Skilled Nursing Facility providers have been concerned about potential changes to Section G that would change common interpretation of coding instructions in Section G. The example cited is as follows:
If the patient had one occurrence of limited assist, one occurrence of extensive assist, and one occurrence of total dependence should Section G be coded as limited assist (as the ADL algorithm on page G-6 states), or supervision (as the recent CMS clarification states)?
Representatives from Harmony (HHI) attended a recent conference where Representatives from CMS spoke. When the above example was presented to Ann Spenard, Vice President of Consulting Services for CMS Contractor Qualidigm in Rocky Hill Connecticut, her answer was that providers couldn’t just follow the ADL coding algorithm. Spenard stressed that if providers were familiar with “the full 17 pages on coding G0110” that they would come to the same conclusion as CMS did that supervision was the correct code to choose. “You cannot use the algorithm in and of itself…without reading all the caveats and all of the boxes”, was Spenard’s reply.
Harmony (HHI) recommends providers use apply energies to increasing scrutiny of ADL documentation and efforts to ensure it is complete and accurate. The example presented to CMS (any single activity happening only three times, and each time at a different level) should be an exceptional circumstance. More often, the resident performs an activity a sufficient number of times to identify clear and distinct occurrences (more than the required three occurrences) at any given level. The rule of three for Section G0110 clearly states that:
If an activity occurs three times at any one given level, code at that level. When an activity occurs three times at multiple levels, code the most dependent level.
RAI User’s Manual updates, released May 20, 2013, provided an addition of “and/or” to coding instructions and updated the ADL coding algorithm to include a more complete definition of extensive assist. While this update did not directly address the questions providers have, CMS officials clearly stated this is a topic that will likely be a part of future updates. Changes to coding instructions, in order to better clarify CMS’s intent for this item, should be anticipated in the future. CMS stated they are working on an ADL algorithm that can be used independently of the text of Section G0110 in the RAI User’s Manual.
Harmony (HHI) would recommend that providers spend their efforts ensuring that each occurrence of an ADL activity is accurately coded in the documentation. This will provide the information that the MDS Coordinator needs to correctly code Section G0110 of the MDS.
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