How are reviewers determining PDPM payment accuracy from Section GG coding?
The Function Score calculated from coding responses to certain Section GG items impacts your PDPM rate in the nursing component and the OT/PT component. Not surprisingly, reviewers are focusing on usual performance accuracy as well as documentation to support the IDT collaboration for assessment data.
In medical review, positive or negative discrepancies identified between the final MDS coding decisions and supporting documentation will contribute to the medical review error rate and potentially result in recoupment. If the documentation in the medical record does not support MDS coding, this could result in a need for repayment, or even lower initial reimbursement due to inappropriate case-mix assignments.
Ensure your team consists of qualified clinicians involved in assessing the individual during the appropriate three-day assessment period. If GG data collection begins on day four, none of that assessment data can be considered for the Function Score calculation.
At minimum, documentation should be collaborative from nursing and therapy, but the RAI guidance also includes incorporating resident self-reports and reports from qualified clinicians, care staff or family documented in the resident’s medical record during the three-day assessment period.
Also, the usual performance coded in Section GG must be consistent with the clinical assessment documentation in the medical record. You may consider documenting an IDT note to clarify coding decisions. This could include justification for determining coding decisions when the usual performance is not obvious, as well as noting necessary information such as data determined prior to the patient’s benefit from treatment interventions.