MDS Changes: Why Section GG Does Not Equal Section G

WHhen it comes to recent MDS (minimum data set) changes, one letter stands out: G. That’s because the biggest impact of the 2023 adjustment in ADL (Activities of Daily Living) scoring comes from the removal of Section G and implementation of Section GG.  Section GG scoring touches on everything from who completes assessments to what factors are tracked, and, ultimately, how SNFs (skilled nursing facilities) are paid through Medicare Part A. The 2023 updates to the MDS were some of the most dramatic since MDS 3.0 was introduced in 2010.  

Similarly, these changes are intended to improve reliability and accuracy and assist all providers in planning for the best care possible for their patients. Many other sections of the CMS (Centers for Medicare & Medicaid Services) assessment will also change over the next two years, but one of the biggest and most cumbersome changes will be to the former Section G scores.

In the 2023 update, Section G is completely eliminated and replaced with Section GG. The intent is to streamline some of the processes around MDS assessment and collect more information that has a direct impact on both patient care and operations at an SNF or other acute rehab facility.

While some of the terminology from Section GG is the same, there are fundamental differences in the way to think about, assess, score and record the data. Section GG includes assessments of functional cognition as part of the comprehensive evaluation.

The IMPACT Act of 2014 and 2023’s MDS assessment changes for skilled nursing facilities

To understand the current structure and priorities for CMS assessments, we need to look back to the IMPACT (Improving Medicare Post-Acute Care Transformation) Act of 2014. This legislation required the standardization of patient assessment data for both Quality Measures and SPADEs (Standardized Patient Assessment Data Elements) in post acute care facilities, including LTCHs (Long-Term Care Hospitals), Skilled Nursing Facilities (SNFs), HHAs (Home Health Agencies), and IRFs (Inpatient Rehabilitation Facilities). Physical or occupational therapists, especially those involved in medicaid services in post acute care should familiarize themselves with these changes from centers for medicare (CMS).

The goal of this legislation was to create a common language among all healthcare providers for a better continuity of care for patients. Providers can plan better for treatment, discharge, and support if they all have access to the same data and it is recorded using the same methodology. Patterns can be detected and monitored for patients, and a DEL (Data Element Library) was established for better communication between providers.

The new Section GG allows for more detailed information to be collected in support of this effort to provide comprehensive information to all parties and make care planning easier, especially between disparate settings scoring section GG. Assessing prior device use, including manual wheelchairs, motorized wheelchairs, and other assistive devices, is crucial as part of this standardized assessment. Capturing accurate data is critical to patient outcomes, whether at home health agencies, long term care hospitals or nursing homes. Any post acute care facility where assistance provided results in billing medicare.

What do MDS coordinators need to know about the update? 

Changes to the look-back period for MDS assessment 

One of the biggest changes from Section G to Section GG is the look-back period for MDS assessment data. MDS assessment requires coordinators to gather information from everyone who had contact with the patient to make an accurate assessment of the amount of assistance a patient requires, as well as determine gg scores.

Section G looked at an entire seven-day period. Section GG only considers the past three days. The new measure asks MDS nursing homes to evaluate the usual amount of assistance a patient requires instead of the most assistance that was required during the past week. This change is meant to support discharge planning and coordination of care.

Updated scoring procedures

When using Section G for MDS assessment, the most dependent episode in the seven-day assessment window was scored. The higher the score in this section, the more dependent the patient is on assistance from providers.  

The Section GG changes require a mindset shift from this. Instead, Section GG asks for the patient’s usual performance level over the past three-day assessment window. This can be a bit subjective but aims to be more accurate to the patient’s actual abilities and needs.  Section GG does not ask for the typical status of the individual, rather than an extreme example. As a result, the scoring methodology is changed.

In this case, the higher the score, the more independent the patient is. It is a six-level rating system that ranges from independent to dependent. As you will see below, this update differentiates between self-care and mobility activities of daily living, which will result in a more comprehensive picture of well-being.

Changes to additional measures of self-care ADL performance and self care items

The Functional Status measures in Section G have been replaced by two distinct parts in Section GG: self-care and mobility. The assessment of Section GG asks for the usual level of support needed for these seven self-care items, rather than the previous standard of four:

• Eating
• Oral hygiene
• Toileting hygiene
• Shower/ bathe self
• Upper body dressing
• Lower body dressing
• Putting on/ taking off footwear

The goal of Section GG is to precisely capture the resident’s dependency. For example, Section G included information on IV hydration or tube feeding. Section GG asks about the ability to use a utensil and to swallow the food. Additionally, the differentiation between three separate dressing skills clearly assesses the resident’s ability to perform these very different tasks. Dividing them out will create a better picture of what support services are required for ADLs.

Additional measures for mobility ADL performance 

Similar changes can be found in the measures of mobility ADLs. With Section GG there are now 17 mobility items for MDS coordinators to assess. Some of the these include:

• Bed mobility, organized into three different skill sets—rolling left and right, lying to sitting on the side of the bed, and sitting to lying.
• Transfer skill, separated into sit to stand, chair to bed, and car transfer. This better prepares teams to focus on the specific skills that are lacking before discharge.
• Toilet transfer has been pulled out of the toileting hygiene self-care ADL and given its own spot in mobility. These are very different skills and, as such, are now measured separately.
• Prior to 2023, walking was just measured in relation to the room and the corridor. It is now measured in specific distances to determine stamina. The new measures assess walking between ten and 150 feet with additional measures for uneven surfaces and stairs.
• Similarly, locomotion is measured up to 150 feet, including turning in a wheelchair or scooter.

Accurate assessment of functional mobility is crucial for proper outcome reporting and reimbursement.

Short-stay and long-stay quality measure changes

Because Section G has been eliminated, some of the standard Quality Measures are no longer calculated as they were in the past. Several short-stay and long-stay measures that were impacted by this have been replaced by new processes. Because of the updated standards and metrics with Section GG, expect to see changes in your MDS assessment rates for many of these measures.

The measures being rewritten within Section GG are: 

• The short stay improvement in function measure becomes the discharge function score measure from the SNF Quality Reporting Program.  
• The long- stay residents who need help with ADLs is replaced by a similar measure that assesses residents whose needs with late-loss ADLs have increased. 
• The long stay worsening mobility measure now only looks at the resident’s ability to walk. It is covered in the mobility ADL performance measures.  
• The high-risk pressure ulcer measure has been updated to eliminate the high-risk consideration. It covers the entire percentage of the population with pressure ulcers.  
• The incontinence measure is being replaced with those who have new or worsening bowel or bladder incontinence.  

Additional measures look different in the 2023 MDS assessment, but essentially measure the same skills. The existing measures of Section GG may be relabeled or remapped. For example, the weight loss measure and the depression measure are still present in the revamped assessment but are mapped to new items.

Frozen measures while reporting takes effect 

Any time there are significant factors that will impact MDS quality measures, some components go into a freeze. For many of these measures, there is a substantial delay between the time the data is collected and when it is publicly reported. This freeze will give regulators more time to adjust to the calculations of Section GG and allow facilities to gather enough information to be useful to the public.  

A variety of measures will be frozen for different lengths of time thanks to Section GG. Skilled nursing facilities, and MDS coordinators in particular, will need to quickly adjust to the new system and will want to make patient’s families and referral partners aware of the freeze on certain measures. Make sure these stakeholders in SNFs or inpatient rehabilitation facilities understand that the measures are currently frozen, but that updates to the assessments are coming.  

Keep track of these important dates for when new measurement data will be publicly available. 

• Care Compare will be refreshed with 2023 Q3 data in April 2024. 
• The four long-stay measures discussed above will be frozen for three quarters until they are fully replaced in January 2025.  
• The Discharge Function Score reporting will begin in October 2024. 
• Staffing measures and ratings will freeze for three months starting in April 2024 to allow for the transition from RUG-IV to PDPM. A new methodology for this measure will be released in July.  
• PBJ data from Q4 of 2023 will be reported in July 2024.  

Developing and training your multidisciplinary team 

A sole MDS coordinator is not going to be able to manage all of the nuanced changes this update involves on their own. This update touches nearly every area of Skilled Nursing Facility billing, coding, assessment, and payment. It will take a multidisciplinary team coming together with the goal of keeping everyone a patient interacts with up to date on the changes and how they affect their daily tasks.  

Education is the first step and should be addressed immediately and continuously. All team members will need to understand how quality measures are calculated, the changes currently being implemented, and how this affects reporting. First and foremost, everyone in post acute care inpatient rehab facilities  need to understand that Section G is being completely replaced by Section GG, and the changes this switch implies for MDS assessments.  

Conclusions on Section GG and 2024 MDS Changes

When it comes to the measures that will be frozen for a time, tracking will still need to take place internally but will be unavailable in CMS or CASPER reporting. Facilities will need a way to monitor changes in resident’s’ key quality measures, like mobility, self-care, mood, or depression. If you have an internal analytics team or scrubber program, it will flag any measure the team is missing or coding incorrectly. Technology can be incredibly helpful in this process.  

Because significant change assessments are not scheduled, each facility will need a detailed process to determine when the assessment will take place and the three-day window that will be considered. Data will need to be captured throughout the three days. There are also certain US states that will have an additional assessment specific to that location.

Knowing the regulations in your state will be as essential for accurate reporting and reimbursement as capturing accurate data would be. Section GG scoring will depend upon it, and implementing a standardized assessment therapy providers in post acute care facilities can trust is crucial.