Section GG GG 1. MDS Coding Essentials: Section GG and Function. MDS Essentials. Section GG Assessment Types. Content 4/24/2017.

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1 Section GG GG 1 MDS Coding Essentials: SECTION GG: FUNCTIONAL ABILITIES AND GOALS Intent: This section assesses the need for assistance with self care and mobility activities. Sections GG and K 1 4 MDS Essentials Section GG and Function Section GG focuses on 2 areas: Resident s self care (GG0130) Resident s mobility (GG0170) Section GG assesses: Resident s admission performance; Resident s discharge goals; and GG 1 Resident s performance at the time of discharge 2 5 Content Section GG Assessment Types User s Manual Chapter 3 Section GG and K Intent Rationale Basic coding instructions Section GG Admission Performance Discharge Goals Section GG Discharge Performance 3 6 1

2 Section GG Admission Performance GG 1 GG 2 Only required for traditional Medicare SNF Part A stays Section GG Admission Performance Steps for Assessment GG 2 Assess the resident s self care status based on direct observation, resident s self report, family reports, and direct care staff reports documented in the resident s medical record during the 3 day assessment period, (days 1 through 3), starting with date in A2400B, Start of most recent Medicare stay Residents should be allowed to perform activities as independently as possible (as long as they are safe) Continued. 10 Section GG Admission Performance Column 1. Admission Performance Code resident s usual performance at START of SNF PPS stay (admission) for each activity using the 6 point scale data collected will be from first 3 days of the SNF PPS stay and prior to initiating any therapeutic interventions Safety and Quality of Performance Scale 06 = Independence 05 = Setup or Clean Up 04 = Supervision/Touching 03 = Partial/Moderate 02 = Substantial/maximal 01 = Dependent GG 1 GG 16 Section GG Admission Performance Code self performance of resident based on their usual performance, or baseline performance identified as resident s usual activity for any of the self care or mobility activities, NOT the most independent or dependent performance over the assessment period GG Section GG Admission Performance Column 1. Admission Performance If activity was not attempted at the start of stay, code one of the Activity not attempted reasons Section GG Admission Performance If there s fluctuation in the performance of activities during the three day assessment: Activity not attempted reason: 07 = Resident refused 09 = Not applicable 88 = Not attempted due to medical condition or safety concerns 9 GG 1 GG 16 the performance wouldn t be the worst, and it wouldn t be the best, but it would be what s usual (or baseline performance) for that individual 12 GG 3 2

3 Section GG Discharge Goals Column 2. Discharge Goal We will come back to this GG0130 GG 4 GG 6 Self Care Activities in GG0130 Discharge End of SNF PPS Stay Completed when a resident has a planned discharge from the SNF Part A stay NOT completed when a resident discharges out to the hospital BUT, the GG Admission performance is required with each new admission/readmission When the resident has a planned discharge, the assessment period for discharge performance is the last 3 days prior to the discharge, including the discharge date. (Last 3 days of SNF stay ending on date coded in A2400C) These items will indicate the resident s performance ability at the time of the their discharge from a SNF stay GG0130 and GG0170 GG 17 GG 20 Functional Items 2 Categories 1. GG0130: Self Care Activities GG 3 GG0130: Self Care (3 day assessment period) Discharge (End of SNF PPS Stay) Only completed on an SNF PPS Part A discharge Assessment (NPE) Section GG is not completed on the NPE if: This assessment is also an unplanned discharge A0310G=2 This assessment discharge status is to the acute hospital A2100=3 Medicare stay is 2 days or less (A2400C A2400B = 2 or less) Make sure you know what each item is asking Safety and Quality of Performance Scale 06 = Independence 05 = Setup or Clean Up 04 = Supervision or Touching 03 = Partial/Moderate 02 = Substantial/maximal 01 = Dependent Complete when Medicare Part A coverage has ended and remains in the facility or planned discharge! Activity did not occur reasons: 07 = Resident refused 09 = Not applicable 88 = Not attempted due to medical concern or safety concerns Section GG0130: Self Care Functional Abilities GG0130A. Eating GG0130B. Oral Hygiene GG0130C. Toileting Hygiene The ability to use suitable utensils to bring food to the mouth and swallow food Once the meal is presented on a table/tray Includes modified food consistency The ability to use suitable items to clean teeth Dentures: o The ability to remove and replace dentures from and to the mouth, o And manage equipment for soaking and rinsing them The ability to maintain perineal hygiene, Adjust clothes before and after using the toilet, commode, bedpan, or urinal If managing an ostomy, include wiping the opening but not managing equipment 18 3

4 Section GG0170: Mobility Functional Abilities GG0170B. Sit to Lying GG0170C. Lying to Sitting on Side of Bed GG0170D. Sit to Stand GG0170E. Chair/Bed-to- Chair Transfer GG0170F. Toilet Transfer The ability to move from sitting on side of bed to lying flat on bed The ability to safely move from lying on the back to sitting on the side of the bed With feet flat on the floor And with no back support The ability to safely come to a standing position from sitting in a chair Or on the side of the bed The ability to safely transfer to and from a bed to a chair (or wheelchair) The ability to safely get on and off a toilet or commode GG0130 GG0170 Steps for Assessment Helper GG 3 For Section GG a helper is defined as facility staff who are direct employees and facility contracted employees (e.g., rehabilitation staff, nursing agency staff). Does not include individuals hired, compensated or not, by individuals outside of the facility's management and administration such as hospice staff, nursing/certified nursing assistant students, etc. Helper is NOT family members and sitters hired by the family Functional Items 2 Categories 2. GG0170: Mobility Items Make sure you know what each item is asking Gateway? Gateway? GG 22 GG 40 GG0130 GG0170 Steps for Assessment GG 3 If a helper s assistance is required because a resident s performance is unsafe or of poor quality, only consider staff assistance when scoring according to the amount of assistance provided Activities may be completed with or without assistive device(s). Use of assistive device(s) to complete an activity should not affect coding of the activity Section GG0170: Mobility Functional Abilities GG0170J. Walk 50 ft. with 2 turns GG0170K. Walk 150 Feet GG0170R. Wheel 50 ft. with 2 Turns GG0170S. Wheel 150 Feet Once standing, the ability to walk at least 50 feet and make two turns Once standing, the ability to walk at least 150 feet in a corridor or similar space Once seated in wheelchair/scooter, can wheel at least 50 feet and make two turns Once seated in wheelchair/ scooter (manual or motorized), can wheel at least 150 feet in a corridor or similar space The intent is to assess usual performance and if the resident is able to perform the task safely GG0130 and GG0170 GG 2 GG

5 CODE Point Rating Scale Definitions DESCRIPTION Independent: if the resident completes the activity by him/herself with no assistance from a helper Setup or clean up assistance: helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity but NOT during the activity Supervision or touching assistance: helper provides VERBAL CUES OR TOUCHING/STEADYING assistance as resident completes the activity. Help may be provided throughout the activity or intermittently GG0130 GG0170 Coding Tips Admission or Discharge Performance If two or more helpers are required to assist the resident to complete the activity, code 01, Dependent Do not record the staff s assessment of the resident s capability to do an activity only code the actual performance To clarify your own understanding of the resident s performance, ask probing questions to staff about the resident Point Rating Scale Definitions CODE DESCRIPTION Partial/moderate assistance: If helper does LESS THAN 03 HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Substantial/maximal assistance: If helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort Dependent: If the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two (2) or more helpers is required for the resident to complete the activity GG0130 GG 13 Examples of Probing with Staff Oral hygiene: Example of a probing conversation between a nurse and a CNA to determine a resident s oral hygiene score Nurse: Does Mrs. K help with brushing her teeth? Certified nursing assistant: She can help clean her teeth. Nurse: How much help does she need to brush her teeth? Certified nursing assistant: She usually gets tired after starting to brush her upper teeth. I have to brush most of her teeth. Code 02 = Substantial/maximal assistance (more than half of the effort) Examples please also check Manual Eating: Ms. S has multiple sclerosis, affecting her endurance and strength. Ms. S prefers to feed herself as much as she is capable. During all meals, after eating three fourths of the meal by herself, Ms. S usually becomes extremely fatigued and requests assistance from the CNA to feed her the remainder of the meal. Coding: GG0130A. Eating would be coded 03, Partial/moderate assistance. Rationale: The CNA provides less than half the effort for the resident to complete the activity of eating for all meal Rating Scale Definitions GG 4 In addition to the 6-point scale some other responses that can be coded but NOT for Discharge Goals: CODE DESCRIPTION 07 Resident refused: resident refused to complete the activity 09 Not applicable: if resident did not perform this activity prior to current illness, exacerbation or injury 88 NOT ATTEMPTED DUE TO MEDICAL CONDITION OR SAFETY CONCERNS Use ONLY for Admission and Discharge Performance!

6 Examples More help in Manual Eating: Mr. R is unable to eat by mouth due to his medical condition. He receives nutrition through a gastrostomy tube (G tube), which is administered by nurses. Coding: GG0130A. Eating would be coded 88, Not attempted due to medical condition or safety concerns. Rationale: The resident does not eat by mouth at this time. Assistance with G tube feedings is not considered when coding the item Eating. 31 GG 8 Discharge Goals for GG0130/GG0170 Coding tips for discharge goals: At least one discharge goal, established on admission, is required for at least one of the self care or mobility items for each resident. Dashes ( ) may be used to indicate that a goal was not set for a particular activity. Using the dash in this way is permitted and does not affect the facility s payment update through the SNF Quality Reporting Program. Even though only one discharge goal is required, the facility may choose to code more than one discharge goal for a resident. Goals may be determined based on the resident s admission functional status, prior functioning, medical conditions/comorbidities, discussions with the resident and family, and the clinician s consideration of expected treatments, and resident motivation to improve. 34 GG 13 Discharge Goals for GG0130 /GG0170 GG 13 Discharge Goals for GG0130/GG0170 GG 13 Expected to Improve The IDT determines the resident is expected to make gains in function by discharge Utilizing the Safety and Quality of Performance Scale 06 = Independence 05 = Setup or Clean Up 04 = Supervision / Touching 03 = Partial/Moderate 02 = Substantial/maximal 01 = Dependent Activity did not occur reasons: 07 = Resident refused 09 = Not applicable 88 = Not attempted due to medical concern or safety concerns Not Expected to Improve Expected to Decline The IDT determines the resident is not expected to progress to a higher level of functioning during the Medicare Part A stay The IDT determines decline in function is anticipated and unavoidable GG0130 GG0170 Discharge Goal: Coding Tips for Column 2 Licensed clinicians can establish a resident s discharge goal(s) at the time of admission based on the 5 day PPS assessment, 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 This is the resident s goal along with what therapy hopes to accomplish during a skilled stay (if the resident is receiving therapy services) 33 Second Column Discharge Goal: Coding Tips Using GG0170K Walk 150 Feet as an example: Mr. Jones was admitted to the SNF after a fall with a humeral fracture. He used a walker prior to his fall. Section GG0170K column 1 Admission Performance might be a 03: Partial/Moderate assist, but his goal for his skilled stay is to get back to the walker, so column 2 Discharge Goal, would be coded as a 06 because he hopes to be become independent again

7 Mobility Coding Scenarios Sit to Lying: Mr. Tucker has a diagnosis of Parkinson's Disease. He is able to hold on to one side rail, but the nursing assistant has to support his trunk when assisting him to a lying position. Choose one How would you code GG0170B? 04. Supervision or touching assistance 02. Substantial/maximal assistance 01. Dependent 07. resident refused 37 Mobility Coding Scenarios Toilet transfer: Mr. H has paraplegia incomplete, pneumonia, and a chronic respiratory condition. Mr. H prefers to use the bedside commode when moving his bowels. Due to his severe weakness, history of falls, and dependent transfer status, two CNAs assist during the toilet transfer. How would you code GG0170B? 01. Dependent Rationale: The activity required the assistance of two or more helpers for the resident to complete the activity 40 Mobility Coding Scenarios Sit to Lying: Mr. Tucker has a diagnosis of Parkinson's Disease. He is able to hold on to one side rail, but the nursing assistant has to support his trunk when assisting him to a lying position How would you code GG0170B? 02. Substantial/maximal assistance RATIONALE: The helper lifts or holds trunk or limbs and provides more than half the effort Section GG Assessment Types Section GG Admission Performance Discharge Goals Section GG Discharge Performance Mobility Coding Scenarios Toilet transfer: Mr. H has paraplegia incomplete, pneumonia, and a chronic respiratory condition. Mr. H prefers to use the bedside commode when moving his bowels. Due to his severe weakness, history of falls, and dependent transfer status, two CNAs assist during the toilet transfer. Choose one How would you code GG0170B? 04. Supervision or touching assistance 02. Substantial/maximal assistance 01. Dependent 07. resident refused 39 Little break 42 7

8 Little break K0100 K 1 43 Steps for assessment Ask the resident if he or she has had any difficulty swallowing during 7 day look back period Observe resident during meals and at other times when eating, drinking or swallowing Interview staff on all shifts Review the medical record, including nursing, physician, dietician and speech language pathologist notes Check all that apply (even if occurred only once in look back period) 46 Section K K 1 K0200 K 2, K 3 SECTION K: SWALLOWING/NUTRITIONAL STATUS Intent: The items in this section are intended to assess the many conditions that could affect the resident s ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately. Rationale Diminished nutritional and hydration status can lead to debility that can adversely affect health and safety as well as quality of life K0100 K 1 K0200 K 3 Rationale The ability to swallow safely can be affected by many disease processes and functional decline Alterations in the ability to swallow can result in choking and aspiration, which can increase the resident s risk for malnutrition, dehydration and aspiration pneumonia 45 Steps for assessment: Height 1. Base height on the most recent height since admission/entry or reentry 2. Measure height consistently over time in accordance with facility policy and procedure 3. For subsequent assessment, check the medical record. If the last height recorded was more than one year ago, measure and record the resident s height again Record height to the nearest whole inch Use mathematical rounding to nearest whole inch 48 8

9 K0200 K 3 Steps for assessment: Weight 1. Base weight on most recent measure in the last 30 days 2. Measure weight consistently over time in accordance with facility policy and procedure 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD for this assessment 4. If the last recorded weight was taken more than 30 days prior to the ARD, weigh the resident again 5. If the resident weight was taken more than once during the preceding month, record the most recent weight K0300 K 5 This item compares the resident s weight in the current observation period with his or her weight at two snapshots in time At a point closest to 30 days preceding the current weight At a point closest to 180 days preceding the current weight Steps for assessment 1. Identify weight from current observation period and from 30 days prior to current weight 2. If current weight is less than weight 30 days ago, calculate percentage of weight loss K0200 Record the residents weight to the nearest whole pound Use mathematical rounding K 3 If a resident cannot be weighed, for example because of extreme pain, immobility or risk of pathological fractures, use the standard no information code ( ) and document rationale on the resident s medical record 50 K day weight loss calculation Multiply the 30 days ago by 0.95 to identify 5% threshold If current weight is equal to or less than threshold, the resident has lost more than 5% body weight Example Weight 30 days ago = 165 lbs. 165 lbs. x 0.95 = lbs. (5% threshold) Weight 30 days from current weight = 155 lbs. 155 lbs. < lbs. Resident has experienced a 5% weight loss 53 K 6 K0300 K 4 K0300 K 6 Rationale Weight loss can result in debility and adversely affect health, safety and quality of life For persons with morbid obesity, controlled and careful weight loss can improve mobility and health status For persons with a large volume (fluid) overload, controlled and careful diuresis can improve health status 180 day weight loss calculation Multiply weight 180 days ago by 0.90 to identify 10% threshold If current weight is equal to or less than threshold, the resident has lost more than 10% body weight Example Weight 180 days ago = 165 lbs. 165 lbs. x 0.90 = lbs. (10% threshold) Current Weight= 152 lbs. 152 lbs. > lbs. Resident has not experienced a 10% weight loss

10 K0300 Coding instructions Code based on if resident had weight loss in either the last 30 days or the last 6 months Determine if resident was on a physicianprescribed weight loss regimen 55 K 5 K day weight gain calculation Multiply weight 180 days ago by 1.10 to identify 10% threshold If current weight is equal to or more than threshold, the resident has gained more than 10% body weight Example Weight 180 days ago = 165 lbs. 165 lbs. x 1.10 = lbs. (10% threshold) Current weight = 183 lbs. 183 lbs. > lbs. Resident has experienced a 10% weight gain 58 K 9 K0310 K 8 K0310 K 9 Rationale Weight gain can result in debility and adversely affect health, safety and quality of life This item compares the resident s weight in the current observation period with his or her weight at two snapshots in time At a point closest to 30 days preceding the current weight At a point closest to 180 days preceding the current weight 56 Coding instructions Code based on if resident had weight gain in either the last 30 days or the last 6 months Determine if resident was on a physicianprescribed weight gain regimen 59 K0310 K 8 30 day weight gain calculation Multiply weight 30 days ago by 1.05 to identify 5% threshold If current weight is equal to or more than threshold, the resident has gained more than 5% body weight Example Weight 30 days ago = 165 lbs. 165 lbs. x 1.05 = lbs. (5% threshold) Current Weight = 170 lbs. 170 lbs. < lbs. Resident has not experienced a 5% weight gain 57 K0510 Rationale Nutritional approaches that vary from the normal or rely on alternative methods can diminish an individual s sense of dignity and self work as well as diminish pleasure from eating 60 K 10 10

11 K0510 K 11 K0710 K 13 Rationale Nutritional approaches that vary from the normal, such as parental/iv or feeding tubes, can diminish an individual s sense of dignity and selfworth as well as diminish pleasure from eating K0510A. Parenteral/IV Feeding Coding tips Parenteral/IV feedings may be included when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutritional or hydration need Must be noted in the resident medical record according to state and internal facility policy Does not include: IV Medications IV fluids used to:» Reconstitute or dilute medications, routine part of operative or diagnostic procedure, administered K 11 solely as flushes, in conjunction with chemotherapy or dialysis Enteral feeding formulas 62 Steps for assessment: Review intake records to determine actual intake through parenteral or tube feeding routes Calculate proportion of total calories received through these routes K0710A. K 14 Oral Tube Sun Mon Tues Wed Thurs Fri Sat Total 2,450 15,000 Tube Cal/ Total Cal x 100 = % of intake by tube 2, ,000 = 17,450 (total calories) 15,000 / 17,450 = x 100 = 85.9% 65 K0510B. Feeding Tube Definitions 63 K 11 Steps for assessment Add total amount of fluids received each day by IV and/or tube feedings only Divide total by 7 to calculate average fluid intake per day K0710B. 66 IV Fluid K 15 Sun 1250 Mon 775 Tues 925 Wed 1200 Thurs 1200 Fri 500 Sat 450 Total 6,300 Total fluids by IV or tube feeding / 7 days 6300 / 7 = 900 cc/day average 11

12 K0710B. K 15 MDS Essentials 1 While in the hospital While in the Facility Mon 400 cc Fri 510 cc Tues 520 cc Sat 520 cc Wed 500 cc Sun 490 cc Thurs 480 cc Total 1900 cc Total cc/ 4 days in hospital = 475 cc/day average K0710B. K 16 While in the hospital While in the Facility Mon 400 cc Fri 510 cc Tues 520 cc Sat 520 cc Wed 500 cc Sun 490 cc Thurs 480 cc Total 1900 cc Total 1520 cc cc/ 3 days in the facility = 507 cc/day average Please continue with MDS Coding Essentials: Sections L, M, N, and P 71 K0710C. While in the hospital While in the Facility Mon 400 cc Fri 510 cc Tues 520 cc Sat 520 cc Wed 500 cc Sun 490 cc Thurs 480 cc Total 1900 cc Total 1520 cc 69 K 17 1, ,520 = 3,420 cc 3420 / 7 days = 489 cc/day average 1 MDS Essentials RAC CT Education Advancement Education Advancement 72 Professional Development Expert within your Organization Successfully Completed RAC CT Completed QCP CT Completion of Medicare University RAC MT, QCP MT 12

13 Questions Please submit questions to: The New to MDS Community 73 13