Illuminate
Skilled Nursing
5 Tips to be OK with GG Documentation
May 27, 20255 Tips to Be OK with GG Documentation
All changes, revisions, and updates to nursing home regulations and guidance have one thing in common. They impact documentation. For instance, the transition of functional activities of daily living (ADL) calculations from section G to GG in the MDS involves completely different metrics. Improving accuracy of GG functional documentation is crucial for enhancing resident care planning and ensuring accurate reimbursement. But don’t let worries or questions about GG documentation keep you awake at night. Use these five tips to ensure your data presents a complete, accurate, and up-to-date picture of the care your team is providing.
1. Have documentation guidelines and policies that direct your staff regarding documentation behind GG. “When someone is on the interdisciplinary documentation team, they are collecting information to be processed onto the MDS. This is called data formulation, and everyone involved in this needs to have a very, very strong respect for the importance of GG documentation,” said Leah Klusch, founder and director of The Alliance Training Center. This should include people working in facility operations, she stressed. Documentation guidelines and policies will ensure everyone knows their role and responsibilities and that the team shares common knowledge about expectations, timelines, requirements, and definitions.
2. Plan for the higher number of assessments required. Klusch said, “We are doing a much higher number of assessments on long-term care residents than we were doing previously, both on a quarterly and annual basis, so the coding on GG is much more mainstream than it was before.” She further said, “There were times when the only things we coded on GG were our Part A Medicare cases.” There wasn’t a great deal of discussion, she noted, about how to code in GG; and the directions were minimal. Now, there are 74 pages of directions to code GG, as well as expanded definitions and a richer set of instructions, all of which complicate the coding process. She noted that team members other than the MDS nurse need to be knowledgeable about how to code the functional performance of residents in a very short period of time – in their last three days in hospital or first three days in the long-term care facility.
3. Understand the concept of “usual performance.” In those three days, Klusch said, “We have to complete very intense documentation that needs to be properly interpreted by the MDS nurse and determines ‘usual performance.’” This is defined by CMS as “the resident’s usual activity/performance for any of the self-care or mobility activities, not the most independent or dependent performance over the assessment period.” This can be challenging, Klusch noted, explaining, “As far as ADLs and mobility are concerned, most older adults are inconsistent in their ability to function in a 24-hour period.” In reality, she observed, they may wake up in the morning and feel quite strong. They walk to breakfast and are alert and social. By 4:00 pm, their cognitive skills or physical strength may be waning; and they’re less mobile and/or alert. “Someone knowledgeable about the definition of what usual performance is has to look at raw data from that 24-hour period to determine this. That’s what gets coded on the MDS.”
4. You can’t count on second-hand or common-sense information. Data has to be accurate and captured through appropriate channels. For instance, Klusch said, “The MDS nurse or other team member responsible for documenting usual performance can’t just ask the physical therapist for that determination. This PT only sees the resident for a short time and doesn’t know what happens in a full 24-hour period.” She added, “We know our staff are busy and have a lot on their plates; but if we try to cut corners, we can fall into the trap of having bad data.”
5. Conduct audits. How do you know what you’re doing right and catch gaps or issues before they cause problems? Klusch suggested, “You should be able to conduct a simple audit. This involves going to the MDS coding that shows the usual performance and comparing that with the medical record for the time period during that was assessed. The information in both sources should be comparable. She added, “You should be able to find shift-by-shift documentation and a sentence or so about the logic used to determine the coding for usual performance.” If you start with consistent auditing, she suggested, you can get to a point where you know that you are or aren’t coding correctly. Most commonly, Klusch noted, “Audits often find that there’s no information in the record about the person’s actual performance and someone’s created a code without this documentation. That’s against the rules.” She emphasized again that no single observation by staff is sufficient to make a determination about what is happening with a resident or what their usual performance is; but all observations should be conducted and considered in determining this, as well as care planning and MDS coding.
This all is doable, but it’s complex, Klusch concluded. Create a training plan for your team that involves multiple opportunities for and means of learning. Efforts such as case studies and role playing can help identify gaps in knowledge and misunderstandings about documentation and coding. Encourage questions and requests for additional training or support. “Training can’t be one and done. It will take time for everyone to get on board and feel confident in their roles related to section GG,” Klusch said.