As the skilled nursing industry steadily moves toward an Oct. 1 deadline for changes to the Minimum Data Set (MDS), operators are stressing the importance of training staff to help accurately code under the new system, a byproduct of the switch to the Patient Driven Payment Model (PDPM).
While details of the most notable shift – from section G to GG – are still being worked out by the Centers for Medicare & Medicaid Services (CMS), providers are gearing up to use existing information about residents as they acclimate their clinical staff to code correctly.
This is especially true for certified nursing assistants (CNAs), who will be instrumental in helping the rest of the nursing team code information correctly, Heather Haberhern told Skilled Nursing News.
Moreover, agency staff is foreseen as posing a particular problem to a swift changeover.
Haberhern, SVP of quality at Health Dimensions Group, last week spoke on MDS changes – and their potential repercussions – during SNN’s CLINICAL event.
“We’re going to have to look at a more interdisciplinary team approach, so that we capture the performance of the residents,” said Haberhern. “We’re also going to have to consider what information we’re going to be losing with G.”
Specifically, Section G is used to determine if a resident has had a functional decline, and is used to determine if a resident needs physical therapy to improve their independence, she said. Operators will need to be mindful with what they do with that information, in terms of still coding activities of daily living (ADLs) and perhaps use that for internal purposes.
Certainly providers are aware of a basic difference between section G and GG. For Section G, CMS guidance calls for coding the most amount of assistance provided within a 7-day history. Meanwhile, Section GG requires coding the baseline performance ability within the first three days following admission and before treatment begins. However, a lot remains unknown.
“We’re still waiting to get information from CMS on how that’s going to impact the quality measures, impact the states,” said Haberhern. “I know that they’ve had to think about that at some point, but there’s so many different pieces to that puzzle that we use ADL information.”
Among changes that remain to be seen, for example, is if the change to GG will affect a facility’s ability to quickly intervene when there’s been a decline in resident function, especially if a resident needs physical therapy, she said.
Section GG shift and Medicaid
Fellow panelist Shawna Rainey, VP of clinical reimbursement at Ignite Medical Resorts, said that operator strategies in adjusting to the changes will be largely dependent on which states facilities happen to be in.
Mertz Photography for AMN | CC0States still using the case mix index-based RUGs system may still have operators revert back to ADL questions from Section G, while others like Illinois and Wisconsin that already made the switch to PDPM would move ahead with GG.
Missouri is in the most unique situation going into Oct. 1, Rainey said, with the state still looking to change to a case mix index-based payer system for their Medicaid clientele. Introduced last July, the change has still not been approved by CMS.
“They’ve of course promised that they won’t require any extra work or duplication of work, meaning that optional state assessment [OSA],” Rainey said of state decisions.
The optional state assessment was released on Monday as a supplement for operators to fill out in states that are still making the transition to PDPM. It’s a temporary solution for states with an expiration date sometime in 2025, Rainey added.
That’s a surprising difference from what other state associations have said on the OSA – SNN has been told in the past this supplement would force staff to do twice as much work in measuring the functional status of residents.
Ultimately, it may come down to more confusion, Haberhern said, an unwelcome prospect given the continuing workforce crisis.
“It’s going to be hard,” said Haberhern. “If we’re asking the CNAs to continue to document ADLs from prior, and they’re also trying to figure out GG, there’s different definitions and processes that they’re working from. It’s going to be complicated.”
Haberhern wishes there was a more unified approach to the changes. Rainey doesn’t believe it’s too late for CMS to make this change, but wonders if operators will ever see it. Such plans for a unified approach would need to have been made prior to the launch of PDPM.
“Not to take control away from the states, but it’s really difficult for every state to have a different methodology,” said Haberhern. “It makes it really difficult for us to know how to train our teams when you work across a number of different states. From a skilled nursing perspective, you’re having to then become an expert for every single state that you’re operating in, and figure out what that’s going to be.”
Side effects with ratings, surveys, workforce
Rainey said there have been “crickets” in terms of how the Five-Star Quality System will be affected by MDS updates. Five star quality measures are dependent on Section G – it’s central to calculating a facility’s performance.
Any sort of revisions to Five Star ratings as a result of the MDS likely wouldn’t come until October, Rainey predicted. And so, Ignite has been working simultaneously to strategize staff training around MDS and five star changes, optimizing certain quality measures.
CMS officials did say in an April Open Door Forum that the agency plans to re-specify some of the measures listed in ratings systems, potentially in future MDS training for operators.
Mertz Photography for AMN | CC0With so many state surveys based on ADL scoring, Haberhern sees the removal of Section G as problematic for surveyors too.
“Are they going to continue to look at how we address residents with functional decline? Are they going to base that off of G or are we going to have to change that methodology and figure out how that’s going to be impacted from Section GG? There may be a risk of our CNAs or our team members not coding that information accurately, putting us at risk for not having accurate assessments and accurate pictures of the residents,” said Haberhern.
It will really all depend on how states will be looking at true functional decline and how operators document that information. There’s “some risk involved,” she added.
MDS changes may clash with the existing workforce shortage too, added Haberhern, considering the high stakes to train staff to accurately code resident function.
She’s already seeing difficulty from agency staff to code residents correctly. The removal of Section G and focus on GG will add more confusion for agency nurses that don’t understand the changes in requirements for documentation.
“I think that puts us at risk,” she said.
However, Rainey doesn’t anticipate too much of an upset from insurance companies surrounding the MDS changes. Most MCOs have changed to more of a leveled or per diem-based payment system, she said, or they’re paying operators PDPM rates.
Other changes
Conducting mood interviews will be another major MDS change operators should be training their staff on, Haberhern said, one that may negatively impact reimbursement.
Currently, staff must ask residents nine questions to determine their depression score, and if they have a 10 or above there’s more reimbursement since more care is required. MDS changes require staff only ask the first two questions and depending on how those are answered, the interview concludes.
“It can have a tremendous change in reimbursement,” said Haberhern. “I think we struggled with capturing depression historically because we don’t always do the interviews correctly, or we don’t ask the resident, we don’t build a rapport ahead of time. This is going to make it even more of a challenge.”
Companies featured in this article:
