MDS Alert

How should you code items when the resident is unable to complete the tasks?

If you have tough questions about how to code the new Section GG — Functional Abilities and Goals, you’re certainly not alone. In fact, your questions about this section are probably similar to other common questions that fellow professionals are asking.

Here are the top Section GG questions that our experts are encountering lately — and the answers that you’re searching for:

Don’t Make Therapy Solely Responsible

Question 1: Who is supposed to complete the assessment portion of Section GG? Should it be therapy?

Answer 1: “The RAI Manual does not specify who is to complete the assessment for Section GG,” says Scott Heichel, Rn, RaC-Ct, Dns-Ct, Director of Clinical Reimbursement for LeaderStat (www.LeaderStat.com). On page GG-2, the RAI Manual specifies:

“Assess the resident’s self-care status based on direct observation, the resident’s self-report, family reports, and direct care staff reports documented in the resident’s medical record during the 3-day assessment period, which is days 1 through 3, starting with the date in A2400B, Start of most recent Medicare stay.”

You should make the assessment process a multidisciplinary approach, involving nursing, therapy, observation, resident/family report, etc., Heichel recommends.

Mistake: “Placing the responsibility for completion of the assessment portion on one discipline, specifically therapy, can put facilities at risk,” Heichel warns. “Not every Medicare resident will receive therapy services for the entirety of their stay, so assessing for Section GG will require other trained disciplines also.”

Code Eating ‘Pleasure Foods’ in GG0130A

Question 2: If a tube-fed resident receives a food item such as pudding as a pleasure food, how should we code eating in Section GG?

Answer 2: If the resident eats by mouth, you can score this in item GG0130A — Eating, answered presenter Anne Deutsch, Rn, PhD, CRRn during a recent Skilled Nursing Facility Quality Reporting Program (SNF QRP) Provider Training hosted by the Centers for Medicare & Medicaid Services (CMS). This is true regardless of whether the resident may or may not be on tube feedings also.

“So just because somebody has a G-Tube doesn’t mean you can’t score Eating,” Deutsch said. You can still score GG0130A “if the person is eating, even it’s just a little bit, and it might only be in therapy.”

Strive for At Least 1 Discharge Goal

Question 3: Do we have to set a discharge goal on each of the 12 self-care and mobility items?

Answer 3: No, you don’t. To meet the minimum requirement for the Quality Reporting Program (QRP), you need to select only one discharge goal, Heichel says.

“This goal can be to improve, stay the same, or decline compared to the assessment at the beginning of the stay,” Heichel explains. CMS has stated that you are allowed to dash [-] fill the remaining items for which you do not set goals.

Watch Out for Incomplete Stays

Question 4: If a resident discharges back to the hospital, do I still have to complete Section GG at discharge?

Answer 4: No. The End of Medicare Stay assessment for Section GG is not required if the resident discharges to the hospital, has an unplanned discharge, or has a stay of less than three days, Heichel states.

You do not need to complete Section GG at the time of discharge for residents with incomplete stays or unplanned discharges, agrees Kris Mastrangelo, President and CEO of Harmony Healthcare International headquartered in Topsfield, Mass. Residents who have incomplete stays are those:

• With unplanned discharges due to a medical emergency;
• Who leave the SNF against medical advice; or
• Who die while in the SNF.

“For residents with incomplete stays, admission functional status data and at least one treatment goal would be required,” Mastrangelo notes. But discharge functional status data would not be required.

Choose the Right Code for Failed Tasks

Question 5: How do we code Section GG if the resident isn’t able to complete the task?

Answer 5: If there are safety concerns, or if the resident’s medical condition does not allow for completion of the activity and a helper does not complete the activity for the resident, you should code the item as 88 — Not attempted due to medical condition or safety concerns, Heichel instructs.

Also, you have two other coding options for this type of situation: 07 — Resident refused or 09 — Not applicable.

Make Discharge Goals Realistic

Question 6: What if the discharge goals that the resident or family voice are unrealistic?

Answer 6: The discharge goals for Section GG items have to be as realistic as possible, according to an Oct. 10 FAQ document (https://hhs.texas.gov/sites/hhs/files/documents/doing-business-with-hhs/providers/long-term-care/mds/section-ggand-npe-discharge-asmt-faq.pdf) from the Texas Department of aging and Disability services (DADS).

On page GG-13, the RAI Manual states: “Licensed clinicians can establish a resident’s discharge goals at the time of admission based upon the 5-day PPS assessment, discussion with the resident and family, professional judgment and the professional’s standards of practice.”

Example: If a resident expresses that his goal is to walk unassisted, but this hasn’t been his usual practice, then this would not be a realistic goal, DADS explained. “Remember, a goal is a desire — we can strive for that goal, but the RAI doesn’t state that the goal must be met.”

Understand What Constitutes Setup/Clean-Up Help

Question 7: For eating and needing setup/clean-up assistance, would removing trays count?

Answer 7: The assessment of Eating (GG0130A) begins once the tray is presented to the resident, Deutsch said. “And so, putting the tray in front of the resident does not count. Removing the tray from the resident’s room does not count.”

You would code 05 — Setup or clean-up assistance for GG0130A for help such as opening containers, cutting up meat, pouring liquids and that kind of help, Deutsch noted.

Two Helpers Equals Dependent

Question 8: If one helper is assisting with gait/mobility and another helper is following with a wheelchair, would this be an automatic score of Dependent?

Answer 8: If two helpers are required for the resident to perform the activity, you would code this as 1 — Dependent, Deutsch answered. “So you’d have to make a determination if the two people were required.”

For instance, one helper is steadying the resident and the other helper is following with a wheelchair, and you’re coding the discharge assessment. When the resident goes home, if your recommendation for the family was that two people would always be with the resident when he walked, then you would code this as Dependent, Deutsch explained.