Although the Centers for Medicare & Medicaid Services (CMS) has delayed release of version 1.18 of the Resident Assessment Instrument (RAI) User’s Manual to reduce provider burden, the update (1.17.2) to the current version, which allows states to collect data to establish a Medicare billing code on Omnibus Budget Reconciliation Act (OBRA) assessments, has the potential to significantly increase providers’ workload.

New Data Requirements

Medicare implemented the Patient-Driven Payment Model (PDPM) on Oct. 1, 2019. PDPM uses many existing Minimum Data Set (MDS) items, but also collects several items solely for skilled residents that were not previously required on OBRA assessments. For states to establish the PDPM billing code, the OBRA assessments must expand to include primary diagnosis information in Section I, functional abilities in Section GG, and prior surgery in Section J.

While these updates appear simple on the surface, collecting data on functional abilities in addition to activities of daily living (ADLs) is quite complex.

For states that opt to collect PDPM data on stand-alone OBRA assessments, function-related data are collected for two different time periods, in two very different ways.

Section G0110: Activities of Daily Living

• Collects self-performance during a 7-day look-back period using the “Rule of 3.”
• Collects the most support provided during the 7-day look-back period.
• Performance scale is coded between 0, Independent, and 4, Total dependence, or one “Activity not attempted” code.
• Many Medicaid case-mix-based payment models use the four late-loss ADLs (bed mobility, transfer, eating, toilet use) to calculate a Resource utilization Groups (RUGs)-based billing code.

Section GG0130 Self-Care and GG0170: Mobility

• Collects usual performance over a 3-day period for state data collection, the 3-day period is the assessment reference date (ARD) of the OBRA assessment and the two previous calendar days.
• Performance scale is 06, Independent, to 01, Dependent, or one of four “Activity not attempted” codes.
• For the Physical Therapy and Occupational Therapy components of PDPM, a Function Score is calculated using the individual scores for eating, oral hygiene, and toileting hygiene and the average scores of two bed mobility items, three transfer items, and two walking items.
• For the nursing component of PDPM, a Function Score is calculated using the individual scores for eating and oral hygiene and the average scores of two bed mobility items and three transfer items.

Providers must complete timely and accurate supporting documentation and MDS coding for both uniquely different functional assessments. To avoid documentation and coding mishaps, follow these three tips:
 
1. Provide ongoing education with a focus on the task and sub-task definitions for all interdisciplinary team members involved in providing supporting documentation or MDS coding for either Section G or GG.
A key to accuracy is understanding the definitions from the RAI User’s Manual. Although the tasks have similar titles, the definitions of the tasks and sub-tasks differ greatly between sections G and GG. Bed mobility is one example.

Section G, bed mobility is captured in one item:

• G0110A, Bed mobility: How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture.

Section GG, Bed mobility, includes two separate items:

• GG0170B, Sit to lying: The ability to move from sitting on the side of the bed to lying flat on the bed.

• GG0170C, Lying to sitting on side of bed: The activity includes resident transitions from lying on his or her back to sitting on the side of the bed with his or her feet flat on the floor and sitting upright on the bed without back support.

Another example is toileting.

Section G, all toileting activities are captured in one item:

• G0110I, Toilet use: How resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag, or ostomy bag.

Section GG, toileting hygiene and toilet transfers are two separate items:

• GG0130C, Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, includes wiping the opening but not managing equipment.

• GG0170F, Toilet transfer: The ability to get on and off a toilet or commode.

In fact, there are no identical tasks between the 10 Section GG items used under PDPM and the four late-loss ADLs used for some Medicaid case-mix payment models. This could lead to inaccurate data collection due to a misunderstanding of the task definitions. Accuracy requires intensive education and support to the nurses and nurse assistants who are responsible for documenting or reporting how a resident completes a task.

For example, if a nurse documents that the resident required weight-bearing assist of one to reposition in bed, this directly supports an episode of extensive assist of one for ADL documentation. However, there is not enough information to support Section GG—did the nurse do more than half the effort or not? Did the repositioning include moving from a sitting to lying position or vice versa?

The staff completing the direct care tasks must be well-educated in the tasks and subtasks to provide meaningful documentation to support MDS coding and must remain aware of differing look-back periods for data collection.

2. Create a strong facility process establishing how the document will be completed or how to collect
Section GG supporting data.

Many providers have electronic data collection methods that nurse assistants use to complete daily ADL documentation; however, this will not provide the information needed to support coding of Section GG on the MDS.

Providers will need to determine if Section GG data collection will be completed only during the 3-day performance period, over a larger time frame, or collected daily to allow for fluid adjustments of the assessment reference dates to capture other clinical conditions.

Providers will also need to determine how to implement data collection—will the nurse assistant complete paper or electronic data collection? Will the nurse assessment coordinator complete interviews of direct care staff during and immediately after the performance period?

There are many ways to collect the data needed to support Section GG, and approaches may vary greatly between providers. Facility teams will need to develop a process, policy, or procedure if their state requires this data collection.

3. Audit for accuracy.
Accuracy is still key. States that opt to collect this information to establish a PDPM billing code are using this information to inform future payment model decisions. Inaccurate coding or the overuse of dashes may result in misleading data, which may in turn negatively affect payment model decisions.

Another detail to consider is that CMS has delayed the MDS 3.0 version 1.18 item set, which had originally announced the retirement of Section G from the MDS. If this decision still comes to fruition, Quality Measure data that use Section G will likely convert to functional abilities and goals in Section GG—yet another increase to the many ways this information is being used.

Strengthening Section GG data collection now provides a great opportunity for providers to fine-tune Section GG information gathering for long term care residents before those data impact a facility’s Medicaid payments and quality measurement.

Jessie McGill, RN, RAC-MT, RAC-MTA, is a curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). McGill can be reached at jmcgill@AAPACN.org.​