PDPM Coding Question – If MDS Section GG documentation information is not filled out, can we use section G documentation to code Section GG?

If MDS Section GG documentation information is not filled out, can we use section G documentation to code Section GG?

A:

The difference between Section G & Section GG is more than one letter.  Key variances include the steps for assessment, assessment/look-back periods, rating scales and scoring and activity definitions.  For Section G, the RAI manual instructs to code for the most support provided within the 7 day look-back period.  With Section GG Self Care, the RAI Manual states to record the resident’s usual ability to perform each activity for the assessment period of the first three days following admission or the last 3 days for an IPA.  Eating in Section G includes intake by tube feeding, TPN and IV fluids and Section GG does not.  If more than one helper is required, Section GG self-performance is considered dependent. GG also includes reasons an activity is not being attempted. Finally, Section GG includes IDT collaboration for determining usual performance.

Reference

Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from this site.