among the therapy documentation, nursing documentation, resident self-report, and the rest of the medical record helps answer the question of why the team made that coding decision.”

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