October 1 is an important day in the world of Long Term Care as a new Section on the MDS becomes mandatory call Section GG and ICD10 coding transition period comes to an end.
Section GG is required on all admissions starting October 1 that have a Medicare Part A payer. Section GG is a 3 day look back period that allows for the facility to determine the resident’s “most usual” performance and then code the mobility and self- care items accordingly. To establish “most usual” performance, there should be a strong collaboration between nursing and therapy. Integration of software programs, tracking methods, discussion protocols and decision trees for coding are all beneficial tools to assist in this process.
Once the admission assessment is completed on the 5- day assessment and “most usual” performance with goals are coded, if the resident is a planned discharge, Section GG must be completed at that time as well. The discharge assessment uses the last 3 days of their skilled stay to determine “most usual” performance which correlates to goal achievement.
Collaboration and training are critical elements for a successful transition to Section GG. Education provided to the facility staff and therapy at the same time to ensure conformity of message and process as well as a solid understanding of the coding criteria and goal setting on the admission assessment will assist with a successful transition.
ICD10 transition is complete as of October 1 and the expansion to more specific diagnosis coding is complete. Diagnosis must include items such as laterality and more specific detail as provided in ICD10. Denials are now possible due to improper coding using the ICD10 system as of October 1, 2016.
Collaboration between facility and therapy is important to ensure correct codes are submitted on the UBO4 form and processes such as Triple Check can assist with submission of clean claims.