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[Blog Series] Preparing for the Patient Driven Payment Model (PDPM): Week 2

June 28, 2018
Reimbursement By Armi Hernandez, Consultant

 Thank you for joining us for week 2 of our blog series, “Preparing for the Patient Driven Payment Model (PDPM).” This week we will review: Section GG of the PDPM.

PDPM_series Week 2--01-01-1

On April 27, 2018, the Centers for Medicare and Medicaid Services (CMS) released a proposal to replace the Resource Utilization Groups (RUGs) with a new system for Medicare payment called the Patient Driven Payment Model (PDPM). Although this new model is similar to last year’s proposed Resident Classification System (RCS-1), the CMS used comments received from the proposed RCS-1 to revise the PDPM.

Under the RUG-IV system, the four late-loss activities of daily living (ADLs) have been heavily weighted and include:
  • Bed mobility,
  • Transfers,
  • Eating, and
  • Toileting.

The ADLs are currently recorded in Section G of the Minimum Data Set (MDS)

It is essential to understand the Rule of Three in coding for these four late-loss ADLs because it is used to determine the RUG-IV category for every scheduled MDS. If the CMS implements the proposed changes to the PDPM, then the adoption of Section GG of the MDS would be utilized to capture all ADL functions. 

The RUG-IV system captures information on Section GG; however, this is not included in the RUG level that is billed. Regardless of whether the PDPM is implemented in the Final Rule, the requirements for completing Section GG will remain the same.  The proposed PDPM uses the coding for reimbursement purposes, and it will be included in some Case Mix Index (CMI) calculations.

Section GG coding that applies the 6-point scale to the patient’s usual admission performance for each activity is outlined below:

Code   Coding Definition
01 Dependent Helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity.
02 Substantial/Maximal Assistance Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
03 Partial/Moderate Assistance Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
04 Supervision or Touching Assistance Helper provides verbal cues or touching/steadying assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.
05 Setup or Clean-up Assistance Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
06 Independent Resident completes the activity by him/herself with no assistance from a helper.

If the activity was not attempted:

Code Coding Identification
07 Resident refused.
09 Not applicable.
88 Not attempted due to medical condition or safety concerns.

Coding should reflect the safety and quality of the patient’s performance. For example, if a patient requires assistance with performance due to it being unsafe or of poor quality, the score is determined according to the amount of support provided. The patient can use an assistive device without it affecting the coding.

MDS Section GG, Self-Care:

Self care

MDS Section GG, Mobility:

MDS Section GG- Mobility

Check out our complimentary infographic on "How to Code Section GG" to get a better understanding of this practice. 

The proposed PDPM will set a rate for the entire stay, based on the 5-day MDS, by adding the 5 case-mix components:

  • Nursing
  • Physical Therapy (PT)
  • Occupational Therapy (OT)
  • Speech-Language Pathology (SLP)
  • Non-Therapy Ancillary

The coding in Section GG is calculated to determine the case-mix group for the Nursing, PT, and OT components: 

Section GG Coding, Patient's Admission Performance PDPM Score based on the GG Coding
Dependent: 01
Resident refused: 07
Not Applicable: 09
Not attempted due to medical condition or safety concerns: 88
0
Substantial/maximal assistance: 02 1
Partial/moderate assistance: 03 2
Supervision or touching assistance: 04 3
Set-up or clean up assistance: 05
Independent: 06
4

 

Section GG Coding
Patient's Admission Performance
PDPM Score based on the GG Coding
Section GG item - Self-care:
GG0130A1 - EATING
(PDPM scoring range 0 - 4)
Section GG item - Self-care:
GG0130C1 - TOILETING HYGIENE
(PDPM scoring range 0 - 4)
Section GG items - Bed Mobility:
GG0170B1 - SIT to LYING
GG0170C1 - LYING to SITTING on SIDE of BED
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Bed Mobility)
Section GG items - Transfers:
GG0170D1 - SIT to STAND
GG0170E1 - CHAIR/BED to CHAIR TRANSFER
GG0170F1 - TOILET TRANSFER
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Transfers)
PDPM Total Function Score
for the Nursing Component =
Note: Per CMS, round the sum
to the nearest integer.
(Nursing Score range 0 - 16)
Calculate the sum of the following PDPM Scores:
Eating
+
Oral Hygiene
+
Toileting Hygiene
+
Average Bed Mobility
+
Average Transfers

Combining the patient’s hierarchical classification and the nursing total function score will determine the nursing case-mix group for the nursing component.

 Follow these steps below:

  • Start with the Extensive Services at the top of the PDPM nursing classification model
  • Go down through the groups in hierarchical order
  • Find the FIRST PDPM nursing group that the patient qualifies into
  • Assign that group as the PDPM nursing classification

The PDPM hierarchical classification uses the same nursing classification under RUG-IV. Per the CMS, “Hierarchical classification is used in some payment systems, in staffing analysis, and in many research projects.”.

See chart below for example:

HIERARCHIAL

PT Component:

Section GG Coding
Patient's Admission Performance
PDPM Score based on the GG Coding
Dependent: 01

Resident refused: 07

Not Applicable: 09

Not attempted due to medical condition or safety concerns: 88
0
Substantial/maximal assistance: 02 1
Partial/moderate assistance: 03 2
Supervision or touching assistance: 04 3
Set-up or clean up assistance: 05

Independent: 06
4

 

Section GG Coding
Patient's Admission Performance
PDPM Score based on the GG Coding
Section GG item - Self-care:
GG0130A1 - EATING
(PDPM scoring range 0 - 4)
Section GG item - Self-care:
GG0130B1 - ORAL HYGIENE
(PDPM scoring range 0 - 4)
Section GG item - Self-care:
GG0130C1 - TOILETING HYGIENE
(PDPM scoring range 0 - 4)
Section GG items - Bed Mobility:
GG0170B1 - SIT to LYING
GG0170C1 - LYING to SITTING on SIDE of BED
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Bed Mobility)
Section GG items - Transfers:
GG0170D1 - SIT to STAND
GG0170E1 - CHAIR/BED to CHAIR TRANSFER
GG0170F1 - TOILET TRANSFER
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Transfers)
Section GG items - Walking:
GG0170J1 - WALK 50 FEET with 2 TURNS
GG0170K1 - WALK 150 FEET
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Walking)
PDPM Total Function Score
for the PT Component =
Note: Per CMS, round the sum
to the nearest integer.
(PT Scoring range 0 - 24)
Calculate the sum of the following PDPM Scores:
Eating
+
Oral Hygiene
+
Toileting Hygiene
+
Average Bed Mobility
+
Average Transfers
+
Average Walking

Combine the patient’s clinical category and the PT total function score to determine the PT case-mix group for the PT component:

Clinical PT

OT Component:

Section GG Coding
Patient's Admission Performance
PDPM Score Based on the GG Coding
Dependent: 01
Resident refused: 07
Not Applicable: 09
Not attempted due to medical condition or safety concerns: 88
0
Substantial/maximal assistance: 02 1
Partial/moderate assistance: 03 2
Supervision or touching assistance: 04 3
Set-up or clean up assistance: 05
Independent: 06
4

 

Section GG Coding
Patient's Admission Performance
PDPM Score based on the GG Coding
Section GG item - Self-care:
GG0130A1 - EATING
(PDPM scoring range 0 - 4)
Section GG item - Self-care:
GG0130B1 ORAL HYGIENE
(PDPM scoring range 0 - 4)
Section GG item - Self-care:
GG0130C1 TOILETING HYGIENE
(PDPM scoring range 0 - 4)
Section GG items – Bed Mobility:
GG0170B1 - SIT to LYING
GG0170C1 - LYING to SITTING on SIDE of BED
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Bed Mobility
Section GG items - Transfers:
GG0170D1 - SIT to STAND
GG0170E1 - CHAIR/BED to CHAIR TRANSFER
GG0170F1 - TOILET TRANSFER
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Transfers)
Section GG items - Walking:
GG0170J1 - WALK 50 FEET with 2 TURNS
GG0170K1 - WALK 150 FEET
(PDPM scoring range 0 - 4 for each GG item,
then calculate the average Walking)
PDPM Total Function Score
for the OT Component =
Note: Per CMS, round the sum
to the nearest integer.
(OT Scoring range 0 - 24)
Calculate the sum of the following PDPM Scores:
Eating
+
Oral Hygiene
+
Toileting Hygiene
+
Average Bed Mobility
+
Average Transfers
+
Average Walking

Combine the patient’s clinical category and the OT total function score to determine the OT case-mix group for the OT component:

Clinical OT

Keep in mind that the PT and OT components calculate to the same case-mix group, but they will have different corresponding rates.

In Section G, the higher the ADL score, the more assistance that must be provided to the patient. However, in section GG, the lower the ADL score, the more help must be provided to the patient to complete the functional tasks. 

Once the PDPM is in effect, most healthcare software used for MDS preparation will likely calculate for the case-mix group of the five components in determining the rate for the patient’s SNF stay. However, knowing the foundation of the calculation will assist with accuracy and documentation of the MDS coding.

Change can be unsettling, but adapting and learning the new process can be a refreshing experience.  Now is the time to prepare for potential changes under the proposed PDPM! Contact one of our consultants today!


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