The Centers for Medicare & Medicaid Services (CMS) just recently released their Q2 OASIS Q&As providing insights into the latest updates on OASIS documentation.
The new set of Q&As provides important guidance specifically on updating the OASIS within (or after) the 5-day Request for Anticipated Payment (RAP) filing window and on scoring several M and GG items.
Here are selected specific questions about the GG items with very insightful answers:
Question 7: For GG0100 – Prior Functioning: Everyday Activities, does Code 1 – Dependent have the same definition as the Code 01 – Dependent for GG0130 – Self-Care and GG0170 – Mobility activities? Specifically, for GG0100, would Code 1 – Dependent be used if a patient previously required the assistance of two helpers to complete an activity?
Answer 7: Yes, for GG0100 – Prior Functioning: Everyday Activities Code 1 – Dependent is indicated if the patient required one helper to complete all the activities for the patient or if two people were required to assist the patient complete the activities.
Question 8: How should GG0100C – Prior functioning: Everyday Activities Stairs be coded if a patient uses a ramp to enter their home and does not use any other stairs?
Answer 8: GG0100C – Prior functioning: Everyday Activities Stairs, identifies the patient’s need for assistance with internal or external stairs (with or without a device such as a cane, crutch, walker, railing or stair lift) prior to the current illness, exacerbation or injury. The activity being assessed in GG0100C is going “up and down the stairs.” A ramp is not considered stairs for coding GG0100C. If the patient was able to go up and down stairs prior to the current illness, exacerbation, or injury, code based on the amount of assistance the patient required to complete the activity. If, even with assistance and/or devices, the patient was not able to go up and down stairs prior to the current illness, exacerbation, or injury, code 9 – Not applicable.
Question 9: A patient is admitted for home health services with quadriparesis from a previous spinal cord injury. Once an occupational therapist applied a universal cuff to the patient’s hand, the patient was able to eat the entire meal without further assistance. What is the performance code for GG0130A – Eating?
Answer 9: The intent of GG0130A – Eating is to assess the patient’s ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. In the scenario provided, if the patient only required assistance to apply a universal cuff, and no further assistance was required during the eating activity, code 05 – Setup or clean-up assistance. This is because assistance is required prior to or following the activity, but not during the activity.
Question 10: How should GG0130C – Toileting Hygiene be coded if a patient requires different types and amount of assistance after voiding versus after having a bowel movement?
Answer 10: The intent of GG0130C – Toileting Hygiene is to assess the patient’s ability to maintain perineal hygiene and adjust clothing (including undergarments and incontinence briefs) before and after voiding or having a bowel movement. When the patient requires different levels of assistance to perform toileting hygiene after voiding versus after a bowel movement, code based on the type and amount of assistance required to complete the ENTIRE activity. This is true even in scenarios where GG0130C – Toileting Hygiene is not completed entirely during one clinical observation.
GG0170I, GG0170J, GG0170K, GG0170L
Question 11: At SOC, if it is not recommended that a patient ambulate outside of home health visits, should the GG walking activities still be assessed and coded with a performance code or should an “activity not attempted” code be used?
Answer 11: Assessment of the GG self-care and mobility items is based on the patient’s ability to complete the activity with or without assistance and/or a device. This is true regardless of whether or not the activity is being/will be routinely performed (e.g., walking may be assessed for a patient who did/does/will use a wheelchair as their primary mode of mobility). If the patient is able to complete a walking activity with the assistance of one or two people, code based on the type and amount of assistance required even if walking is not being recommended or used as a functional mode of mobility outside of the home health visit.
Question 12: For the GG stair activities, is a patient permitted to take a seated rest at the top of a staircase, prior to descending, and still have stair activity be considered as completed?
Answer 12: For GG0170N – 4 steps and GG0170O – 12 steps code based on the type and amount of assistance required for the patient to go up and down 4 steps and 12 steps by any safe means, with or without any assistive devices (for example, railing or stair lift). Ascending and descending stairs does not have to occur sequentially or during one session. If the going up and down stairs occurs sequentially, the patient may take a rest break between ascending and descending the 4 steps or 12 steps.
Question 13: If a patient utilizes a wheelchair for mobility and is able to wheel 50 feet with 2 turns but is unable to wheel 150 feet, how should we code items GG0170S/SS1? There is not a skip pattern if one of the “activity not attempted” codes are coded in GG0170S, and the directions on the OASIS states for GG0170SS1 to “Indicate the type of wheelchair or scooter used”. Selecting one or the other (manual versus motorized) does not feel logical.
Answer 13: You are correct that there is no skip pattern for GG0170S – Wheel 150 feet and GG0170SS1 – Indicate the type of wheelchair or scooter used, unless GG0170Q – Does the patient use wheelchair and/or scooter is answered 0 – No. However, for the wheelchair items, a helper can assist the patient to complete the activity or make turns if required. Therefore, if the patient is unable to wheel the entire distance with or without assistance, the activity can still be completed and a performance code can be determined based on the type and amount of assistance required to complete the entire activity. If, in your scenario, the patient was unable to complete the 150 feet themselves GG0170S – Wheel 150 feet could still be coded with a performance code based on the type and amount of assistance required to complete the entire activity. Then, GG0170SS1 could indicate the type of wheelchair used.
How the GG Items Differ from M Items
There is a lot of confusion around answering GG and M items. The way to resolve this is to hone in on their differences.
While both GG and M items take into account various aspects including environmental factors and circumstances in the home, the GG items require a more narrow evaluation of only a specific activity, based on functional abilities and goals identified in the Start of Care (SOC) and Resumption of Care (ROC), and including the required assistance.
On the other hand, M items cover a broader spectrum to describe the patient’s ability to perform more than 50% of activities under one task at a given time period based on all available information, including evaluations and assessments.
How to Maximize Provider Support
While the accuracy of M and GG items relies heavily on the clinician’s ability to assess patients’ ability to perform certain activities and/or tasks, the reality is that this is a rather complex undertaking influenced by a number of factors. Hence, assessments for M and GG items are prone to result in many inconsistencies in the documentation.
Your QA program plays a vital role in making the OASIS assessment on M and GG items more cohesive by making sure clinicians’ assessment findings are supported on other medical documentation.
In addition, your OASIS QA provider must be knowledgeable and updated on key guidelines such as the OASIS Guidance Manual, the Quarterly OASIS Q&As, and the ‘Majority of Task’ convention for GG item assessment.
Beyond the routine OASIS review, your QA provider must be able to capture and analyze data pertaining to your documentation workflow and clinician charting performance to allow you to identify areas for improvement and work on clinician re-education, especially on answering the different sections of the OASIS.