Section GG Coding for PDPM and SNFQRP QMs · applies if “unplanned discharge” so no Section GG). 4 ... • Code 1, Dependent, if the helper completed the activities for the resident

Section GG Coding for PDPM and SNFQRP QMs

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POST TEST

1. The four new Measures calculated from GG measure functional outcomes at discharge?

a. True

b. False

2. There are Risk Adjustments applied to the Discharge Outcomes?

a. True

b. False

3. Which of the following apply?

a. New QRP QMs will impact 5 Star

b. Section GG has a 3-day observation period based on ARD

c. None of the above

4. For GG Performance Items, document usual performance at admission and discharge:

a. True

b. False

5. Function Score calculation is the same for Nursing Component as it is for PT Component

of the rate:

a. True

b. False



POST TEST ANSWERS

6. The four new Measures calculated from GG measure functional outcomes at discharge?

a. True

b. False

7. There are Risk Adjustments applied to the Discharge Outcomes?

a. True

b. False

8. Which of the following apply?

a. New QRP QMs will impact 5 Star

b. Section GG has a 3-day observation period based on ARD

c. None of the above

9. For GG Performance Items, document usual performance at admission and discharge:

a. True

b. False

10. Function Score calculation is the same for Nursing Component as it is for PT Component

of the rate:

a. True

b. False


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Section GG for PDPM & SNFQRP QMs

1


CODING DIRECTIONS GG

2



Section GG at Start of Stay

• Section GG completed with first Traditional Medicare (5-day MDS) upon admission or readmission (if discharged return anticipated)

• 5-day MDS has Medicare Start Date A2400B

• Look-back is Medicare Start Date plus 2 more days

OR stated another way - Starting with Medicare Start day, days 1, 2, 3

3


Section GG at Part A Discharge MDS

• Last Three days of stay with Medicare End Date as third day.

• Item set for GG part of Planned Discharge MDS combined with Part A Discharge Designation or stand alone Part A Discharge MDS.

• Only applies to Planned Discharges (Skip pattern applies if “unplanned discharge” so no Section GG).

4



Collected at SOC – 5-day MDS

5


Coding Definitions

• Code 3, Independent, if the resident completed the activities by himself or herself, with or without an assistive device, with no assistance from a helper

• Code 2, Needed Some Help, if the resident needed partial assistance from another person to complete the activities

• Code 1, Dependent, if the helper completed the activities for the resident or the assistance of two or more helpers was required for the resident to complete the activity

• Code 8, Unknown, if the resident’s usual ability prior to the current illness, exacerbation, or injury is unknown

• Code 9, Not Applicable, if the activity was not applicable to the resident prior to the current illness, exacerbation, or injury 6



Section GG0100

Self-Care: Ms. R was admitted to an acute care facility after sustaining a right hip fracture and subsequently admitted to the SNF for rehabilitation. Prior to the hip fracture, Ms. R was independent in eating, bathing, dressing, and using the toilet. Ms. R used a raised toilet seat because of arthritis in both knee joints. Both she and her family indicated that there were no safety concerns when she performed these everyday activities in her home.

7


Section GG0100

Self-Care: Code 3 Independent

8



Section GG0100

Self-Care: Mr. F was admitted with a diagnosis of stroke and a severe communication disorder. Mr. F is unable to communicate with staff using alternative communication devices. Mr. F had been living alone prior to admission. The staff has not been successful in contacting either Mr. F’s family or his friends. Mr. F’s prior self-care abilities are unknown.

9


Section GG0100

Self-Care: Code 8 Unknown

10



Section GG0100

• Indoor Mobility (Ambulation): Mrs. L had a stroke one year ago that resulted in her using a wheelchair to self-mobilize, as she was unable to walk. Mrs. L subsequently had a second stroke and was transferred from an acute care unit to the SNF for skilled services.

11


Section GG0100

• Indoor Mobility (Ambulation): Code 9 Not applicable

12



Section GG0100

• Stairs: Prior to admission to the hospital for bilateral knee surgery, followed by his recent admission to the SNF for rehabilitation, he experienced severe knee pain upon ascending and particularly descending his internal and external stairs at home. Required assistance from wife when using the stairs to steady him in the event his left knee would buckle. Wife was interviewed about her husband’s functioning prior to admission, and the therapist noted prior functional level information in his medical record.

13


Section GG0100

• Stairs: Code 2 Needed Some Help

14



Section GG0100

• Functional Cognition: Mr. K has mild dementia and recently sustained a fall resulting in complex multiple fractures requiring multiple surgeries. Mr. K has been admitted to the SNF for rehabilitation. Mr. K’s caregiver reports that when living at home, Mr. K needed reminders to take his medications on time, manage his money, and plan tasks, especially when he was fatigued.

15


Section GG0100

• Functional Cognition: Code 2 Needed Some Help

16



Section GG0100

• Functional Cognition: Mrs. R had a stroke. Since hospitalization and continuing during her SNF stay, she has had a severe communication disorder. Her family members have not returned phone calls requesting information about Mrs. R’s prior functional status. Her medical records do not include information about her functional cognition prior to the stroke.

17


Section GG0100

• Functional Cognition: Code 8 Unknown

18



Collected at SOC - 5-day MDS

• Check all that apply. Interview resident/family, review records. Only code device used immediately before current illness. 19


Section GG0110

• For GG0110D, Prior Device Use - Walker: “Walker” refers to all types of walkers (for example, pickup walkers, hemi-walkers, rolling walkers, and platform walkers).

• Consider what is being documented in Prior Level of Function

• These are Risk Factors for the new functional SNFQM

20



CODING DIRECTIONS GG

21


Section GG Coding Changes

22

Change

New



Admission and Discharge Performance Coding Directions

• Based on direct observation, resident’s self report, family reports, and direct care reports as documented in medical record. – Helper must be a facility staff or contracted employee

by facility

• Not Hospice staff, students, or private staff by family

• If family/private duty gives all care, then code as 07 Resident Refuses or 09 Not Applicable

23


• May be completed with or without a device

• “Usual performance” is not most independent or most dependent; if there is a fluctuation, code to the most usual for that resident. “average care”– Coding on admission should reflect the person’s

baseline admission functional status, and is based on a clinical assessment that occurs soon after the resident’s admission

– CMS focuses on therapy initial evaluation as assessment

24




Section GG

• The admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission.

• CMS has made it clear that treatment should not be withheld in order to conduct the functional assessment: “If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted” Coding considers set-up and cleanup, touching assistance, verbal cues.

25


• CMS states this is an “assessment” and should focus on baseline at time of admission or discharge.

26




• CMS states this is an “assessment” and should focus on baseline at time discharge. – Discharge – best reflection of performance status at

discharge. CMS focused on Therapy Discharge note.

27



Assistance in Coding

28




29



30




31



32




33


• 06 Independent - Similar to coding Independent Section G without set-up help support.

• 05 Set-up or Clean-up Assistance - Similar to coding Independent in Section G but WITH set-up only support.

• Could easily apply to oral hygiene, or eating skills.

• No physical help or cueing needed most of the time. 34



• Similar to coding Supervision in Section G

• Similar to coding “limited assist” in Section G

• This is verbal cueing or Contact Guard support.

• This is clearly non-weight bearing support to provide safety to complete task.

• Again, usual care, versus most dependent. 35


• Weight Bearing Support usually provided – 03 – More like Minimum Assist used by Rehab

• Extensive Assist in Section G – one person

– 02 – More like Moderate to Maximum Assist by Rehab – so more weight bearing support provided

• Extensive Assist in Section G – one person

36



• First Step:

– Determine if weight bearing support is usually provided (does not usually require two staff)

• Second Step:

– If yes, then does resident perform less than half the activity/half the effort or more than half of the activity/more than half the effort (tasks with most weight bearing effort)

• Three subtasks - resident perform two, staff one or visa versa. 37


• Dependent code on MDS Section G

• Usually resident does not participate in activity

• Even if resident performs some of activity, if it requires two or more staff to assist, code as dependent.

38



39

07 - Document refusal if applies

09 - Document reason, info indicates not performed prior to current status

10 – Not Attempted due to environmental limitations

88 - Not attempted, Medical Condition supports coding



40



Coding Self Care

41

New


42

• Aligns with Eating in Section G

• Independent for most of meal, then requires some physical help to finish: Code 03 - Partial/moderate assistance

• Physical help to eat more than half the meal: Code 02 –Substantial/maximal assistance

• Both of the above provide weight bearing support

• Encouragement, reminders, handing utensils/cup: Code 04 Supervision/touching

• Fed entire meal: Code 01- Dependent



43

• Clinicians may code the eating item using the appropriate response codes if the resident eats using his/her hands rather than using utensils (e.g., can feed himself/herself using finger foods). If the resident eats finger foods with his/her hands independently, for example, the resident would be coded as 06, Independent.


44

• Subtask of Personal Hygiene in Section G

• Staff puts toothpaste on toothbrush, then brushes teeth without cueing: Code 05 – Set-up or clean-up assistance

• Starts to brush teeth, but stops and completed by staff; Code 02 – Substantial/Maximal Assistance since more than half the activity by staff

• Brushes gums and starts dentures but staff completes: Code 03 Partial/Moderate Assistance

• Fully dependent: Code 01 - Dependent

• Brushes teeth/dentures with set-up but needs cueing to complete: Code 04 - Supervision/Touching assistance



• Aligns with Toilet Use in Section G minus the transfer itself to toilet/commode; this item is only hygiene tasks.

• Uses commode, aide only provides steadying assistance while resident wipes self, and pulls up pants: Code 04 -Supervision/touching assistance

• Staff lifts gown, and pulls down pants, but resident wipes and pulls pants back up: Code 03 - Partial/Moderate assistance

• Staff wipes and pulls pants down, resident only lifts gown: Code 02 - Substantial/Maximal assistance

• Staff do all activities: Code 01 - Dependent

45


46

• Shower/bathe self: • Includes the ability to wash, rinse, and dry the face,

upper and lower body, perineal area, and feet • Does not include washing, rinsing, and drying the

resident’s back or hair • Does not include transferring in/out of a tub/shower

• Assessment of shower/bathe self can take place in a shower or bath, at a sink, or at the bedside (i.e., sponge bath)



47

• If the resident bathes himself or herself and a helper sets up materials for bathing/showering, then code as 05, Set-up or clean-up assistance

• If the resident cannot bathe his or her entire body because of a medical condition, then code shower/bathe self based on the amount of assistance needed to complete the activity


Coding GG0130E

• Shower/bathe self:

• Mr. J sits on a tub bench as he washes, rinses, and dries himself. A certified nursing assistant stays with him to ensure his safety, as Mr. J has had instances of losing his sitting balance. The certified nursing assistant also provides lifting assistance as Mr. J gets onto and off of the tub bench.

• How would you code GG0130E. Shower/bathe self?

48



Coding GG0130E

• Code 04, Supervision or touching assistance

• Code 03, Partial/moderate assistance

• Code 02, Substantial/maximal assistance

• Code 01, Dependent

49


Coding GG0130E Answer





50



Upper Body Dressing--Tips

• Upper Body Dressing includes:– Clothing, blouse, shirt, bra,

sweater.

– Buttons, Snaps, Zippers

– Prosthesis, Braces, Binders

– Includes Pajamas, but NOT hospital gowns.

51


Upper body dressing: GG0130F• Mr. K sustained a spinal cord injury that has affected both

movement and strength in both upper extremities. He places his left hand into one - third of his left sleeve of his shirt with much time and effort and is unable to continue with the activity. A certified nursing assistant then completes the remaining upper body dressing for Mr. K.

• How would you code GG0130F. Upper body dressing?

52



Coding GG0130F





53


Coding GG0130F Answer





54



Lower Body Dressing -- Tips

• Lower Body Dressing Includes: – Clothing: Underwear, shorts,

slacks, briefs, PJ’s

– Knee/Leg Braces

– Lower Extremity Prosthesis

– Lower Extremity Shrinker

55


• Lower body dressing:

• Mrs. R has peripheral neuropathy in her upper and lower extremities. Each morning, Mrs. R needs assistance from a helper to place her lower limb into, or to take it out of (don/doff), her lower limb prosthesis. She needs no assistance to put on and remove her underwear or slacks.

• How would you code GG0130G. Lower body dressing?

56



Coding GG0130G

• Code 05, Setup or clean - up assistance




57


Coding GG0130G Answer

• Code 05, Setup or clean - up assistance




58



• Putting on/taking off footwear:

• Mr. M is undergoing rehabilitation for right - side upper and lower body weakness following a stroke. He has made significant progress toward his independence and will be discharged to home tomorrow. Mr. M wears an ankle - foot orthosis (AFO) that he puts on his foot and ankle after he puts on his socks but before he puts on his shoes. He always places his AFO, socks, and shoes within easy reach of his bed. While sitting on the bed, he needs to bend over to put on and take off his AFO, socks, and shoes, and he occasionally loses his sitting balance, requiring staff to place their hands on him to maintain his balance while performing this task.

• How would you code GG0130H. Putting on/taking off footwear? 59


Coding GG0130H

• Code 05, Set-up or clean-up assistance




60



Coding GG0130H Answer





61


• Putting on/taking off footwear: Mrs. F was admitted to the SNF for a neurologic condition and experiences visual impairment and fine motor coordination and endurance issues. She requires setup for retrieving her socks and shoes, which she prefers to keep in the closet. Mrs. F often drops her shoes and socks as she attempts to put them onto her feet or as she takes them off. Often a certified nursing assistant must first thread her socks or shoes over her toes, and then Mrs. F can complete the task. Mrs. F needs the certified nursing assistant to initiate taking off her socks and unstrapping the Velcro used for fastening her shoes.

• How would you code GG0130H. Putting on/taking off footwear?

62



Coding GG0130H





63


Coding GG0130H Answer





64



Section GG Mobility Items

65

New


66

Roll left and right: Mr. Z had a stroke that resulted in paralysis on his right side and is recovering from cardiac surgery. He requires the assistance of two certified nursing assistants when rolling onto his right side and returning to lying on his back and also when rolling onto his left side and returning to lying on his back.

How would you code GG0170A. Roll left and right?



Coding GG0170A


• Code 04, Supervision and touching assistance

• Code 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury

• Code 88, Not attempted due to medical condition or safety concerns

67


Coding GG0170A Answer





68



69

Roll left and right: Mrs. R has a history of skin breakdown. A nurse instructs her to turn onto her right side, providing step-by-step instructions to use the bedrail, bend her left leg, and then roll onto her right side. Mrs. R attempts to roll with the use of the bedrail, but indicates she cannot perform the task. The nurse then rolls her onto her right side. Next, Mrs. R is instructed to return to lying on her back, which she successfully completes. Mrs. R then requires physical assistance from the nurse to roll onto her left side and to return to lying on her back to complete the activity.


Coding GG0170A





70



Coding GG0170A Answer


• Code 02 Substantial/Maximal assistance



71


• B & C are subtasks of Bed Mobility in Section G.

72



• Requires assistance from sitting on bed to lying on bed, staff lifts up legs, but resident uses arms to position upper body; weight bearing support for less than half of tasks: Code 03 -Partial/Moderate assistance

• Staff support trunk when lying down and lifts legs weight bearing support for all tasks: Code 02 - Substantial/Maximal assistance

73


• Resident pushes up from bed from lying to sitting; staff only provides steadying support: Limited assistance: Code 04 - Supervision or Touching Assistance

• Staff provide much of the lifting assistance to get from lying to sitting position, weight bearing support: Code 02 - Substantial/Maximal Assistance

• Resident rolls to side and pushes self up from lying to sitting with verbal cues: Code 04 - Supervision or Touching Assistance

• Full staff support: 01 - Dependent 74



75


76

• D & E are subtasks of Transfer in Section G



• Resident transitions from sitting to standing with only contact limited assistance: Code 04 - Supervision or Touching assistance

• Two person assistance: Code 01 – Dependent

• Staff provide weight bearing support to rise to standing position and balance: Code 02 - Substantial/maximal assistance

• Staff provide weight bearing support to initially start to rise but resident does most of work: Code 03 -Partial/moderate assistance

77


• Transfers safely once wheelchair positioned, with set-up only: Code 05 – Set-up or clean-up assistance

• Pivots and transfers to wheelchair with only contact limited assistance: Code 04 - Supervision or Touching assistance

• Resident requires weight bearing support but pushes self and moves own feet to pivot: Code 03 -Partial/Moderate assistance

78



• Transfer to toilet/commode is subtask of Toilet Use in Section G; ONLY transfer to toilet or commode applies

• Transfers safely to toilet after putting wheelchair by commode: Code 05 – Set-up or clean up assistance

• Transfers on and off toilet with contact limited assistance for safety: Code 04 - Supervision or Touching assistance

• Weight bearing assistance on and off toilet or commode; so more than half of effort: Code 02 - Substantial/maximal assistance

• Staff provides full assist to rise, and resident lowers self with grab bars by toilet: Code 03 - Partial/Moderate assistance 79


• Car transfer:

• During her rehabilitation stay, Mrs. N works with an occupational therapist on transfers in and out of the passenger side of a car. On the day before discharge, when performing car transfers, Mrs. N requires verbal reminders for safety and light touching assistance. The therapist instructs her on strategic hand placement while Mrs. N transitions to sitting in the car’s passenger seat. The therapist opens and closes the door.

• How would you code GG0170G. Car transfer?

80



Coding GG0170G





81







82



• Car transfer: Mrs. W uses a wheelchair and ambulates for only short distances. She requires lifting assistance from a physical therapist to get from a seated position in the wheelchair to a standing position. The therapist provides trunk support when Mrs. W takes several steps during the transfer turn. Mrs. W lowers herself into the car seat with steadying assistance from the therapist. She lifts her legs into the car with support from the therapist.

83


Coding GG0170G





84








85


Walk 10 Feet

86



Coding GG0170I

• Walk 10 feet:

• Mr. L had bilateral amputations 3 years ago, and prior to the current admission, he used a wheelchair and did not walk. Currently, Mr. L does not use prosthetic devices and uses only a wheelchair for mobility. Mr. L’s care plan includes fitting and use of bilateral lower extremity prostheses.

• How would you code GG0170I. Walk 10 feet? 87


Coding GG0170I




• Code 07, Refused

88



Coding GG0170I Answer




• Code 07, Refused

89


Coding GG0170I

• Walk 10 feet: Mrs. C has Parkinson’s disease and walks with a walker. A physical therapist must advance the walker for Mrs. C with each step. The physical therapist assists Mrs. C by physically initiating the stepping movement forward, advancing Mrs. C’s foot, during the activity of walking 10 feet.

• How would you code GG0170I. Walk 10 feet? 90



Coding GG0170I





• Code 07, Refused91


Coding GG0170I Answer





• Code 07, Refused92



• J - Walks around 60 feet with two turns, therapy only provided cueing and contact limited assistance: Code 04 - Supervision or Touching assistance

• J - Walks around 70 feet with crutches, and staff provides some weight bearing support to trunk: Code 03 - Partial/moderate assistance

• J – Walks 50 feet with two turns, loses balance and requires significant supports: Code 02 -Substantial/Maximal Assistance

93


Coding Clarifications

• Turn is 90 degree turn– Can be in same direction such as two 90 degree

turns to right; or different directions; and can include use of assistive device such as a cane

• RAI does not say what to code if can walk but only 10 feet with no turns. – Suggest code 88 Activity not attempted due to

medical condition or safety concerns 94



• K – Cannot walk 150 feet due to CHF: Code 88 -Activity not attempted due to medical concerns (but can walk shorter distance)

• K – Walks length of hallway, weight bearing support that prevents from falling, provides more than half the effort: Code 02 - Substantial/maximal assistance

• K – Walks length of hallway, using quad cane, requires some weight bearing support: Code 03 -Partial/moderate assistance

95


Coding Clarification

• Bottom line:– If can walk, but not up to 50 feet with two turns,

and/or up to 150 feet - code as 88 Activity Not attempted due to Medical condition or safety.

– Exception: resident refuses – code 07 Resident Refuses, or code 09 Not Applicable if not walking now but you hope they will.

96



97

All New


• Walking 10 feet on uneven surfaces:

• Mrs. N has severe joint degenerative disease and is recovering from sepsis. Upon discharge, Mrs. N will need to be able to walk on the uneven and sloping surfaces of her driveway. During her SNF stay, a physical therapist takes Mrs. N outside to walk on uneven surfaces. Mrs. N requires the therapist’s weight - bearing assistance less than half of the time during walking to prevent Mrs. N from falling as she navigates walking 10 feet over uneven surfaces.

• How would you code GG0170L. Walking 10 feet on uneven surfaces?

98



Coding GG0170L





99


Coding GG0170L Answer





100



• If you answer M with 07, 09, 10 or 88, you skip to P (picking up object). If you answer it with an assessment, you proceed to N.

• If you answer N with a 07, 09, 10 or 88 you skip to P. If you answer it with an assessment, you proceed to O.

• Regardless of whether you answer O with 07, 09, 10 or an assessment, you still proceed to P.

101


Coding GG0170M

• 1 step (curb):

• Mrs. Z has had a stroke; she must be able to step up and down one step to enter and exit her home. A physical therapist provides standby assistance as she uses her quad cane to support her balance in stepping up one step. The physical therapist provides steadying assistance as Mrs. Z uses her cane for balance and steps down one step.

• How would you code GG0170M. 1 step curb?

102



Coding GG0170M

• One Step/curb





103


Coding GG0170M Answer

• One Step/curb





104



Coding GG0170N or O

• 4 Steps or 12 Steps - only complete 12 steps if able to complete 4 steps; otherwise skip patterns applies

• Ms. Y is recovering from a stroke resulting in motor issues and poor endurance. Ms. Y’s home has 12 stairs, with a railing, and she needs to use these stairs to enter and exit her home. Her physical therapist uses a gait belt around her trunk and supports less than half of the effort as Ms. Y ascends and then descends 12 stairs.

• How would you code GG0170O. 12 steps? 105


Coding GG0170N or O





106



Coding GG0170N or O Answer





107


• Picking up object:

• Ms. C has recently undergone a hip replacement. When she drops items, she uses a long-handled reacher that she had been using at home prior to admission. She is ready for discharge and can now ambulate with a walker without assistance. When she drops objects from her walker basket, she requires a certified nursing assistant to locate her long-handled reacher and bring it to her in order for her to use it. She does not need assistance to pick up the object after the helper brings her the reacher.

• How would you code GG0170P. Picking up object? 108



Coding GG0170P

• Code 06, Independent




109


Coding GG0170P Answers





110



• Picking up object: Mr. P has a neurologic condition that has resulted in balance problems. He wants to be as independent as possible. Mr. P lives with his wife and will soon be discharged from the SNF. He tends to drop objects and has been practicing bending or stooping from a standing position to pick up small objects, such as a spoon, from the floor. An occupational therapist needs to remind Mr. P of safety strategies when he bends to pick up objects from the floor, and she needs to steady him to prevent him from falling.

111


Coding GG0170P





112



Coding GG0170P Answers





113


• Q1 – Does resident use wheelchair and/or scooter

114



Coding Wheelchair

• R - Once in w/c resident propels self in wheel chair 60 feet with two turns with no help: Code 06 – Independent

• R - Staff must make frequent adjustments of hand positions, and resident becomes stuck near walls, but when repositioned, can propel and turn self: Code 03 -Partial/moderate assistance

• R - Can wheel self only 10 feet, then asks aide to push them: Code 02 - Substantial/maximal assistance

115


Coding Wheelchair

• S – Motorized w/c requires safety reminders, and requires staff assistant to backing up when barriers present: Code 03 - Partial/moderate assistance

• S – Uses motorized scooter around SNF with only cues for safety issues: Code 04 – Supervisions or touching assistance

• S – Uses w/c around SNF after positioned by bed: Code 05 Set-up only

116



Coding Clarification

• If resident uses wheelchair but never propels themselves, then for each distance (assuming they are pushed both distances) code 01 Dependent.

• Once propels self in wheelchair any distance, like their example of 10 feet, then staff complete distance, code 02 Substantial/maximal assistance.

• If uses any type of motorized scooter, code as motorized.

117


Section GG

118



Section GG

119


Section GG

120



Discharge Goal Coding

• 5-day MDS

– Use same scale

• Established at time of admission when coding 5-day MDS, based on discussions with resident, family, staff, and professional judgement.

• Goal is part of overall care plan

• Only code a Discharge Goal if there is one; Only need ONE goal coded across all performance items to meet criteria for QM.

121



• Additions to “Activity Not Attempted”

• 07 Resident refused

• 09 Not Applicable – Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury

• 10 Not Attempted due to environmental limitations (e.g. lack of equipment, weather constraints)

• 88 Not attempted due to medical condition or safety concerns.

122




• Can use codes for “Activity Not Attempted” for Discharge Goals on 5-day MDS

• This allows more options for coding Goals

• Enter a Performance Code if a Goal exists for this care area (a minimum of one for QM) should be supported in Therapy POT or Nursing Care PlanOr

• Use applicable Code for “Activity Not Attempted” is suggested instead of “blank” or “dash”

123


124



125


GG SNFQRP QMs

126



127

This is a process measure; complete coding got all Performance items and at least one Goal coded at Start of Care

No change, don’t dash performance codes & one Goal needed


Four New GG related Quality Measures

128



Functional Measures - Final Measures in Rules for FY 2018 That Could Impact Payment FY 2020

94

Data gathering could begin Oct. 1, 2018

• Outcome Measure: Change in Self-Care Score

• Outcome Measure: Discharge Self-Care Score

• Outcome Measure: Change in Mobility Score

• Outcome Measure: Discharge Mobility Score

• Note: These are OUTCOME measures, not PROCESS measures. Functional outcomes expected and/or achieved.


CHANGE in Self-Care or Mobility Score

How it works!!!

130



CHANGE in Self Care or Mobility

• Overview of how it works– Adds up coding for Self Care at SOC (5-day)

– Adds up Coding for Self Care at End of Care

– Adjustments for risk factors, compares the expected to achieved and creates a score

– Adds up coding for Mobility at SOC (5-day)

– Adds up coding for Mobility at End of Care

– Adjustments for risk factors, compares the expected to achieved and creates a score 131


Scores for Performanceare added up; Assign 1 point for Activity not attempted:

132

All count as One Point



Score Calculated at Admission for Self-Care Score – All Criteria Apply

Scores for performance are added up for a total score (Activity not Attempted scores 1)

Range 7-42133

6+5+2+2+3+2+2=22 points

0205

06

02

0202

03


End of Stay Coding and Self-Care Score

Calculates End of Stay Score and compares to Start of Stay score to create a “change” score

134

060604040504

04

6+6+4+4+5+4+4=33 points Improved!



Activity Not Attempted Codes count as “1” Point

Remember “Activity Not Attempted” codes count as only “1”

135

06

060404

050407 – this will count as only 1 point, NOT 7

6+6+4+4+5+4+1=32 points


Mobility Items Used in Measure – at Start and End of Stay

136

Total Score range is 15-90



Mobility Items Used in Measure for both Start and End of Stay

137

Total Score range is 15-90



138


Range 15-90

06

05

05

06

04

03

03

10

03

03

07

6+5+5+4+3+3+1+3+3+1= 34




139

34+1+2+1+1+2= 41

10

02

10

10

02


Range 15-90


Change in Self-Care or Mobility Score Calculation

• Calculates Score at Admission

• Calculates Score at Discharge

• Calculates the difference between scores

• Calculates expected change scores based on risk factors for each resident

140



Change in Self-Care or Mobility Score Calculation

• Calculates Score at Admission

• Calculates Score at Discharge

• Calculates the difference between scores

• Calculates expected change scores based on risk factors for each resident

141


CHANGE in Self-Care or Mobility Score Calculation

• Calculates an average observed change score

• Calculates an average expected change score

• Calculates difference between observed and expected change scores to create an observed minus expected difference - Value of 0 means no difference; value greater than 0 means “better” than expected and below 0 means “worse” than expected.

• Adds up all SNFs, creates risk adjusted mean score for comparison.

142



DISCHARGE Self-Care and Mobility Scores

143


Discharge Self-Care or Mobility Score Calculation

• Calculate discharge score using same scoring method as is used for Change measure

• Calculates an observed score

• Calculate an expected discharge Score

• Compare each residents observed and expected discharge score and classify the difference as

– Observed is equal to or higher than expected

– Observed is lower than expected

144



Discharge Self-Care or Mobility Score Calculation

• The total sum of residents with equal to or greater than expected is the numerator

• Denominator is Medicare Stays minus exclusions

• Percentage is then calculated

145


Exclusions Generally the Same for all Four Measures

1. Incomplete stays –– Death

– Unplanned discharge

– LOS less than 3 days

2. Resident was independent in all Self-Care OR All Mobility Care areas at admission

3. Resident younger than 21 years

4. Residents discharged to Hospice (A2100+7)

146



Exclusions Generally the Same for all Four Measures

5. Residents with certain medical conditions: coma, persistent vegetative state, complete tetraplegia, locked-in syndrome, severe anoxic brain damage, cerebral edema, or compression of brain.

6. Resident is not traditional Medicare Part A

7. Residents who do not receive PT or OT services as demonstrated “0” PT or OT minutes on Start of Care 5-day MDS

147


Risk Factors for Change and Discharge – Self Help

Risk AdjustmentThe risk adjustors used for this finalized quality measure are the following:• Age group at SNF admission (A1600, Entry Date – A0900,

Birth Date)– Younger than 54 years– 55 to 64 years– 65 to 74 years (reference category)– 75 to 84 years– 85 to 90 years– >90 years of age and older

• Admission self-care function score: continuous form• Admission self-care function score: squared form 148




• Primary medical condition category– Stroke (I0020, Primary medical condition category = 01)– Non-traumatic brain dysfunction (I0020, Primary medical

condition category = 02) and traumatic brain dysfunction (I0020, Primary medical condition category = 03)

– Non-traumatic spinal cord dysfunction (I0020, Primary medical condition category = 04)

– Traumatic spinal cord dysfunction (I0020, Primary medical condition category = 05)

– Progressive neurological conditions (I0020, Primary medical condition category = 06)

– Other neurological conditions (I0020, Primary medical condition category = 07)

149



• Primary medical condition category– Amputation (I0020, Primary medical condition = 08)– Hip and knee replacement (reference category)(I0020, Primary medical

condition category = 09)– Fractures and other multiple trauma (I0020, Primary medical condition

category = 10)– Other orthopedic conditions (I0020, Primary medical condition category =

11)– Debility and cardiorespiratory conditions (I0020, Primary medical condition

category = 12)– Medically complex conditions (I0020, Primary medical condition category =

13)– Other medical condition (I0020, Primary medical condition category = 14)

• Interactions between primary medical condition category and SNF admission self-care score 150




• Prior Surgery: Major surgery during the 100 days prior to the SNF admission (J2000, Prior surgery = 1)

• Prior Functioning: Self-care– Dependent (GG0100A = 1)– Some help (GG0100A = 2)– Independent (GG0100A = 3), unknown (GG0100A = 8), not

applicable (GG0100A = 9), or not assessed/no information (GG0100A = [-])(reference category)

• Prior Functioning: Indoor ambulation– Dependent or some help (GG0100B = 1 or 2)– Independent (GG0100B = 3), unknown (GG0100B = 8), not

applicable (GG0100B = 9), or not assessed/no information (GG0100B = [-])(reference category)

151



Prior Device Use: Walker– Yes (GG0110D is checked)

– No (GG0110D not checked)(reference category)

Prior Device Use: Wheelchair/scooter– Yes (GG0110A, manual wheelchair is checked or GG0110B,

motorized wheelchair and/or scooter is checked)

– No (GG0110A, manual wheelchair is not checked and GG0110B, motorized wheelchair and/or scooter is not checked)(reference category)

152




Prior Device Use: Mechanical lift– Yes (GG0110C, mechanical lift is checked)

– No (GG0110C, mechanical lift not checked)(reference category)

Prior Device Use: Orthotics/prosthetics– Yes (GG0110E, orthotics/prosthetics is checked)

– No (reference category)(GG0110E, orthotics/prosthetics not checked)

153



Presence of Stage 2 pressure ulcer(s) at admission (M0300B1≥1)

Presence of severe pressure ulcer/injury at admission– Stage 3 (M0300C1, Number of Stage 3 pressure≥1), Stage 4

(M0300D1, Number of Stage 3 pressure ulcers ≥1) or Unstageable pressure injury (M0300E1, Number of unstageable pressure ulcers due to non-removable dressing ≥1 or M0300F1, Number of these unstageable pressure ulcers due to slough and/or eschar ≥1 or M0300G1, Number of these unstageable pressure ulcers due to deep tissue injury ≥1)

154




Cognitive Abilities: Brief Interview for Mental Status (BIMS) score

– Severely impaired = C0500, BIMS Summary Score ≥7 or C0900Z, None of the above were recalled is checked or only one of the following is checked: C0900A, C0900B, C0900C, C0900D;

– Moderately impaired: if C0500, BIMS Summary Score = 8,9,10,11,12 or 2 of the following are checked: C0900A, C0900B, C0900C, C0900D;

– Intact (reference category): if C0500, BIMS Summary Score = 13,14 or 15 or 3 or 4 of the following are checked: C0900A, C0900B, C0900C, C0900D)

155



• Communication Impairment: Ability to express ideas and wants and Understanding verbal and non-verbal content– Moderate to severe communication limitations: Rarely/never

understands (B0800, Ability to understand others = 3); or sometimes understands (B0800, Ability to understand others = 2); or rarely/never understood (B0700, Makes self understood = 3); or sometimes understood (B0700, Makes self understood = 2);

– Mild to no communication limitations (reference category): Usually understands (B0800, Ability to understand others = 1), understands (B0800, Ability to understand others = 0); and usually understood (B0700, Makes self understood = 1), understood (B0700, Makes self understood = 0), or Not assessed/no information (B0700 =[-] or B0800 =[-])

156




• Urinary Continence– Occasionally (H0300, Urinary continence = 1), frequently incontinent

(H0300, Urinary continence = 2) or always continent (H0300, Urinary continence = 3)

– Continent (H0300, Urinary continence = 0), catheter, ostomy or no urine output (H0300, Urinary continence = 9), or Not assessed/no information (H0300, Urinary continence =[-])(reference category)

157



158

• Bowel Continence– Occasionally (H0400, Bowel continence = 1), frequently incontinent

(H0400, Bowel continence = 2) or always continent (H0400, Bowel continence = 3)

– Continent (H0400, Bowel continence = 0) or had ostomy or did not have a bowel movement for the entire 7 days (H0400, Bowel continence = 9), or Not assessed/no information (H0400, Bowel continence =[-])(reference category)

• Tube feeding (K0510B1 = 1) or total parenteral nutrition (K0510A1 = 1)




159

• Comorbidities (hierarchical condition categories):– Major Infections: Septicemia, Sepsis, Systemic Inflammatory Response

Syndrome/Shock; and other infectious diseases

– Metastatic Cancer and Acute Leukemia

– Diabetes: Diabetes with Chronic Complications; Diabetes without Complication; Type I Diabetes Mellitus

– Other Significant Endocrine and Metabolic Disorders

– Delirium and Encephalopathy

– Dementia: Dementia with Complications; Dementia without Complications

– Tetraplegia (excluding complete tetraplegia) and paraplegia

– Multiple Sclerosis

– Parkinson’s and Huntington’s Diseases



160

• Comorbidities (hierarchical condition categories):– Angina Pectoris

– Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease

– Hemiplegia, Other Late Effects of Cerebrovascular Accident: Hemiplegia/Hemiparesis; Late Effects of Cerebrovascular Disease, Except Paralysis

– Dialysis Status and Chronic Kidney Disease – Stage 5

– Urinary Obstruction and Retention

– Amputations: Traumatic Amputations and Complications; Amputation Status, Lower Limb/Amputation Complications; Amputation Status, Upper Limb



Risk Factors for Change and Discharge – Mobility

161

Risk AdjustmentThe risk adjustors used for this finalized quality measure are the following:• Age group at SNF admission (A1600, Entry Date – A0900,

Birth Date)– Younger than 54 years– 55 to 64 years– 65 to 74 years (reference category)– 75 to 84 years– 85 to 90 years– 90 years of age and older

• Admission mobility function score: continuous form• Admission mobility function score: squared form



162

• Primary medical condition category– Stroke (I0020, Primary medical condition category = 01)– Non-traumatic brain dysfunction (I0020, Primary medical

condition category = 02) and traumatic brain dysfunction (I0020, Primary medical condition category = 03)

– Non-traumatic spinal cord dysfunction (I0020, Primary medical condition category = 04)

– Traumatic spinal cord dysfunction (I0020, Primary medical condition category = 05)

– Progressive neurological conditions (I0020, Primary medical condition category = 06)

– Other neurological conditions (I0020, Primary medical condition category = 07)




163

• Primary medical condition category– Amputation (I0020, Primary medical condition = 08)– Hip and knee replacement (reference category)(I0020, Primary medical

condition category = 09)– Fractures and other multiple trauma (I0020, Primary medical condition

category = 10)– Other orthopedic conditions (I0020, Primary medical condition category =

11)– Debility and cardiorespiratory conditions (I0020, Primary medical condition

category = 12)– Medically complex conditions (I0020, Primary medical condition category =

13)– Other medical condition (I0020, Primary medical condition category = 14)

• Interactions of medical condition category and admission mobility score and primary



164

• Prior Surgery: Major surgery during the 100 days prior to the SNF admission (J2000, Prior surgery = 01)

• Prior Functioning: Indoor Mobility (ambulation)– Dependent (GG0100B = 1)– Some help (GG0100B = 2)– Independent (GG0100B = 3), unknown (GG0100B = 8), not

applicable (GG0100B = 9), or not assessed/no information (GG0100B = [-])(reference category)

• Prior Functioning: Stairs– Dependent (GG0100C = 1)– Some help (GG0100C = 2)– Independent (GG0100C = 3), unknown (GG0100C = 8), not

applicable (GG0100C = 9), or not assessed/no information (GG0100C = [-])(reference category)




165

Prior Functioning: Functional Cognition– Dependent (GG0110D = 1)– Independent (GG0110D = 3), some help (GG0100D = 2), unknown

(GG0110D = 8), not applicable (GG0100D = 9), or not assessed/no information (GG0100D = [-])(reference category)

Prior Device Use: Walker– Yes (GG0110D is checked)– No (GG0110D not checked)(reference category)

Prior Device Use: Wheelchair/scooter– Yes (GG0110A, manual wheelchair is checked or GG0110B, motorized

wheelchair and/or scooter is checked)– No (GG0110A, manual wheelchair is not checked and GG0110B,

motorized wheelchair and/or scooter is not checked)(reference category)



166

Prior Device Use: Mechanical lift– Yes (GG0110C, mechanical lift is checked)

– No (GG0110C, mechanical lift not checked)(reference category)

Prior Device Use: Orthotics/prosthetics– Yes (GG0110E, orthotics/prosthetics is checked)

– No, or unknown (reference category)(GG0110E, orthotics/prosthetics not checked)




167

• Communication Impairment: Ability to express ideas and wants and Understanding verbal and non-verbal content– Moderate to severe communication limitations: Rarely/never

understands (B0800, Ability to understand others = 3); or sometimes understands (B0800, Ability to understand others = 2); or rarely/never understood (B0700, Makes self understood = 3); or sometimes understood (B0700, Makes self understood = 2);

– Mild to no communication limitations (reference category): Usually understands (B0800, Ability to understand others = 1), understands (B0800, Ability to understand others = 0); and usually understood (B0700, Makes self understood = 1), understood (B0700, Makes self understood = 0), or Not assessed/no information (B0700 =[-] or B0800 =[-])



168

• Cognitive Abilities: Brief Interview for Mental Status (BIMS) score:– Severely impaired: C0500, BIMS Summary Score ≤ 7 or C0900Z,

None of the above were recalled is checked or only one of the following is checked: C0900A, C0900B, C0900C, C0900D);

– Moderately impaired: C0500, BIMS Summary Score = 8,9,10,11,12 or 2 of the following items are checked: C0900A, C0900B, C0900C, C0900D);

– Intact (reference category): C0500 BIMS Summary Score = 13,14 or 15 or 3 or 4 of the following are checked: C0900A, C0900B, C0900C, C0900D)




169

• Urinary Continence– Occasionally (H0300, Urinary continence = 1), frequently incontinent

(H0300, Urinary continence = 2) or always continent (H0300, Urinary continence = 3)

– Continent (H0300, Urinary continence = 0), catheter, ostomy or no urine output (H0300, Urinary continence = 9), or Not assessed/no information (H0300, Urinary continence =[-])(reference category)

• Bowel Continence– Occasionally (H0400, Bowel continence = 1), frequently incontinent

(H0400, Bowel continence = 2) or always continent (H0400, Bowel continence = 3)

– Continent (H0400, Bowel continence = 0) or had ostomy or did not have a bowel movement for the entire 7 days (H0400, Bowel continence = 9), or Not assessed/no information (H0400, Bowel continence =[-])(reference category)



170

Presence of Stage 2 pressure ulcer(s) at admission (M0300B1≥1)

Presence of severe pressure ulcer/injury at admission

– Stage 3 (M0300C1, Number of Stage 3 pressure ≥ 1), Stage 4 (M0300D1, Number of Stage 4 pressure ulcers ≥ 1) or Unstageable pressure ulcer/injury (M0300E1, Number of unstageable pressure ulcers (due to non-removable dressing) ≥ 1 or M0300F1, Number of these unstageable pressure ulcers (due to slough and/or eschar) ≥ 1 or M0300G1, Number of these unstageable pressure ulcers (due to deep tissue injury) ≥1)




171

• Tube feeding (K0510B1 = 1) or total parenteral nutrition (K0510A1 = 1)

• History of Falls: history of one or more falls in the 6 months prior to admission (J1700A, fall any time in the last month prior to admission/entry or reentry = 1 or J1700B, fall any time in the last 2-6 months prior to admission/entry or reentry = 1)



172

• Comorbidities (hierarchical condition categories):– Major Infections: Septicemia, Sepsis, Systemic Inflammatory

Response Syndrome/Shock; and other infectious diseases– Metastatic Cancer and Acute Leukemia– Diabetes: Diabetes with Chronic Complications; Diabetes without

Complication; Type I Diabetes Mellitus– Other Significant Endocrine and Metabolic Disorders– Delirium and Encephalopathy– Dementia: Dementia with Complications; Dementia without

Complications– Tetraplegia (excluding complete tetraplegia) and paraplegia– Multiple Sclerosis– Parkinson’s and Huntington’s Diseases




173

• Comorbidities (hierarchical condition categories):– Central nervous system (CNS) Infections: Bacterial, Fungal, and Parasitic

Central Nervous System Infections; Viral and Late Effects Central Nervous System Infections

– Other Infectious Diseases (HCC 7)– Metastatic Cancer and Acute Leukemia– Lymphoma and Other Cancers– Other Majors Cancers: Colorectal, Bladder, and Other Cancers; Other

Respiratory and Heart Neoplasms; Other Digestive and Urinary Neoplasms; Other Neoplasms

– Dementia: Dementia with Complications; Dementia without Complications

– Mental Health Disorders: Schizophrenia; Major Depressive, Dipolar, and Paranoid Disorders; Reactive and Unspecified Psychosis; Personality Disorders



174

• Comorbidities (hierarchical condition categories):– Tetraplegia (excluding complete tetraplegia) and paraplegia

– Multiple Sclerosis

– Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease

– Hemiplegia/Other Late Effects of Cerebrovascular Accident: Hemiplegia/Hemiparesis; Late effects of Cerebrovascular Disease, Except Paralysis

– Aspiration, Bacterial, and Other Pneumonias: Aspiration and Specified Bacterial Pneumonias; Pneumococcal Pneumonia, Empyema, Lung Abscess

– Legally Blind

– Dialysis Status and Chronic Kidney Disease – Stage 5




175

• Comorbidities (hierarchical condition categories):– Chronic Kidney Disease – Stages 1-4, Unspecified: Chronic Kidney

Disease, Severe (Stage 4); Chronic Kidney Disease, Moderate (Stage 3); Chronic Kidney Disease, Mild or Unspecified (Stages 1-2 or Unspecified)

– Major Fracture, except of Skull, Vertebrae or Hip

– Amputations: Traumatic Amputations and Complications; Amputation Status, Lower Limb/Amputation complications; Amputation Status, Upper Limb


Calculating PDPM Function Scores

176



Nursing Component

• Calculate Function Score

– Performance Score for seven (7) GG functional items creates Function Score

177


Function Score - Performance Coding

178



Average Function Score from 5-day MDS

Section GGItem

FUNCTION SCORE RANGE 0‐16

GG0130A1 Self-care: Eating 0-4

GG0130C1 Self-care: Toileting Hygiene

0-4

GG0170B1 Mobility: Sit to lying0-4 (average of 2

items)GG0170C1 Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand0-4 (average of 3

items)GG0170E1 Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer179


Performance Coding on 5-day MDS

• Range for Function Score is 0-16

• Performance Coding determines average Function Score

180

Admission Performance (Column 1) =

Function Score =

05, 06 4

04 3

03 2

02 1

01, 07, 09, 10, 88 0



Average Functional Score

181

Section GG Item

Coding Function Score

GG0130A1 Self-care: Eating 06 Function Score 4


02 Function Score 1

GG0170B1 Mobility: Sit to lying 04

02

3

1GG0170C1 Mobility: Lying to

sitting on side of bed

GG0170D1 Mobility: Sit to stand

03

02

02

2

1

1

GG0170E1 Mobility: Chair/bed-to-chair transfer

GG0170F1 Mobility: Toilet transfer

3+1=4 divided by 2 = Average Function Score 2

2+1+1 =4 divided by 3 = Average 1.3 rounded to Average Function Score 1

Total Function Score = 8


Nursing Index Under PDPM Model

182

Clinical Category

PDPM Nursing Case-Mix Group

Clinical Conditions Depression

# of Restorative

Nursing Services

GG-based Function

Score

Nursing Case-Mix

Index

Extensive Services

ES3Tracheostomy &

Ventilator- - 0-14 4.04

ES2Tracheostomy or

Ventilator- - 0-14 3.06

ES1 Infection - - 0-14 2.91

Special Care High

HDE2

Serious medical conditions e.g.

comatose, septicemia, respiratory therapy

Yes - 0-5 2.39

HDE1



No - 0-5 1.99

HBC2



Yes - 6-14 2.23

HBC1



No - 6-14 1.85



Clinical Category

PDPM Nursing Case-

Mix GroupClinical Conditions Depression

# of Restorative

Nursing Services

GG-based Function

Score

Nursing Case-Mix

Index

Special Care Low

LDE2Serious medical

conditions e.g. radiation therapy or dialysis

Yes - 0-5 2.07

LDE1Serious medical


No - 0-5 1.72

LBC2Serious medical


Yes - 6-14 1.71

LBC1Serious medical


No - 6-14 1.43

Clinically Complex

CDE2

Conditions requiring complex medical care e.g.

pneumonia, surgical wounds, burns

Yes - 0-5 1.86

CDE1



No - 0-5 1.62183



Behavior SX Cognition

BAB2Behavioral or cognitive

symptoms- 2 or more 11-16 1.04

BAB1Behavioral or cognitive

symptoms- 0-1 11-16 0.99

184

Clinical Category

PDPM Nursing Case-

Mix GroupClinical Conditions Depression

# of Restorative

Nursing Services

GG-based Function

Score

Nursing Case-Mix

Index

Clinically Complex

CBC2



Yes - 6-14 1.54

CA2



Yes - 15-16 1.08

CBC1



No - 6-14 1.34

CA1



No - 15-16 0.94




Reduced Physical Function

PDE2Assistance with daily

living and general supervision

- 2 or more 0-5 1.57

PDE1Assistance with daily


- 0-1 0-5 1.47

PBC2Assistance with daily


- 2 or more 6-14 1.21

PA2Assistance with daily


- 2 or more 15-16 0.70

PBC1Assistance with daily


- 0-1 6-14 1.13

PA1Assistance with daily


- 0-1 15-16 0.66

185

Clinical Category

PDPM Nursing Case-Mix

GroupClinical Conditions Depression

# of Restorative

Nursing Services

GG-based Function

Score

Nursing Case-Mix

Index



PT/OT Component

• Calculate Function Score

– Performance Score for ten (10) GG functional items creates Function Score

186



Function Score - Performance Coding

187



Section GGItem


GG0130A1 Self-care: Eating 0-4

GG0130B1 Self‐Care: Oral Hygiene 0-4


0-4

GG0170B1 Mobility: Sit to lying0-4 (average of 2

items)GG0170C1 Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand0-4 (average of 3

items)GG0170E1 Mobility: Chair/bed-to

-chair transferGG0170F1 Mobility: Toilet transfer 188

Additional




Section GGItem


GG0170I1 Mobility: Walk 50 feetwith two turns

0-4 (average of 2 items)

GG0170J1 Mobility: Walk 150 Feet

189


Performance Coding on 5-day MDS


• Performance Coding determines average Function Score 190

Admission Performance (Column 1) =

Function Score =

05, 06 4

04 3

03 2

02 1

01, 07, 09, 10, 88 0



Section GGItem


GG0130A1 Self-care: Eating 06 Function Score 4

GG0130B1 Self‐Care: Oral Hygiene

04 Function Score 3


02 Function Score 1

GG0170B1 Mobility: Sit to lying 04

02

3

1

GG0170C1 Mobility: Lying to sitting on side of bed

GG0170D1 Mobility: Sit to stand

03

02

02

2

1

1



Average Functional Score

191

2+1+1 =4 divided by 3 = Average 1.3 rounded to Average Function Score 1

3+1=4 divided by 2 = Average Function Score 2

Additional



Section GGItem


GG0170J1 Mobility: Walk 50 Feet with two turns

02

88

1

0GG0170K1 Mobility: Walk 150

Feet

192

1+0 =1 divided by 2 = .5 Average Function Score 1


• Function Score – Adds up to 12



PT and OT Case-mix Classification Groups

Clinical Category

Section GG

Function Score

PT OT Case-mix

Group

PT Case-mix

Index

OT Case-mix

Index

Major Joint Replacement or Spinal Surgery 0-5 TA 1.53 1.49

Major Joint Replacement or Spinal Surgery 6-9 TB 1.69 1.63

Major Joint Replacement or Spinal Surgery 10-23 TC 1.88 1.68

Major Joint Replacement or Spinal Surgery 24 TD 1.92 1.53

Other Orthopedic 0-5 TE 1.42 1.41

Other Orthopedic 6-9 TF 1.61 1.59

Other Orthopedic 10-23 TG 1.67 1.64

Other Orthopedic 24 TH 1.16 1.15

Medical Management 0-5 TI 1.13 1.17

Medical Management 6-9 TJ 1.42 1.44

Medical Management 10-23 TK 1.52 1.54

Medical Management 24 TL 1.09 1.11193


PT and OT Case-mix Classification Groups

Clinical CategorySection GG

Function Score

PT OT Case-mix

Group

PT Case-mix

Index

OT Case-mix Index

Non-Orthopedic Surgery and Acute Neurologic

0-5 TM 1.27 1.30


6-9 TN 1.48 1.49


10-23 TO 1.55 1.55


24 TP 1.08 1.09

194



Summary

• IDT approach to coding GG for accuracy as to baseline at admission and discharge – Consider coding at admission as compared to

improvement at discharge for QMs

• Coding on MDS should be supported in record, especially PDPM Self-Care and Mobility items since impact on CMG– G - ADL coding is gone with PDPM

195


Patient-Driven Payment Model (PDPM): Quick Reference

The PDPM establishes a rate on the 5-day MDS for the entire stay by combining five different case-mix components (PT, OT, SLP, Nursing, and Non-Therapy Ancillary) with the non-case mix component (a total of 6 components). A variable rate applies for three components based on length of stay). The rate may be changed during the Medicare Part A stay by completing the voluntary Interim Payment Assessment (IPA) for substantial changes.

Use the following tools to identify the case-mix group for each component and improve your understanding of the Patient-Driven Payment Model.

– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

Final Rule http://s3.amazonaws.com/public‐inspection.federalregister.gov/2018‐16570.pdf

Non‐Case‐Mix Group

PT

Case‐Mix

Group OT

PT

Case-Mix

GroupOT

Case-Mix

Group

SLP

Case-Mix

GroupNursing Case-Mix

Group

Non-Therapy Ancillary Case-Mix

Group

Non-Case-Mix

Group=

Resident’s Total Rate


Nursing Component Patient-Driven Payment Model (PDPM)

Resources: FY 2019 SNF PPS Final Rulemaking and CMS Draft PDPM Calculation Worksheet for SNFs.

Clinical Category

PDPM Nursing

Case-Mix Group

Clinical Conditions

Depression

# of Restorative

Nursing Services

GG-based

Function Score

Nursing Case-Mix

Index

Extensive Services

ES3 Tracheostomy &

Ventilator - - 0-14 4.04

ES2 Tracheostomy or

Ventilator - - 0-14 3.06

ES1 Infection - - 0-14 2.91

Special Care High

HDE2


comatose, septicemia,

respiratory therapy

Yes - 0-5 2.39

HDE1



respiratory therapy

No - 0-5 1.99

HBC2



respiratory therapy

Yes - 6-14 2.23

HBC1



respiratory therapy

No - 6-14 1.85

Special Care Low

LDE2


radiation therapy or dialysis

Yes - 0-5 2.07

LDE1



No - 0-5 1.72

LBC2



Yes - 6-14 1.71




Clinical Category

PDPM Nursing

Case-Mix Group

Clinical Conditions

Depression

# of Restorative

Nursing Services

GG-based

Function Score

Nursing Case-Mix

Index

Special Care Low LBC1



No - 6-14 1.43

Clinically Complex

CDE2

Conditions requiring complex medical

care e.g. pneumonia, surgical wounds,

burns

Yes - 0-5 1.86

CDE1



burns

No - 0-5 1.62

CBC2



burns

Yes - 6-14 1.54

CA2



burns

Yes - 15-16 1.08

CBC1



burns

No - 6-14 1.34

CA1



burns

No - 15-16 0.94

Behavior SX Cognition

BAB2 Behavioral or

cognitive symptoms - 2 or more 11-16 1.04

BAB1 Behavioral or

cognitive symptoms - 0-1 11-16 0.99




Clinical Category

PDPM Nursing

Case-Mix Group

Clinical Conditions

Depression

# of Restorative

Nursing Services

GG-based

Function Score

Nursing Case-Mix

Index

Reduced Physical Function

PDE2 Assistance with daily living and

general supervision - 2 or more 0-5 1.57

PDE1 Assistance with daily living and

general supervision - 0-1 0-5 1.47

PBC2 Assistance with daily living and


PA2 Assistance with daily living and


PBC1 Assistance with daily living and


PA1 Assistance with daily living and


Scoring Response for Section GG Items Score Section GG items Score

05, 06 Set-up assistance, independent 4 GG0130A1 Self-care: Eating 0-4

04 Supervision or touching assistance

3 GG0130C1 Self-care: Toileting hygiene

0-4

03 Partial/moderate assistance 2 GG0170B1 Mobility: Sit to lying 0-4 (avg. of 2 bed

mobility items)

02 Substantial/maximal assistance 1 GG0170C1 Mobility: Lying to sitting on side of bed

01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted

0 GG0170D Mobility: Sit to stand 0-4

(avg. of 3 transfer items)



*Nursing Component: See the CMS PDPM calculation worksheet for inclusion criteria for each nursing classification.


Steps for ICD-10 to PDPM Clinical Mapping

To determine a resident’s clinical category, complete the following steps:

1. Locate the ICD-10 code for the primary reason for SNF care in the tab “SNF_clinical_categories_by_dx”

2. Use the mapping in this tab to determine the default category, in column C

3. Did the resident receive a surgical procedure during the prior inpatient stay that relates to the SNF care plan?

“N/A” – Clinical Category is the default clinical category - STOP

NO

YES

4. Use column D to determine if the resident is eligible for a different clinical category from the default.

5. Is the resident eligible for a different clinical category?

NO

Clinical Category is the default clinical category - STOP

YES, NON-ORTHO

SURGERY

6. Use the tab “Non_Ortho_Surgery” to see if the resident had a qualifying inpatient procedure.

7. Did the resident have a qualifying non-orthopedic procedure?

NO


YES

Clinical category is Non-Orthopedic Surgery - STOP

YES, ORTHO

SURGERY

8. If the resident is eligible for one of the two orthopedic surgery categories, then use the “Orthopedic_Surgery” tab to determine if the resident had a qualifying inpatient procedure.

9. Did the resident have a qualifying orthopedic procedure?

NO


YES

Use column C to determine the clinical category based on the ICD-10-PCS code corresponding to the inpatient procedure – STOP

You can search by ICD-10 code, code description, A to Z, or Z to A. Not all codes are listed, so if actual code doesn’t come up, search by another method. May be necessary to scroll down to locate code manually.

Do not use decimal when searching by ICD-10 code.


Physical Therapy & Occupational Therapy Component Patient-Driven Payment Model (PDPM)


PT & OT Clinical Category

(Collapsed)

GG Function

Score

PT & OT Case Mix

Group

PT CMI

OT CMI

Primary Diagnosis (PDPM Clinical Category)

Major Joint Replacement or Spinal Surgery

0-5 6-9

10-23 24

TA TB TC TD

1.53 1.69 1.88 1.92

1.49 1.63 1.68 1.53

Major Joint Replacement or Spinal Injury

Other Orthopedic 0-5 6-9

10-23 24

TE TF TG TH

1.42 1.61 1.67 1.16

1.41 1.59 1.64 1.15

Orthopedic Surgery (except major joint replacement or spinal surgery) Non-surgical orthopedic/ musculoskeletal

Medical Management

0-5 6-9

10-23 24

TI TJ TK TL

1.13 1.42 1.52 1.09

1.17 1.44 1.54 1.11

Acute infections Cardiovascular and Coagulations Pulmonary Cancer Medical Management

Non-Orthopedic Surgery & Acute Neurologic

0-5 6-9

10-23 24

TM TN TO TP

1.27 1.48 1.55 1.08

1.30 1.49 1.55 1.09

Non-orthopedic surgery Acute Neurologic

*PT Component and OT Component: PT and OT components will always result in the same case-mix group; however, the PT and OT case-mix indices/payment levels differ.

Scoring Response for Section GG Items Score Section GG Items Score

05, 06 Set-up assistance, independent 4 GG0130A1 Self-care: Eating 0-4 04 Supervision or touching assistance 3 GG0130B1 Self-care: Oral hygiene 0-4 03 Partial/moderate assistance 2 GG0130C1 Self-care: Toileting

hygiene 0-4

02 Substantial/maximal assistance 1 GG0170B1 Mobility: Sit to lying 0-4 (avg. of 2 bed

mobility items) GG0170C1 Mobility: Lying to sitting on side of bed

01, 07, 09, 10, 88, [-]

Dependent, refused, not attempted, resident does not walk**

0 GG0170D1 Mobility: Sit to stand 0-4 (avg. of 3

transfer items) GG0170E1 Mobility: Chair/bed-to-

chair transfer GG0170F1 Mobility: Toilet transfer

GG0170J1 Mobility: Walk 50 feet with 2 turns

0-4 (avg. of 2

walking items) GG0170K1 Mobility: Walk 150 feet

** If a resident is coded as not attempted (07, 09, 10, or 88) for GG0170l1 (Walk 10 feet), then walking items for

GG0170J1 (Walk 50 feet with 2 turns) and GG0170K1 (Walk 150 feet) will be scored as zero points.


Physical Therapy & Occupational Therapy Component Patient-Driven Payment Model (PDPM)


Medicare Payment Days Adjustment Factor 1-20 1.00 21-27 0.98 28-34 0.96 35-41 0.94 42-48 0.92 49-55 0.90 56-62 0.88 63-69 0.86 70-76 0.84 77-83 0.82 84-90 0.80 91-97 0.78 98-100 0.76


Speech-Language Pathology Component Patient-Driven Payment Model (PDPM)


Presence of Acute Neurologic Condition/ SLP-Related Comorbidity/

OR Cognitive Impairment (Mild, Moderate, Severe)

Mechanically Altered Diet OR Swallowing Disorder

SLP Case-Mix

Group

SLP Case-Mix

Index

None Neither SA 0.68

None Either SB 1.82

None Both SC 2.66

Any One Neither SD 1.46

Any One Either SE 2.33

Any One Both SF 2.97

Any Two Neither SG 2.04

Any Two Either SH 2.85

Any Two Both SI 3.51

All Three Neither SJ 2.98

All Three Either SK 3.69

All Three Both SL 4.19

Primary Diagnosis Clinical Category SLP Clinical Category Major Joint Replacement or Spinal Surgery Non-Neurologic

Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery) Non-Neurologic

Non-Orthopedic Surgery Non-Neurologic

Acute Infections Non-Neurologic

Cardiovascular and Coagulations Non-Neurologic

Pulmonary Non-Neurologic

Non-Surgical Orthopedic/Musculoskeletal Non-Neurologic

Acute Neurologic Acute Neurologic

Cancer Non-Neurologic

Medical Management Non-Neurologic




Co-morbidity Special Treatments, Procedures and Programs

O0100 O0100E2 Tracheostomy Care I0100F2 Ventilator or Respirator

Section I: Active Diagnoses I4300 Aphasia (R47.01, F80.2, F80.‐, I69.‐, G31.01) I4900 Hemiplegia or Hemiparesis (G81.‐, G83.‐, I69.‐) I4500 CVA, TIA, or Stroke (I69.‐) I5500 TBI (S06.‐)

Other: I8000 Additional Active Diagnoses

See ICD-10 Codes below

Laryngeal Cancer Apraxia Dysphagia ALS Oral Cancers Speech and Language Deficits

SLP-Related Co-morbidity ICD-10-

CM Code Description

ALS G12.21 Amyotrophic lateral sclerosis Apraxia I69.990 Apraxia following unspecified cerebrovascular disease Dysphagia I69.991 Dysphagia following unspecified cerebrovascular disease Laryngeal Cancer C32.0 Malignant neoplasm of glottis Laryngeal Cancer C32.1 Malignant neoplasm of supraglottis Laryngeal Cancer C32.2 Malignant neoplasm of subglottis Laryngeal Cancer C32.3 Malignant neoplasm of laryngeal cartilage Laryngeal Cancer C32.8 Malignant neoplasm of other specified sites of larynx Laryngeal Cancer C32.9 Malignant neoplasm of larynx, unspecified Oral Cancer C00.0 Malignant neoplasm of external upper lip Oral Cancer C00.1 Malignant neoplasm of external lower lip Oral Cancer C00.3 Malignant neoplasm of upper lip, inner aspect Oral Cancer C00.4 Malignant neoplasm of lower lip, inner aspect Oral Cancer C00.5 Malignant neoplasm of lip, unspecified, inner aspect Oral Cancer C00.6 Malignant neoplasm of commissure of lip, unspecified Oral Cancer C00.8 Malignant neoplasm of overlapping sites of lip Oral Cancer C00.2 Malignant neoplasm of external lip, unspecified Oral Cancer C00.9 Malignant neoplasm of lip, unspecified Oral Cancer C01 Malignant neoplasm of base of tongue Oral Cancer C02.0 Malignant neoplasm of dorsal surface of tongue Oral Cancer C02.1 Malignant neoplasm of border of tongue Oral Cancer C02.2 Malignant neoplasm of ventral surface of tongue Oral Cancer C02.3 Malignant neoplasm of anterior two-thirds of tongue, part

unspecified Oral Cancer C02.8 Malignant neoplasm of overlapping sites of tongue Oral Cancer C02.4 Malignant neoplasm of lingual tonsil





CM Code Description

Oral Cancer C02.9 Malignant neoplasm of tongue, unspecified Oral Cancer C03.0 Malignant neoplasm of upper gum Oral Cancer C03.1 Malignant neoplasm of lower gum Oral Cancer C03.9 Malignant neoplasm of gum, unspecified Oral Cancer C04.0 Malignant neoplasm of anterior floor of mouth Oral Cancer C04.1 Malignant neoplasm of lateral floor of mouth Oral Cancer C04.8 Malignant neoplasm of overlapping sites of floor of mouth Oral Cancer C04.9 Malignant neoplasm of floor of mouth, unspecified Oral Cancer C09.9 Malignant neoplasm of tonsil, unspecified Oral Cancer C09.8 Malignant neoplasm of overlapping sites of tonsil Oral Cancer C09.0 Malignant neoplasm of tonsillar fossa Oral Cancer C09.1 Malignant neoplasm of tonsillar pillar (anterior)(posterior) Oral Cancer C10.0 Malignant neoplasm of vallecular Oral Cancer C10.1 Malignant neoplasm of anterior surface of epiglottis Oral Cancer C10.8 Malignant neoplasm of overlapping sites oropharynx Oral Cancer C10.2 Malignant neoplasm of lateral wall of oropharynx Oral Cancer C10.3 Malignant neoplasm of posterior wall of oropharynx Oral Cancer C10.4 Malignant neoplasm of branchial cleft Oral Cancer C10.8 Malignant neoplasm of overlapping sites of oropharynx Oral Cancer C10.9 Malignant neoplasm of oropharynx, unspecified Oral Cancer C14.0 Malignant neoplasm of pharynx, unspecified Oral Cancer C14.2 Malignant neoplasm of waldeyer’s ring Oral Cancer C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and

pharynx Oral Cancer C06.0 Malignant neoplasm of cheek mucosa Oral Cancer C06.1 Malignant neoplasm of vestibule of mouth Oral Cancer C05.0 Malignant neoplasm of hard palate Oral Cancer C05.1 Malignant neoplasm of soft palate Oral Cancer C05.2 Malignant neoplasm of uvula Oral Cancer C05.9 Malignant neoplasm of palate, unspecified Oral Cancer C05.8 Malignant neoplasm of overlapping sites of palate Oral Cancer C06.2 Malignant neoplasm of retromolar area Oral Cancer C06.89 Malignant neoplasm of overlapping sites of other parts of mouth Oral Cancer C06.80 Malignant neoplasm of overlapping sites of unspecified parts of

mouth Oral Cancer C06.9 Malignant neoplasm of mouth, unspecified Speech and Language Deficits

I69.928 Other speech and language deficits following unspecified cerebrovascular disease

Speech and Language Deficits

I69.920 Aphasia following unspecified cerebrovascular disease


I69.921 Dysphasia following unspecified cerebrovascular disease





CM Code Description


I69.922 Dysarthria following unspecified cerebrovascular disease


I69.923 Fluency disorder following unspecified cerebrovascular disease


I69.928 Other speech and language deficits following unspecified cerebrovascular disease

Cognitive Impairment

PDPM Cognitive Level BIMS Score Staff Assessment Score

1-Cognitively Intact 13-17 0

2-Mildly Impaired 8-12 1-2

3-Moderately Impaired 0-7 3-4

4-Severely Impaired - 5-6

Mild to Severe Cognitive Impairment BIMS Interview Summary Score 0-15

To qualify as Cognitively Impaired – must be

Mild, Moderate or Severely Impaired

PDPM Cognitive Level BIMS Score Cognitively Intact Mildly Impaired

Moderately Impaired Severely Impaired

13-15 8-12 0-7 -

If BIMS Interview Summary Score is 99 or “-“ Use Staff Assessment for PDPM Cognitive Level per Calculation Worksheet


Non-Therapy Ancillary (NTA) Component Patient-Driven Payment Model (PDPM)


Condition/Extensive Service Source Points

HIV/AIDS SNF Claim 8 Parenteral IV Feeding: Level High MDS Items K0510A2 &

K0710A2=3 7

Special Treatments/Programs: Intravenous Medication Post-admit Code MDS Item O0100H2 5 Special Treatments/Programs: Ventilator or Respirator Post-admit Code MDS Item O0100F2 4 Parenteral IV Feeding: Level Low MDS Items K0510A2 &

K0710A2=2 & K0710B2=2 3

Lung Transplant Status MDS Item I8000 3 Special Treatments/Programs: Transfusion Post-admit Code MDS Item O0100I2 2 Major Organ Transplant Status, Except Lung MDS Item I8000 2 Active Diagnoses: Multiple Sclerosis Code MDS Item I5200 2 Opportunistic Infections MDS Item I8000 2 Active Diagnoses: Asthma COPD Chronic Lung Disease Code MDS Item I6200 2 Bone/Joint/Muscle Infections/Necrosis – Except Aseptic Necrosis of Bone MDS Item I8000 2 Chronic Myeloid Leukemia MDS Item I8000 2 Wound Infection Code MDS Item I2500 2 Active Diagnoses: Diabetes Mellitus (DM) Code MDS Item I2900 2 Endocarditis MDS Item I8000 1 Immune Disorders MDS Item I8000 1 End-Stage Liver Disease MDS Item I8000 1 Other Foot Skin Problems: Diabetic Foot Ulcer Code MDS Item M1040B 1 Narcolepsy and Cataplexy MDS Item I8000 1 Cystic Fibrosis MDS Item I8000 1 Special Treatments/Programs: Tracheostomy Care Post-admit Code MDS Item O0100E2 1 Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code MDS Item I1700 1 Special Treatments/Programs: Isolation Post-admit Code MDS Item O0100M2 1 Specified Hereditary Metabolic/Immune Disorders MDS Item I8000 1 Morbid Obesity MDS Item I8000 1 Special Treatments/Programs: Radiation Post-admit Code MDS Item O0100B2 1 Highest Stage of Unhealed Pressure Ulcer – Stage 4 MDS Item M0300D1 1 Psoriatic Arthropathy and Systemic Sclerosis MDS Item I8000 1 Chronic Pancreatitis MDS Item I8000 1 Proliferative Diabetic Retinopathy and Vitreous Hemorrhage MDS Item I8000 1 Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code (M1040B)

MDS Item M1040A& M1040C 1

Complications of Specified Implanted Device or Graft MDS Item I8000 1 Bladder and Bowel Appliances: Intermittent Catheterization MDS Item H0100D 1 Inflammatory Bowel Disease MDS Item I8000 1 Aseptic Necrosis Bone MDS Item I8000 1 Special Treatments/Programs: Suctioning Post-admit Code MDS Item O0100D2 1 Cardio-Respiratory Failure and Shock MDS Item I8000 1 Myelodysplastic Syndromes and Myelofibrosis MDS Item I8000 1 Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

MDS Item I8000 1


Non-Therapy Ancillary (NTA) Component Patient-Driven Payment Model (PDPM)


Condition/Extensive Service Source Points

Diabetic Retinopathy – Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

MDS Item I8000 1

Nutritional Approaches While a Resident: Feeding Tube MDS Item K0510B2 1 Severe Skin Burn or Condition MDS Item I8000 1 Intractable Epilepsy MDS Item I8000 1 Active Diagnoses: Malnutrition Code MDS Item I5600 1 Disorders of Immunity – Except: RxCC97: Immune Disorders MDS Item I8000 1 Cirrhosis of Liver MDS Item I8000 1 Bladder and Bowel Appliances: Ostomy MDS Item H0100C 1 Respiratory Arrest MDS Item I8000 1 Pulmonary Fibrosis and Other Chronic Lung Disorders MDS Items I8000 1

NTA Score Range NTA Case-Mix Group CMI

12+ NA 3.25 9-11 NB 2.53 6-8 NC 1.85 3-5 ND 1.34 1-2 NE 0.96 0 NF 0.72

Medicare Payment Days Adjustment Factor

1-3 3.0 4-100 1.0


Steps for ICD-10 to PDPM NTA Comorbidity Mapping

1. Determine if the ICD-10 code is listed in the NTA Comorbidity Mappings.

2. Is the ICD-10 code listed as an NTA Comorbidity Qualifier?

Then the ICD-10 code is not an NTA I8000 Comorbidity Qualifier – STOP

(Keep in mind resident may still qualify for other MDS item NTA Comorbidity Qualifiers unrelated to ICD-10 I8000.)

NO

YES

4. Use column B to determine the NTA Comorbidity Qualifying Category.

You can search by ICD-10 code, ICD-10 code description, or Comorbidity description. Use drop down boxes to enter information or you can sort A to Z, or Z to A.

Do not use decimal when searching by ICD-10 code.

Make sure you are using the most up-to-date version of the NTA Comorbidity Mappings.


PDPM Payments Slope and Create Incentives for Shorter LOS

Costs

Payments

Total Per Diem Payment is the Sum of Payments for Each Component

NTA, OT, and PT taper or decrease over stay. Nursing, SLP, and Non-Case Mix Group remain constant.

NTA – Triple rate first 3 days; normal rate for rest of stay unless complete an Interim Payment Assessment which may change the rate for this component but does not reset to Day One of stay.

OT and PT rates taper 2% every 7 days starting on day 21. Payments Can be Adjusted Using the Interim Payment Assessment (IPA) but

the IPA does not reset to Day One for tapering Components

FY 2019 PDPM Unadjusted Federal Rate Per Diem - Urban

Rate Component

Nursing NTA PT OT SLP Non-Case-

Mix

Per Diem Amount

$103.46 $78.05 $59.33 $55.23 $22.15 $92.63

FY 2019 PDPM Unadjusted Federal Rate Per Diem - Rural

Rate Component

Nursing NTA PT OT SLP Non-Case-

Mix

Per Diem Amount

$98.83 $74.56 $67.63 $62.11 $27.90 $94.34


PDPM Function Score Work Sheet

Created by Polaris Group

Section GG Nursing Function Score 0-16

Coding Function Score Function Score

GG0130A1 Self-care: Eating


GG0170B1 Mobility: Sit to lying (average of Two)


GG0170D1 Mobility: Sit to stand (average of Three)



TOTAL

Section GG PT/OT Function Score 0-24


Function Score

GG0130A1 Self-care: Eating

GG0130B1 Self-Care: Oral Hygiene


GG0170B1 Mobility: Sit to lying (average of Two


GG0170D1 Mobility: Sit to stand (average of Three)



GG0170J1 Mobility: Walk 50 feet two turns two

turns (average of two)

GG0170K1 Mobility: Walk 150 Feet

TOTAL

Performance Code 5 day Function Score

05, 06 4 04 3 03 2 02 1 01, 07, 09, 10, 88 0

Total Nursing Function Score: _________ Add up Score for Eating &

Toileting with average score for each of the two Mobility groups.

Total PT/OT Function Score: _________ Add up Score for Eating, Oral

Hygiene, & Toileting with average score for each of the two different

Mobility groups.


SELF‐CARE QUALITY MEASURE CALCULATION

G0130 Self Care Start of Care Coding

End of Care Coding

A. Eating: The ability to use suitable utensils to bring food

and/or liquid to the mouth and swallow food and/or liquid once

the meal is placed before the resident.

B. Oral hygiene: The ability to use suitable items to clean

teeth. Dentures (if applicable): The ability to insert and remove

dentures into and from the mouth, and manage denture

soaking and rinsing with use of equipment.

C. Toileting hygiene: The ability to maintain perineal hygiene,

adjust clothes before and after voiding or having a bowel

movement. If managing an ostomy, include wiping the opening

but not managing equipment.

E. Shower/bathe self: The ability to bathe self, including

washing, rinsing, and drying self (excludes washing of back and

hair). Does not include transferring in/out of tub/shower.

F. Upper body dressing: The ability to dress and undress above

the waist; including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below

the waist, including fasteners; does not include footwear.

H. Putting on/taking off footwear: The ability to put on and

take off socks and shoes or other footwear that is appropriate

for safe mobility; including fasteners, if applicable.

Total Points Start of Care End of Care Change Calculation

Add up the Codes Numbers to create a total score from

points

(Example if code a “3” that equals “3” points)

Exception:

Code of 01,07, 09, 10, 88 – Score is 0 Points

G0170 Mobility Start of CareCoding

End of Care Coding

A. Roll left and right: The ability to roll from lying on back to left and

right side, and return to lying on back on the bed

B. Sit to lying: The ability to move from sitting on side of bed to lying

flat on the bed.

C. Lying to sitting on side of bed: The ability to move from lying on

the back to sitting on the side of the bed with feet flat on the floor,

and with no back support.


SELF‐CARE QUALITY MEASURE CALCULATION

G0170 Mobility Start of CareCoding

End of Care Coding

D. Sit to stand: The ability to come to a standing position from sitting

in a chair, wheelchair, or on the side of the bed.

E. Chair/bed‐to‐chair transfer: The ability to transfer to and from a

bed to a chair (or wheelchair).

F. Toilet transfer: The ability to get on and off a toilet or commode.

G. Car transfer: The ability to transfer in and out of a car or van on

the passenger side. Does not include the ability to

I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a

room, corridor, or similar space. If admission performance is coded

07, 09, 10, or 88 Skip to GG0170M, 1 step (curb)

J. Walk 50 feet with two turns: Once standing, the ability to walk at

least 50 feet and make two turns.

K. Walk 150 feet: Once standing, the ability to walk at least 150 feet

in a corridor or similar space.

L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step. If admission performance is coded 07, 09, 10, or 88 Skip to GG0170P, Picking up object.

N. 4 steps: The ability to go up and down four steps with or without a rail.

O. 12 steps: The ability to go up and down 12 steps with or without

a rail.

P. Picking up object: The ability to bend/stoop from a standing

position to pick up a small object, such as a spoon,

Total Points Start of Care End of Care Change Calculation

Add up the Codes Numbers to create a total score from points

(Example if code a “3” that equals “3” points)

Exception:

Code of 01,07, 09, 10, 88 – Score is 0 Points

Original: Change in Score: ______________ Corrected Change in Score: _______________


Documents

Section GG Coding for PDPM and SNFQRP QMs · applies if “unplanned discharge” so no Section GG). 4 ... • Code 1, Dependent, if the helper completed the activities for the resident