MDS Alert

Decide not only who will chart, but also what charting forms and tools you’ll use.

If you’re nervous about coding the new Section GG — Functional Abilities and Goals come Oct. 1, 2016, you’re not alone. Follow these expert tips to overcome key challenges before the looming effective date and ensure that you can complete the new section accurately starting day one.

1. Determine Who Will Complete Section GG

“Section GG, effective Oct. 1, will pose new challenges for nurses and therapists alike, requiring a clear workflow and effective collaboration among staff for the section’s completion,” says Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CT, VP of Curriculum Development for the American Association of Nurse Assessment Coordination (AANAC) based in Denver.

Strategy: SNF providers “need to be working collaboratively with their therapy partners to ensure accurate coding of Section GG,” advises Becky LaBarge, RN, RAC-MT, consultant and AANAC Master Teacher. “The expertise of those therapy professionals will absolutely be required in order to appropriately code these functional items upon admission and discharge from Medicare skilled services.”

And deciding who will complete Section GG — the MDS nurse or a therapist — is the first step toward getting this new section right, Kulus stresses. “Facility staff may elect to have the therapist conduct the assessment, but what if the therapist is not involved with the resident as part of the Medicare Part A treatment plan?”

Section GG’s assessment period is the three days both at the beginning and at the end of the Medicare stay. So nursing and therapy staff should start collaborating now to develop a policy and procedure for how you’ll complete this section.

What to do: “Taking time to discuss the different types of Medicare residents will help to determine which staff will participate in completing Section GG,” Kulus suggests. “When conducting your internal analysis, consider whether physical therapy, occupational therapy, or both are involved. Then, consider who will complete Section GG if none of these disciplines are treating the resident.”

2. Learn the Different Coding Scales

Plan ahead: There is no doubt that understanding and preparing for proper coding of Section GG is crucial. “I would recommend that providers begin very soon to plan, educate staff, and determine accountability for completion of these new fields since this implementation is right around the corner on Oct. 1,” LaBarge urges.

Important: Specifically, you need to understand the differences in the coding scales for Section G — Functional Status versus Section GG. “In Section G of the MDS, the scoring scale goes up in number, with higher numbers indicating greater levels of resident dependency,” Kulus notes.

But the new Section GG has an opposite scale — the scoring scale descends in number, with lower numbers indicating the resident is more dependent, Kulus explains. If you’re not careful, you could easily code incorrectly, misrepresenting the resident’s status and inaccurately impacting the associated quality measure that will be publicly reported.

Example: Say you have a resident who is independent. In Section G, you would score the resident as 0 — Independent, but in Section GG his score is 06 — Independent.

3. Establish a Charting System

Another key component to preparing for the new Section GG is deciding who will chart the resident’s performance for the section.

You may decide to have nursing assistants chart the resident’s performance, Kulus says. “Asking nursing assistants to chart at least once every shift on the resident’s status will provide insight into the resident’s usual performance.”

Best bet: But you should “plan to use multiple sources of information to accurately assess and code Section GG, such as nursing assistant charting, resident observation, and staff interviews,” Kulus recommends. “Take time now to determine what charting system you will implement beginning Oct. 1.”

Decide who will chart and how often, as well as what charting forms or tools you will use.

Consider this: If you plan to use an electronic point-of-care (POC) charting system, make sure you take the opportunity to code ADLs at admission or within the first 24 hours, because the POC documentation for the resident is not immediately available, Kulus notes. Also, have your POC software set to automatically provide access to the director caregiver at the time of entry, instead of requiring clinical staff to manually “turn it on.”

Resource: If you haven’t already, you can download the draft RAI Manual v1.14 containing the new Section GG at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.