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Complying with the Resident Assessment Instument (RAI) User’s Manual section GG, “Functional Abilities and Goals,” along with the Part A prospective payment system (PPS) Discharge assessment (NPE), can sometimes feel like groping around in the dark hoping to get it right. Even though facility staff have been completing these Minimum Data Set (MDS) items for months, some managers are still losing sleep worrying about accuracy and future payments.

Noncompliance with completion of section GG and the NPE has a bite. Beginning Oct. 1, 2017, a skilled nursing facility’s (SNF’s) Medicare Part A payment rates may be reduced by 2 percent if its submitted assessments contain too many dashes—various MDS items can be coded with a dash, which indicates the item was not assessed. Too many dashes will result in the Centers for Medicare & Medicaid Services (CMS) being unable to calculate the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Quality Measure.

In the SNF PPS Final Rule (FY 2016), CMS indicated that for FY 2018, “any SNF that does not meet the proposed requirement that 80 percent of all MDS assessments submitted contain 100 percent of all data items necessary to calculate the SNF QRP measures would be subject to a reduction of two percentage points.”

The damage may already be done to the facility’s upcoming market basket payment adjustment, if facility staff did not complete section GG and the NPE last fall in compliance with the 80 percent threshold.

The data collection time frame was Oct. 1 through Dec. 31, 2016, for the SNF QRP Quality Measure, “Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function,” which was required by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act).

What staff did last fall can’t be changed. But fixing problems now can shore up the facility against payment penalties in the future.

Because CMS is measuring only completion of the NPE and section GG and not accuracy of the assessed items, some clinicians may not prioritize accuracy. However, facility leaders should be aware that the state surveyors may check section GG accuracy during the annual survey process.

Accuracy of the items is also important because CMS has indicated its intent to implement section GG-outcome Quality Measures in the future. On the current list of measures under consideration (the MUC list), in conjunction with the work of the National Quality Forum (NQF), CMS is considering a Quality Measure for “Change in Mobility Score for Skilled Nursing Facilities.”

If those reasons aren’t enough for careful and accurate assessment of residents’ functional abilities and goals in section GG, the process of establishing resident-focused goals for care planning and discharge should be well worth it on its own merits. When nursing and therapy staff collaborate to establish the resident’s baseline and outcomes for the section GG items, the resident wins.

Knowing when section GG is required is the first step in accuracy. This section is always required on all traditional Medicare Part A five-day assessments and all PPS Discharge assessments, unless the resident is physically discharged after a stay of fewer than three days, the discharge is to acute care, or it was an unplanned discharge. The NPE Discharge assessment is not required if the resident dies while on Medicare.

Some clinicians assume that if the resident is not on therapy, section GG is not required. But section GG is required, whether the resident received skilled therapy or not. This is important to consider because if nursing is relying on therapy to assess and complete section GG and the resident is not on the therapy caseload, confusion and conflict may result.

The three-day assessment periods at the beginning and end of a Medicare Part A stay, which are used to establish the resident’s function in self-care and mobility, have created a lot of confusion.

The RAI User’s Manual instructs: “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 three-day assessment period, which is days one through three, starting with the date in A2400B, “Start of most recent Medicare stay” (p. GG-2).

On a resident’s admission to traditional Medicare Part A, assessors are instructed to determine the individual’s “usual performance,” or baseline status, during the three-day window but prior to the start of therapeutic interventions (p. GG-4).

Capturing the resident’s baseline status prior to the start of therapeutic interventions can be tricky. CMS has indicated that the assessment is likely to occur soon after the resident’s admission, before the resident benefits from treatment. If, during that observation period, the resident’s functional status varies, that
should be taken into consideration when completing section GG items.

A determination of the resident’s status should not routinely rely on a single observation. On the other hand, therapy or other treatment should not be withheld for three days in order to establish baseline status.

In some SNFs, the policy is to complete only one discharge goal in either the self-care or mobility items of section GG, because that is all that is required for the QRP. In others, goals are being set for all 12 items in order to avoid dashes.

Neither of these is the best practice. Goals should be established that are clinically appropriate and based on the individual resident’s baseline and desired outcomes. The goals can be for expected decline, maintaining the same level, or projecting improvement.

Each goal that is selected should then be carefully care-planned so that the care coordination for treatment plans can be established.

It’s okay to dash some of the discharge goal items. Penalties are assessed only when the admission or discharge performance items are dashed or if all of the discharge goals are dashed.

Charting takes a team approach. Even after months of completing section GG, it continues to be a challenge to capture accurate data in the medical record to support the assessment.

Some facilities are exclusively using a therapy evaluation. While that is a prime source for completing these items, what happens when the resident is not on therapy caseload? Perhaps the resident is receiving only physical therapy, and a mobility assessment is completed but not the self-care items.
Nursing and therapy staff can use the Medicare meetings to discuss residents’ usual performance and discharge goals.

Medicare Advantage companies may expect facility staff to complete section GG and the NPE, but this is not required by CMS. Contract requirements must not be confused with federal requirements.
Assessments completed for Medicare Advantage residents will not be considered for the QRP or the 2 percent payment penalty for dashes. The simple reason for this is that they are not considered traditional Medicare A, the only type of assessments included in this QM. But more importantly, Medicare Advantage-required assessments don’t count for the QM because they are not submitted to CMS.

The RAI User’s Manual clearly states that “assessments that are completed for purposes other than OBRA [the Omnibus Budget Reconciliation Act of 1989] and SNF PPS reasons are not to be submitted, e.g., private insurance, including but not limited to Medicare Advantage Plans” (p. 5-1).

For some nursing or therapy clinicians, section GG is just a blip in their MDS assessment day. For others it has been a source of stress and confusion. It needn’t be. With collaboration and a focus on accuracy, patients’ success rates in their therapy programs can be enhanced and the facility’s future Medicare Part A payments and Quality Measures can be well protected.