By Melissa Keiter, RN, RAC-CT, DNS-CT, DON And Melissa Sabo, OTR/L, CDP, CSRS
It seems like as far back as I can remember as an MDS Coordinator (this statement seems odd since this white paper is co-authored by two people), one of the main areas of focus and significance was Section G. Reviewing ADLs, especially the late-loss ADLs, and confirming their accuracy is a major component of our job as RNACs/MDS Coordinators because the reimbursement categories are partially based on the ADL score. However, we have to shift our priorities with PDPM due to all of the changes surrounding this new Prospective Payment System (PPS). One of the key changes is that the foundation for establishing the functional ADL score will shift from Section G to Section GG. Under PDPM, Section GG will now impact the per diem rates for PT, OT and Nursing categories and their respective individual CMIs.
Under RUGs-IV, the ADL score is captured only by scoring the four late-loss ADLs, which are documented in Section G. Under PDPM, Section GG includes additional functional categories beyond the four late-loss ADLs and thus expands the system’s ADL scoring foundation. This expansion is due, in part, to provider and advocate comments that both the late-loss ADLs and the restricted Section GG metrics under RUGs-IV for SNFs did not accurately represent the progress made by residents in therapy or the entire scope of necessary skills to return to the next level of care.
As MDS Coordinators, we have been “trained” to understand that the higher the ADL score of Section G means the resident requires more assistance, thus resulting in a higher CMI and RUG reimbursement rate. In PDPM, it is the opposite. Under PDPM, a higher level of independence results in a higher functional score yielding in an increased per diem rate (except for some diagnoses with a functional score of 24 which would correlate with a resident who is completely independent). This is because PDPM is helping to bridge the transition from volume to value. The research conducted by Acumen on behalf of CMS reveals that the most improvement in ADLs was shown for residents who received additional therapy services when they started out at a higher level of independence.
Another key benefit of the shift from Section G to Section GG is that CMS could collapse and simplify the Nursing RUG categories in PDPM. Specifically, the Special Care High, Special Care Low, Clinically Complex, and Reduced Physical Function classification groups (RUGs beginning with H, L, C, or P) had some of the ADL scores combined for nursing groups. Due to the fact that Section GG is more accurate than Section G, CMS was able to more accurately align reimbursement with cost and could reduce the number of ADL score categories and eliminate cognition as a determinant of payment.
To help better understand this opposition in scoring, in the tables below, you can see the changes with RUGs IV and PDPM in relationship to the current ADL score categories and the nursing function score. Also, note the opposition of the higher versus lower scores and how they relate to RUG classification.
RUGS IV Classification
|RUG ADL Score||Nursing Rehab||RUG|
|16-18||2 or more||PE2|
|16-18||0 or 1||PE1|
|11-15||2 or more||PD2|
|11-15||0 or 1||PD1|
|9-10||2 or more||PC2|
|9-10||0 or 1||PC1|
|6-8||2 or more||PB2|
|6-8||0 or 1||PB1|
|4-5||2 or more||PA2|
|4-5||0 or 1||PA1|
|Nursing Function Score||Restorative Nursing||PDPM Nursing Classification|
|0-5||2 or more||PDE2|
|0-5||0 or 1||PDE1|
|6-14||2 or more||PBC2|
|15-16||2 or more||PA2|
|6-14||0 or 1||PBC1|
|15-16||0 or 1||PA1|
Providers need to be proactive in preparing for this shift of focus on to Section GG. Education for CNAs/GNAs and nursing team members, as well as therapy team members and staff educators, will be critical in the preparation for PDPM. Providers should also consider standardized training during the orientation process and at annual retraining for all staff who could potentially contribute to Section GG data under PDPM.
If past performance is any indication, it is very likely that the Office of Inspector General (OIG) and/or Medicare Administrative Contractors (MACs) will be auditing Section GG for accuracy and supportive documentation now that it is directly tied to reimbursement under PDPM. Providers with inaccurate Section GG coding could see denials, recoupment and fines, so it is imperative to prepare your teams now and continue to promote accuracy with Section GG as you move forward.