Section GG Coding and Therapy

This article is intended to provide education and clarification on the purpose, the deficits and the coding parameters for Section GG. In addition, HHI offers suggestions that healthcare providers can implement to prevent further damages resulting from the imperfect Section GG Coding system.

Through voluminous medical record reviews and appeal letter preparation, HHI has uncovered that the Section GG Coding system erroneously displays patient/resident outcomes secondary to the vagueness of the Section GG Coding system. Provider Quality Measure Outcomes and Provider Quality Reporting Program Data are misrepresented. In addition, the Section GG Coding system is threatening reimbursement under the Medicare Part A Payment system during governmental audits, such as TPE’s and UPIC reviews.

HHI strongly recommends that providers immediately assess their current documentation structure in relation to Section GG Coding Protocols. 

Section GG is used in healthcare settings to assess functional abilities and care needs of patients. Its purpose is to provide a standardized, comprehensive assessment of patients' functional abilities related to self-care and mobility.

Specifically, Section GG evaluates a patient's ability to perform activities such as eating, grooming, transferring, walking, and using stairs. The information is used to develop an individualized care plan that addresses the patient's specific needs and goals.

Section GG is used in a variety of healthcare settings, including hospitals, nursing homes, and rehabilitation facilities. It is important for accurate documentation and communication among healthcare providers, as well as for quality improvement and reimbursement purposes.

Section GG is an important component of the Quality Reporting Program (QRP). The QRP is a federally mandated program that requires nursing homes to report quality measures to the Centers for Medicare & Medicaid Services (CMS). The purpose of the QRP is to promote quality care and ensure that nursing homes are meeting the needs of their residents.

The data collected in Section GG is used to calculate several quality measures that are reported as part of the QRP. These quality measures include:

• Application of Percent of Skilled Nursing Facility Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function.
• Percent of Residents or Patients with Pressure Ulcers that Are New or Worsened (Short Stay)
• Percent of Skilled Nursing Facility Patients with an Admission and Discharge Assessment for Pressure Ulcers.

The quality measures related to Section GG of the MDS are designed to assess the extent to which nursing homes are providing quality care that supports the functional abilities and overall health of their residents. The measures encourage nursing homes to use the data collected in Section GG to develop individualized care plans that are tailored to the needs of each resident. By doing so, nursing homes can improve the quality of care they provide, reduce the risk of adverse events such as pressure ulcers, and help residents achieve their functional goals.

Section GG assesses a patient’s/resident's functional abilities and goals related to mobility and self-care. There are 18 items in Section GG, which are divided into two parts: Self-Care and Mobility.

Goals established should be based on the patient’s/resident's functional status and their individual needs and preferences. These goals should be documented in the resident's care plan and used to guide the care provided by the health care provider.

Section GG of the Minimum Data Set (MDS) is used in the assessment of Medicare and Medicaid beneficiaries in skilled nursing facilities. It is a standardized tool that measures the functional status and goals of the resident in various areas, including self-care, mobility, and communication.

Section GG involves identifying goals that the resident wants to achieve in the areas of self-care, mobility, and communication. The goals should be measurable and achievable within the timeframe of the resident's care plan. They should also be individualized and based on the resident's needs and preferences.

The goals identified in Section GG can be used to develop an individualized care plan that addresses the resident's needs and helps them to achieve their desired outcomes. The care plan should include specific interventions and strategies that will be used to help the resident reach their goals.

1. Section GG was created (via the CARE Tool) to monitor outcomes across the continuums of care (SNF, IRF, LTACH, HHA). Spurred by the IMPACT Act in 2014.

The IMPACT Act (Improving Medicare Post-Acute Care Transformation Act) is a federal law that was enacted in 2014. Its purpose is to improve the quality of care and communication across Post-Acute care (PAC) settings, such as skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals.

The IMPACT Act requires these PAC providers to report standardized assessment data, such as patient functional status, cognitive status, and medical conditions, to Medicare. The data is used to improve care coordination and patient outcomes across different PAC settings, and to inform payment policies for these providers.

By requiring standardized assessment data across PAC settings, the IMPACT Act aims to facilitate better communication and care coordination among healthcare providers, ultimately leading to improved patient outcomes and reduced healthcare costs. It also aims to promote greater transparency in PAC quality measures, which can help patients and their families make more informed decisions about their care options.

2. The priority in creating Section GG was interrater reliability (meaning how accurate between two different coders), not accuracy of the coding system.

3. Section GG Coding is significantly vague compared to how a therapist describes a level of assist.

4. The Assessment Reference Date (ARD) on the Admission MDS Assessment has no impact on the assessment period for coding Section GG.

5. The timeframe for coding the Admission Section GG is aways the first 3 days since Admission and is unrelated to the ARD. See below excerpt which explicitly states that the Section GG Assessment period is days 1 through 3 of the SNF PPS Stay. Per the MDS’s RAI Version 3.0 Manual CH 3: MDS Items [GG], October 2019 Page GG-13 (Page 277 of PDF):

“For the 5-Day PPS assessment, code the resident’s functional status based on a clinical assessment of the resident’s performance that occurs soon after the resident’s admission. This functional assessment must be completed within the first three days
(3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start of Most Recent Medicare Stay, and the following two days, ending at 11:59 PM on day 3.

The admission function scores are to reflect the resident’s admission baseline status and are to be based on an assessment. The scores should reflect the patient’s/resident's status prior to any benefit from interventions. The assessment should occur, when possible, prior to the resident benefitting from treatment interventions to determine the resident’s true admission baseline status. Even if treatment started on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld to conduct the functional assessment.

“For Section GG on the IPA, providers will use the same 6-point scale and activity not attempted codes to complete the column “Interim Performance,” which will capture the interim functional performance of the resident. The ARD for the IPA is determined by the provider, and the assessment period is the last 3 days (i.e., the ARD and the 2 calendar days prior). It is important to note that the IPA changes payment beginning on the ARD and continues until the end of the Medicare Part A stay or until another IPA is completed. The IPA does not affect the variable per diem schedule.”

“Please see Chapter 2 and Section A of the RAI Manual for additional details regarding the Part A PPS Discharge assessment.”

“For the Discharge assessment (i.e., standalone Part A PPS or combined OBRA/Part A PPS), code the resident’s discharge functional status, based on a clinical assessment of the resident’s performance that occurs as close to the time of the resident’s discharge from Medicare Part A as possible. This functional assessment must be completed within the last three calendar days of the resident’s Medicare Part A stay, which includes the day of discharge from Medicare Part A and the two days prior to the day of discharge from Medicare Part A.”

6. Therapy Coding Terminology is far more sophisticated than Section GG Coding Terminology.

7. Section GG Coding cannot effectively portray a patient’s /resident’s function.

8. Section GG Coding is used in QRP Quality Measures for SNF, IRF, LTACH, HHA settings.

9. Section GG Coding Terminology should not be used in therapy coding terminology because it misrepresents the outcomes.

10. Section GG Coding Terminology should not be used in therapy terminology because it understates the outcomes.

11. Section GG Coding Terminology should not be used in therapy terminology because it optically dilutes the skilled therapy interventions rendered to the patient/resident.

12. Therapy should NOT be involved in any aspect of Section GG Admission If CMS expects therapy to participate in the coding of Section GG, this requires skilled services as Therapy Evaluations constitute skilled care.

Per the RAI Manual:

“The admission functional assessment, should be conducted prior to the resident benefitting from treatment interventions to reflect the resident’s true admission baseline functional status.”

“If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld to conduct the functional assessment.”

13. Section GG “raw data” can be extracted from many sections of the medical record. Because the terminology in Section GG is so vague, it is extremely easy to code Section GG from multiple sources. This is coming from an Occupational Therapist, whose entire career is based upon helping people perform daily activities, despite physical, mental, or emotional barriers.

Data is obtained via reviewing the medical record, interviewing staff, and observing the resident.

14. Therapy Contractors must provide EHR access to LTPAC Providers and not restrict the right to use. Therapy Contractors and employees (healthcare professionals) have a legal and ethical obligation to share clinical information with the interdisciplinary team members. If a healthcare professional were to restrict medical information without a legitimate reason, they could face legal consequences such as lawsuits or disciplinary action by their licensing board. In addition, Patients / Residents could potentially suffer harm if their medical information is not shared with healthcare providers who need it to provide appropriate care.

15. HHI recommends setting one goal for self-care and one goal for mobility.  Each goal set must be care planned. (The facility does not need a goal for every item.)  Currently, the QRP requires only one goal to meet the standard. 

16. HHI recommends regularly reviewing and updating the resident's goals to ensure that they are still appropriate and relevant. By setting and working towards goals, residents can maintain or improve their functional status and quality of life.

17. HHI recommends setting one goal for self-care and one goal for mobility.  Each goal set must be care planned. (The facility does not need a goal for every item.)  Currently, the QRP requires only one goal to meet the standard. 

18. Unlike Skilled Nursing Facilities (SNFs), IRFs are not required to document specific goals for Section GG.

19. IRFs are required to document a patient's expected discharge status and expected length of stay based on the patient's functional status at admission and progress during the IRF stay.

20. HHI strongly recommends removal of Section GG Coding from all therapy documentation and resume usage of Therapy Traditional Codinge., the former method of describing functional levels.

The below grid displays the difference between Section GG Coding and Therapy Traditional Coding. The dissection of Section GG Coding Levels encompass many levels of therapy traditional coding levels.

As stated above, if therapy documentation applies Section GG Coding, this will inaccurately reflect patient/resident status as progress will not be properly reflected.

Examples of Section GG Misrepresentations

The below table depicts examples of documentation misrepresentations when therapists indoctrinate Section GG Coding into the therapy evaluations, therapy assessments, therapy progress notes, therapy goal writing and therapy discharge assessments.

*Example from the MDS RAI Manual page G-22 (Page 286 of 1309).

*Toileting Hygiene: Mr. C 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, but asks the certified nursing assistant to help him with perineal hygiene after moving his bowels. He then pulls up his pants without assistance.

Coding: GG0130C would be coded 03, Partial/Moderate Assistance.

Rationale: The helper provides less than half the effort. The resident performs two of the three toileting hygiene tasks by himself. Walking to the bathroom is not considered when scoring toileting hygiene.

Toilet Hygiene is defined in Section GG as the ability of a patient/resident to clean their genital and anal areas and manage their clothing before and after toileting. The assessment in Section GG asks the clinician to evaluate the level of assistance needed by the resident for toilet hygiene on a scale of 0 to 6, where 0 indicates independence, and 6 indicates total dependence. The assessment also considers the use of assistive devices, such as grab bars or raised toilet seats, and the need for verbal or physical cues to complete the task.

The information gathered from Section GG is used to develop care plans that address the resident's functional limitations and promote independence in activities of daily living, including toileting.

Coding Tips for GG0130C, Toileting Hygiene

• Toileting hygiene includes managing undergarments, clothing, and incontinence products and performing perineal cleansing before and after voiding or having a bowel movement. If the patient/resident does not usually use undergarments, then assess the resident’s need for assistance to manage lower body clothing and perineal hygiene.

• Toileting hygiene takes place before and after use of the toilet, commode, bedpan, or urinal. If the resident completes a bowel toileting program in bed, code Toileting hygiene based on the patient’s/resident's need for assistance in managing clothing and perineal cleansing.

• If the resident has an indwelling urinary catheter and has bowel movements, code the Toilet hygiene item based on the amount of assistance needed by the resident before and after moving his or her bowels.

In closing, HHI urges providers to review their current documentation composition in relation to Section GG Coding Protocols. By implementing the above recommendations, providers will improve accuracy of performance outcomes, perfect care planning and improve quality of care.

See below links to the LTPAC Continuums of Care and related assessments.

Home Health Agency (HHA) Outcome and Assessment Instrument Set (HHA-OASIS)

Inpatient Rehabilitation Facility (IRF) Resident Assessment Instrument (IRF–PAI)

Long Term Care Hospital (LTCH) Continuity Assessment Record (LTCH-CARE)

Skilled Nursing Facility (SNF) Minimum Data Set (SNF-MDS)