From QRM’s office of Medical Review Author: Ashley Duggan, OTR, RAC-CT, Vice President of Medical Review and Clinical Compliance With resumption of contractor medical review activity, ensuring back up documentation of the IDT determined “Usual Performance” is in place for MDS Section GG has risen to the forefront as an essential component in substantiation of HIPPS code(s) billed. Section GG Functional Scores impact the PT/OT and Nursing Components reimbursement significantly. Through proactive PDPM auditing, discipline specific GG documentation is routinely identified within the medical record, but the collaborative, signed and dated GG support is not as readily available.
Recommendation for best practice:
Ensure a team assessment of resident “usual performance” during the first 3 days (admission through 11:59pm, day 3 of stay) has been documented, signed, and dated by the contributing team members
Provide Education/Training to IDT group assessing Section GG Functional Performance - Self Care and Mobility Items
Establish a routine process and Audit for presence of determination statement of “usual performance” in the medical record
Note of Importance:
Quick access for inclusion with medical record requests will be key to justification of MDS Section GG
QRM IDT GG UP Log for gathering of Usual Performance to utilize in an IDT entry to the medical record
CMS GG training Webinars Link
Let's Get to the Point:
Ensure assessment of resident usual performance has been collaboratively documented, signed and dated by the IDT, then uploaded to the EMR for easy access in order to back up and protect your GG scores.