I love Christmas! Ever since I was a child, I have resonated with the sentiment in the movie, “A Christmas Story,” where the narrator, articulating Ralphie’s thoughts states, “Oh, but no matter. Christmas was on its way. Lovely, glorious, beautiful Christmas, around which the entire kid year revolved.”

I loved everything about it, the decorations, the gifts, the food, family, even the 24/7 Christmas music on the local public radio station.

In this stage of life, I am incredibly nostalgic, particularly at Christmas. I love to reminisce, especially since my mom is no longer with us. My memories of Christmas are happy ones. This year, my in-laws are moving to our town, and I can’t wait to have them this close for the holidays. My wife and I are like kids again, filled with excitement, anticipating this change, looking forward to the season.

As the skilled nursing sector, we have collectively begun to anticipate the changes coming our way related to MDS 3.0 v1.18.11. In particular, the elimination of section G. Very soon, we will have only nostalgia when it comes to this section of the MDS that has been such a major portion of the data since the MDS was required.

How are you reacting to this news? Is this something you are looking forward to or dreading? As we prepare, one task we can do is to consider the ripple effect an MDS with no section G will have on other areas of RAI impact. Consider the CAA triggers and resources, Quality Measures, Five-Star rating/staffing acuity and state Medicaid reimbursement. 

CAA triggers and resources

Consider the implications to the elimination of section G in the Care Area Assessment process. Section G items are triggers in four CAAs, CAA 5 – ADL Functional/Rehabilitation Potential, CAA 6 – Urinary Incontinence and Indwelling Catheter, CAA 11 – Falls and CAA 16 – Pressure Ulcer. 

Furthermore, section G items impact the Care Area Assessment Resources found in Appendix C of the RAI Manual. Consider that of the 20 CAAs, the only CAA Resources that do not rely explicitly on section G in some way for further analysis are CAA 3 – Visual Function, CAA9 – Behavioral Symptoms, and CAA 13 – Feeding Tubes.

Section GG items will most likely replace section G with respect to the CAAs. As CMS begins to release additional resources throughout the next year, it will be vital that providers get up to speed quickly as to how the elimination of section G will shift the analysis of the CAAs. 

MDS-based quality measures

The MDS-based quality measures have been around for a long time. We have all gotten used to them. For time’s sake, consider just the quality measures that impact the Five-Star rating. Of the twelve MDS-based measures, three (LS Percentage of residents whose ability to move independently worsened, LS Percentage of residents whose need for help with daily activities has increased, and SS Percentage of residents who improved in their ability to move around on their own), can be calculated only with items coded in section G. Furthermore, the SS Percentage of high-risk residents with pressure ulcers is adjusted with covariates coded in section G. 

These quality measure calculations will be non-functional once section G items are no longer being collected. CMS has yet to detail how they plan to move forward with the quality measure calculations once section G is no longer available. How will these individual QM calculations work? How can a four-quarter average really explain anything meaningful if part of the QM data is calculated with section G items and part with GG items? On a recent ODF, CMS hinted at a G to GG crosswalk. Time will tell. 

Five-Star Rating

Along with the aforementioned Five-Star quality measure issues, three of the staffing measures that now impact the Five-Star rating also will be nonfunctional when section G data is no longer available, including adjusted RN staff PPD 7 days, adjusted total staff PPD 7 days and adjusted total staff PPD weekends. The data used to compile these measures comes from PBJ, the MDS and STRIVE data. 

The STRIVE data uses RUG 66 categories to determine the acuity of the resident population over a reporting quarter. That data is used to calculate an adjusted staffing ratio that determines the staffing star rating. 

RUG 66 categories cannot be calculated without section G late loss ADL data. So the current staffing star calculation will be unusable when there is no section G data available. CMS has yet to provide us with updated technical specifications related to the staffing measures and how they anticipate acuity adjusting the staffing data using only section GG items.

State Medicaid payment calculations

Finally, States that use legacy RUG systems (34, 48, 53 etc.) to calculate a case mix index used in Medicaid rate calculations will need to do something different when section G data is no longer available. 

In a recent letter to state Medicaid directors, CMS made the following statements: 

•  “CMS will no longer support the Medicare RUGs systems after October 1, 2023…”. 

•  “States that wish to continue to use RUG-III or RUG-IV after October 1, 2023… will need to implement a new process called “Optional State Assessments” or OSAs to gather the needed assessment data which will allow the states to calculate a RUGs payment amount for the services provided to the Medicaid beneficiaries.” 

•  “Absent available RUGs MDS data from CMS, states will likely have to consider collecting data independently from providers to support RUGs state plan payment methodologies.”

So far, only a handful of states have made, or are making, the switch to a PDPM-type CMI calculation for their Medicaid rates. More are sure to follow. My advice: Check with your state to see what they plan to do. 

Do you want to hear a corny one-liner I heard recently? “How does NASA organize a party? They planet.” CMS certainly has plans to accommodate the elimination of section G. The sooner they can share those with us, the better. 

We have much to learn in less than a year, nostalgia for section G or no. Maybe CMS thinks it’s too early to push out this kind of material. Like Santa told Ralphie in “A Christmas Story,” they are saying, “You’ll shoot your eye out.” 

However, as October 2023 gets closer, to me the anticipation of these forthcoming changes, without the tools to understand their impact, is starting to feel more like a Christmas gift of socks than a Red Ryder BB gun.

Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.