Effective October 1, 2016, Skilled Nursing Facilities (SNF) are required to submit additional  functional and quality measure data via patient assessments to the Centers for Medicare and Medicaid Services (CMS).  This information will be gathered from the revised Minimum Data Set (MDS) 3.0 Section A and a new Section GG.  Along with these revisions, a new MDS assessment type of an SNF Medicare Part A PPS discharge assessment for when a Medicare Part A stay ends, will be implemented.

Section GG Functional Assessments

The intent of Section GG is to assess the need for assistance with self-care and mobility activities.  Section GG accomplishes the intent through 16 items, which will require the functional assessment of the following:

• Eating
• Oral hygiene
• Toileting hygiene
• Sit to lying
• Lying to sitting on side of bed
• Chair/bed-to-chair transfer
• Toilet transfer
• Does the resident walk?
• Walk 50 feet with two turns
• Walk 150 feet
• Does the resident use a wheelchair/scooter?
• Wheel 50 feet with two turns
• The type of wheelchair/scooter used (Manual or Motorized if the resident uses a wheelchair/scooter) to Wheel 50 feet
• Wheel 150 feet
• The type of wheelchair/scooter used (Manual or Motorized if the resident uses a wheelchair/scooter) to Wheel 150 feet

Completion of Admission Performance and Discharge Goal

Completion of “Admission Performance” and “Discharge Goal” for each of the 16 new items will be required with each 5 Day Prospective Payment System (PPS) MDS. Only “Discharge Performance” for each of the 16 new items will be required for the SNF PPS Part A Discharge (End of Stay) MDS.  The instructions for coding these 16 questions state to “code the resident’s usual performance”.  The updated Resident Assessment Instrument (RAI) Manual defines usual performance as “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.”  These instructions are a drastic departure from the Activities of Daily Living (ADL) coding guidelines in Section G.  Furthermore, the coding terminology in Section GG is dissimilar to Section G.  Upon first glance, the terminology appears to mirror Therapy terminology, but close inspection reveals variances.

The coding of Section GG utilizes a 6 point scale:

• 06 - Independent: Resident completes the activity by him/herself with no assistance from a helper.
• 05 - Setup or clean-up assistance: Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
• 04 - Supervision or touching assistance: Helper provides verbal cues or Touching/Steadying assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.
• 03 - Partial/moderate assistance: Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
• 02 -Substantial/maximal assistance: Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
• 01 - Dependent or Helper does ALL of the effort: Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity.

Skilled Nursing providers should be asking several questions about how they will manage the new Section GG and the Quality Measures the data will represent.

• “Who will be in charge of collecting the information?”
• “How will the information be collected”
• “Who should code this section of the MDS?”
• “How will the required documentation be entered into the medical record during the appropriate time frames?
• “Is my staff prepared to meet and overcome the challenges of Section GG?”

Skilled Nursing providers who fail to comply with the submission requirements will face a financial penalty of 2% reduction in reimbursement beginning in the fiscal year 2018.

Best Practices:

1. Educate, Educate, and Educate Again:
2. Perform immediate and ongoing training sessions for all staff assisting in assessing, observing and documenting in the medical record. This training is imperative to ensure that GG coding accurately depicts the Admission, Discharge Functional Assessment, and Goal Setting.  Skilled Nursing providers should ensure staff responsible for collecting the data to code Section GG have a thorough knowledge the updated RAI Manual’s guidelines on:

1. definitions
2. coding instructions
3. coding tips

Staff responsible for coding Section GG should understand the same guidelines as stated above, and in addition:

1. the intent and item rationale
2. the steps for assessment

1. Develop Your Interdisciplinary Team
2. Develop an interdisciplinary team approach to properly depict the resident’s usual performance within the designated functional performance areas during the given timeframe.  Although the coding terminology is similar to Therapy terminology, coding of Section GG should not be relegated to Licensed Therapists only.  Additionally, leaders in Skilled Nursing Facilities have spent years educating nursing assistants on how to code Section G.  The instructions in Section GG are almost opposite of Section G, which could lead to confusion and miscoding.  To make one person or position responsible for collecting the data for Section GG is a recipe for disaster, rather than success.