External reviewers have begun targeting Section GG as a focal point of pre/post-pay medical review audits. Because the PDPM function score is derived from Section GG data, and that score correlates to a case mix group for payment, reviewers will seek supportive documentation for decision making related to coding on the MDS.
- Therapy evaluations, recertifications, and discharge documents serve as clinical support of that decision making.
- Section GG coding should be reflective of the patient’s clinical characteristics.
- Objective data within the therapy evaluation/discharge should correlate to the section GG scores.
- Example: Bathing noted as Min assist by OT would be scored as 3 – Partial/Moderate Assistance.
Ensuring accurate data information at the beginning of the stay is the first key to successful outcomes. Accurate coding on sections I, C, and K of the MDS are critical. This clinical classification serves as a predictor of resource needs (therapy needs) from CMS and establishes an admission (baseline) for the patient that may be used as parameters in the future for patient progression.
Consider implementing proactive internal audits that review supportive documentation for MDS coding and continue to educate staff on proper coding to strengthen medical review success.
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