Welcome back to the Section GG training. This is segment two.
There are several coding tips in the RAI User's Manual that can help
ensure accuracy in coding Section GG; I'll review them with you at this
point.
The 5-Day PPS assessment is the first Medicare-required assessment to be
completed when the resident is admitted under SNF Part A.
On the Part A PPS Discharge assessment, the Self-Care items in GG0130
are completed only if the Type of Discharge is Planned.
When reviewing the medical record, interviewing staff, and observing the
resident, be familiar with the definition for each activity (such as
eating or oral hygiene). For example, when assessing Eating (in item
GG0130A), determine the type and amount of assistance required to bring
food to the mouth and swallow food once the meal is presented on a table
or tray. When coding the resident's usual performance, use the 6-point
scale or code the reason why an activity was not attempted. At
admission, when coding for the resident's discharge goals, use the
6-point scale. Using the codes that indicate the reason why an activity
was not attempted is not appropriate for discharge goals.
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
most dependent performance, but rather record the resident's usual
performance during the assessment period.
Do not record the staff's assessment of the resident's potential
capability to perform the activity but rather code what they are
actually doing.
If the resident does not attempt the activity and a helper does not
complete the activity for the resident, code the reason the activity was
not attempted. For example, code 07 if the resident refused to attempt
the activity, code 09 if the activity is not applicable for the
resident, or code 88 if the resident was not able to attempt the
activity due to medical condition or safety concerns. If two or more
helpers are required to assist the resident to complete the activity,
code as 01, Dependent. When two helpers are required, the activity is
coded as 01, Dependent even if the resident participated in the
activity.
To clarify your own understanding of the resident's performance of an
activity, ask probing questions to staff about the resident, beginning
with the general and proceeding to the more specific.
A dash is allowed as a valid item response when coding Section GG.
Coding a dash in the Section GG items indicates "No information." CMS
expects dash use for SNF quality reporting program items to be a rare
occurrence. Use of dashes for these items may result in a 2% reduction
in the annual payment update (or APU). If the reason the item was not
assessed was that the resident refused (code 07), the item is not
applicable (code 09), or the activity was not attempted due to medical
condition or safety concerns (code 88), use these codes instead of a
dash. Let's begin to review the specific activities including in GG0130,
beginning with eating which is captured in GG0130A. Eating is defined as
the ability to use suitable utensils to bring food to the mouth and
swallow food once the meal is presented on a table or tray and includes
modified food consistency. With each activity, I'll review coding
scenarios intended to enhance your understanding of how to code Section
GG items beginning with this scenario regarding Ms. S.
Ms. S has multiple sclerosis, affecting her endurance and strength. Ms.
S prefers to feed herself as much as she is capable. After eating
three-fourths of her meal by herself, Ms. S usually becomes extremely
fatigued and requests assistance from the certified nursing assistant
(or CNA) to feed her the remainder of the meal. Considering the codes
that I reviewed earlier in the presentation, how would you code this
scenario in GG0130A and what is the rationale for that code? GG0130A.
Eating would be coded 03, Partial/moderate assistance for Ms. S. The
rationale for this is that the CNA provides less than half of the effort
for the resident to complete the activity of eating for all meals. The
resident does more than half of the effort. How would you code this
scenario in GG0130A? Mr. R is unable to eat by mouth due to his medical
condition. He receives nutrition through a G-tube which is administered
by nurses. GG0130A. Eating would be coded 88, Not attempted due to
medical condition or safety concerns as Mr. R does not eat by mouth at
this time. Remember that assistance with G-tube feedings is not
considered when coding GG0130A, Eating. Let's move on to the next
activity, Oral hygiene, captured in item GG0130B. Oral hygiene captures
the ability to use suitable items to clean teeth. If the resident has
dentures, their ability to remove and replace dentures from and into the
mouth, and manage equipment for soaking and rinsing them will be
captured here. The first coding example is about Mrs. F. who brushes her
teeth while sitting on the side of the bed. The CNA gathers her
toothbrush, tooth paste, water, and an empty cup and puts them on the
bedside table for her before leaving the room. Once Mrs. F is finished
brushing her teeth, which she does without any help, the CNA returns to
gather her items and dispose of the waste. How would you code item
GG0130B for Mrs. F? The assessor would code GG0130B. Oral hygiene as 05,
Setup or clean-up assistance as the helper provides Mrs. F with only
setup and clean-up assistance. She brushes her own teeth without any
help. Let's look at another example for oral hygiene. Mr. W is
edentulous and his dentures no longer fit his gums; he begins to brush
his upper gums after the helper applies toothpaste onto his toothbrush
but cannot finish due to fatigue. The helper completes the activity of
oral hygiene by brushing his back upper gums and his lower gums. How
would GG0130B be coded for Mr. W? GG0130B. Oral hygiene would be coded
02, Substantial/maximal assistance as Mr. W begins the activity but the
helper completes the activity by performing more than half the effort.
In this next example, the nurse assessor that will complete the item set
needs to interview the CNA in order to clarify information in the
medical record regarding the resident's performance. The nurse uses
probing questions to find out more information about how the resident
performs oral hygiene. The nurse asks, does Mrs. K help with brushing
her teeth? And the response is that she can help clean her teeth. But
that's really not enough to code the item so there's a follow up
question from the nurse who asks the CNA, how much help does she need to
brush her teeth? And the CNA replies, "She usually gets tired after
starting to brush her upper teeth. I have to brush most of her teeth".
How would you code GG0130B in this scenario? GG0130B. Oral hygiene would
be coded 02, Substantial/maximal assistance as the CNA provides more
than half of the effort to complete Mrs. K's oral hygiene. Toileting
hygiene is captured in GG0130C and is the next activity I will discuss.
Toileting hygiene is defined as the ability to maintain perineal
hygiene, adjust clothes before and after using the toilet, commode,
bedpan, or urinal. If managing an ostomy, it would include wiping the
opening, or stoma, but not managing the equipment. Our first example of
toileting involves Mrs. J who uses a bedside commode for toileting. The
CNA provides steadying assistance as Mrs. J pulls down her pants and
undergarments before sitting down on the toilet. When Mrs. J is finished
urinating or having a bowel movement, the CNA provides steadying
assistance as Mrs. J wipes her perineal area and pulls up her
undergarments and pants without assistance. How would you code GG0130C
for Mrs. J? GG0130C. Toileting hygiene would be coded 04, Supervision or
touching assistance because the helper, in this case the CNA, provides
steadying assistance to Mrs. J so that she can complete toileting
hygiene. Our next scenario involves Mr. C who has Parkinson's disease
and significant tremors that cause intermittent difficulty for him to
perform perineal hygiene after having a bowel movement in the toilet. He
walks to the bathroom with close supervision and lowers his pants and
undergarment, but asks the CNA to help him with perineal hygiene after
moving his bowels. He then pulls up his undergarment and pants without
assistance. How would you code GG0130C? For Mr. C, GG0130C. Toileting
hygiene would be coded 03, Partial/moderate assistance as the helper
provides less than half of the effort. Mr. C performs two of the three
toileting hygiene tasks by himself. Walking to the bathroom is not
considered when scoring toileting hygiene; nor is transferring on or off
the toilet. The activity of toileting only includes maintaining perineal
hygiene and adjusting clothes before and after using the toilet,
commode, bedpan, or urinal. Now I am going to move to discussing the
other type of item in section GG related to self-care function: the
self-care discharge goal. As I mentioned before, on the item set, you
will note that there are two columns. We've covered admission
performance which is documented in the first column. And now I'm going
to change gears and discuss the discharge goal which is documented in
the second column and only included on the admission assessment. Let's
start with reviewing the coding tips for the Discharge Goal.
Only use the 6-point scale (independent through dependent) to code the
resident's discharge goals. Do not use codes 07, 09, or 88 to code
discharge goals as they are not appropriate code responses for these
goals.
Licensed clinicians can establish a resident's discharge goals at the
time of admission based on discussions with the resident and family,
professional judgment, and the professional's standard of practice.
Goals should be established as part of the resident's care plan. A
minimum of one self-care or mobility goal must be coded per resident
stay on the 5-Day PPS assessment.
Clinicians may code one goal for each self-care and mobility item
included in Section GG at the time of the 5-Day PPS assessment. In order
to help clarify the concepts related to coding the Discharge goal, I
will share a few examples with you.
In the SNF, there are likely residents who are expected to have
functional improvement. For example, if a resident's admission code for
eating is 03 indicating that the resident requires partial or moderate
assistance, based on the team's assessment, including input from the
resident, it is expected that the resident's performance will improve
such that only minimal set up help will be required which equates to
code 05, set up or clean-up assistance. This is an example where
functional improvement is expected. Therefore, the clinician codes the
discharge goal as Code 05.
The clinician is using professional judgment, discussing the treatment
plan and goals with the resident and family, and comes to the
determination in this instance, that functional improvement is
reasonable to consider and the discharge goal is, therefore, higher. The
second example is a scenario in which the resident's discharge goal is
coded the same as the admission performance; in this case the goal is
that the resident's performance is maintained. For example for oral
hygiene, where the assessor anticipates the resident will have the same
level of function for oral hygiene at admission and discharge because
the resident has a progressive and degenerative condition and the team
and resident feel that, while the resident is not expected to gain
function in terms of oral hygiene, maintaining function is desirable and
achievable as a discharge goal. Therefore, the assessor codes the
discharge goal as Code 02, substantial maximal assistance. In the third
example, a resident is admitted and has a condition that will likely
lead to a decline in function. The goals of the care plan may be
centered on slowing the decline as much as possible, but there still may
be decline expected. Therefore, there are potential situations where the
discharge goal is lower than the admission score. For example, a
resident's participation in skilled therapy is expected to slow down the
pace of her anticipated functional decline but decline from her current
level of performance with eating (which is code 04, supervision or
touching assistance) is none the less expected. In this case, the
discharge goal code will be lower than the admission performance code,
perhaps a 03, partial/moderate assistance or even lower.
This is the end of segment two of the training. With segment three, I
will introduce you to GG0170, Mobility.