Lack of substantiation of MDS Section GG is frequently a citation among medical review findings, especially from Managed Care audit contractors. In absence of GG supporting documentation, reviewers will determine a resident’s function score to be consistent with independent performance. Tips for improving GG documentation follow.
- Designate a process for recording resident performance, considering:
- Timeliness for data collection
- Should occur within the initial 3 days of the stay, or the ARD and 2 days prior
- Should happen prior to benefit of treatment intervention
- Source documentation for data collection
- Should be collaborative in nature through interview of resident, family and staff
- Should assure all items have been addressed and are reflected in documentation
- Should be recorded by IDT members with a demonstrated understanding of definitions and coding of each task
- Timeliness for data collection
- Identify a means for assessing usual performance, considering:
- Documentation (e.g., signed/dated summary by IDT members whose scope of practice includes assessment capacity)
- Timeliness (e.g., by conclusion of Day 3)
- Ensure accuracy of values captured in Section GG
- Review scores recorded in MDS Section GG against the signed/dated assessment
- Confirm all values are supported by source documentation
- Verify source documentation and assessment are contained within the Electronic Medical Record for ease of location in event of an audit
As review of GG items is often a quick win for medical review contractors, taking time to solidify processes and documentation tools will contribute to audit success.
