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Clarice Grote, MS, OTR/L

Clarice Grote, MS, OTR/L

Everything You Need To Know About Section GG

Section GG is a standardized assessment utilized by the Centers for Medicare and Medicaid Services (CMS) in post-acute care settings. The assessment measures a patient’s need for assistance with self-care and mobility while also documenting the patient’s prior level of function. Post-Acute Care settings consist of Long-Term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), and Home Health (HH).

Understanding how to score Section GG accurately is vital for reimbursement and quality measurement and is a fantastic tool to highlight the value of occupational therapy services in post-acute care settings.

What is Section GG in Medicare?

The Centers for Medicare and Medicaid Services (CMS) utilize Section GG to assess patient care and function across post-acute care settings. It is now also utilized to influence payment and reimbursement under the Inpatient Rehab Facility Prospective Payment System (IRF PPS) and the Patient Drive Payment Model (PDPM) in skilled nursing facilities.

This is why accurate scoring is essential when it comes to Section GG because it can literally impact how much you get paid and whether or not a facility can afford to provide services to a patient.

The IMPACT Act of 2014 required CMS to develop a set of standardized outcome measures in post-acute care. For many years, CMS has required functional tests as part of their admission and discharge assessments such as the Functional Independence Measure (FIM) in inpatient rehab, or the M1800 items in home health.

However, before Section GG‘s implementation, all of these items had different definitions, and different scoring mechanisms and didn’t allow CMS to track patient progress from setting to setting. Essentially, CMS was comparing apples to oranges versus apples to apples. Thus, preventing comparison or consistency.

CMS wanted a universal language to track how patients improve/decline as they move through the post-acute care continuum. By collecting this information and data, CMS can evaluate the quality of therapy and services provided to a patient and make inferences about how these services do or do not improve function and mobility for patients.

Relationship With Reimbursement

CMS acknowledges that patients with limitations are at an increased risk of function-related decline or complications due to impaired mobility. So this measure is intended to help facilities identify the amount and type of services a patient requires.

Additionally, CMS recognizes that patients with a lower functional level typically have higher utilization. If a patient is scored as too functional on the initial assessment, Medicare will not provide sufficient reimbursement for all the services that the patient requires.

Currently, this measure is only utilized to directly influence reimbursement in skilled nursing facilities under the Patient-Driven Payment Model (PDPM) and Inpatient Rehab Facilities. However, it is anticipated the measure may later influence reimbursement in other post-acute care settings.

The assessment results can also be utilized to help trigger decision-making regarding steps that need to be taken to prevent adverse complications due to impaired mobility, such as referrals to occupational therapy or additional monitoring.

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Quality Ratings and Outcomes

Section GG is utilized to evaluate outcomes and quality metrics in LTCH, IRF, and SNF. While it does not currently influence quality outcomes in home health, it is still required as part of the OASIS assessment. Quality metrics are important because they directly and indirectly impact reimbursement in all post-acute settings.

Having a consistent way to assess the quality of care provides agencies with the necessary feedback to improve their overall care. Since these quality measures are publicly reported, it gives agencies feedback about how they stack up against others in the area. It also allows patients and facilities. to make informed decisions about what providers to utilize in their recovery. So, better quality outcomes can improve patient referrals and, therefore, revenue.

CMS intends for Section GG to improve care coordination and discharge planning. The information agencies report helps CMS make alterations to payment models. CMS is implementing quality measures that require reporting on the transfer of information between settings in 2022. As value-based purchase models expand, quality outcomes will also be tied to reimbursement through bonuses or penalties.

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Coding and Scoring Section GG

Section GG is assessed at admission and discharge at a minimum in each post-acute setting. Occasionally it is used during reassessments or recertification. Section GG is intended to be an interdisciplinary assessment that is collected over the first 3-5 days of admission. Gathering information from multiple sources is important for accurately reporting the patient’s function.

When scoring Section GG, the clinician should not score the patient’s best or worst performance. The scores reported should reflect the patient’s usual performance, meaning how the patient performs more than 50% of the time.

The way Section GG is scored does vary slightly from how an occupational therapist would typically record the self-care items and assist levels. So it is critical that clinicians take the CMS training prior to scoring Section GG to ensure accurate information is reported.

Each item is scored on a 1-6 scale, with 6 being the most independent and 1 being the most dependent. So, the higher the overall score, the more functional and mobile the patient is. Scores are primarily based on the level of assistance required. Activities may be completed with or without assistive devices.

Section GG Scoring Definitions:

6-Independent – Patient/resident safely completes the activity by him/herself with no assistance from a helper.
5-Setup or clean-up assistance – Helper sets up or cleans up; patient/resident completes activity. Helper assists only prior to or following the activity.
4-Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient/resident completes activity. Assistance may be provided throughout the activity or intermittently.
3-Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.
2-Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
1-Dependent – Helper does ALL of the effort. Patient/resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient/resident to complete the activity.

If the activity was not attempted, code reason:

07-Patient/resident refused
09-Not applicable – Not attempted and the patient/resident did not perform this activity prior to the current illness, exacerbation, or injury.
10-Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88-Not attempted due to medical condition or safety concerns

The activity not attempted codes or ANA should be used sparingly. In some settings, the use of an ANA code automatically defaults to a 1 or dependent for quality metrics and overall functional scores. While observation is the best way to score these items (as discussed below) you are able to score GG items based on subjective questioning. So, if at all possible, a score of 1-6 should be entered unless the ANA code is the absolute best option.

CMS has great Section GG training that is FREE! I highly recommend all clinicians complete the training. The CMS videos below are also helpful for quick reviews.

Observation is Key

To ensure accuracy, have the patient engage in the activity before providing any cues or physical help. CMS does allow scoring to be completed through subjective interviews with the patient, hired help, or family, but observation is always the best way to identify the patient’s true functional status.

When assessing the patient, keep in mind that to be scored as independent (6), the patient must complete all elements of the task including gathering necessary equipment. So, while it may be tempting to hand a patient their shoes or eyeglasses or provide a reminder to keep one hand on the bed for a transfer, this would be seen as assistance and result in a 5 or lower score depending on the assistance provided.

During the assessment, only assist the individual if it is necessary for the task to be completed safely. A patient’s safety should never be put in jeopardy in order to try and achieve a more functional score on Section GG.

Also, do NOT provide assistance and then score the patient based on what you think they would be able to do. Assuming the patient is more functional than they appear does not help the patient or the facility.

Ideally, education or interventions would not start until Section GG scoring is completed. This does not mean therapy should be delayed! Okay, let’s finally dive into the 3 main sections of Section GG.

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GG0100. Prior Functioning and GG0110. Prior Device Use

GG0100 Prior functioning includes reporting a patient’s prior self-care abilities, indoor mobility (ambulation), stairs, and functional cognition. These items are scored using the following:

  • 3, Independent, if the patient or resident completed the activities by themselves, with or without an assistive device, with no assistance from a helper.
  • 2, Needed Some Help, if the patient or resident needed partial assistance from another person to complete activities.
  • 1, Dependent, if the helper completed the activities for the patient or resident.
  • 8, Unknown, if the patient’s or resident’s usual ability prior to the current illness, exacerbation or injury is unknown.
  • 9, Not Applicable, if the activity was not applicable to the patient or resident prior the current illness, exacerbation or injury.

At admission, Section GG includes GG0110 where data is collected on the patient’s prior device use including manual wheelchair, motorized wheelchair or scooter, mechanical lift, walker, and orthotics/prosthetics. This section is scored as check boxes for all that apply, or “Z” for none of the above.

GG0110. Prior Device Use with Information from Multiple Sources. (3:58)

GG0130. Self-Care

Self-care items are the same across settings except for LTCH, where “bathing” includes only the upper body. LTACH does not report upper and lower body and footwear (F, G, and H). Self-care is the most obvious section to be completed by an occupational therapist due to their expertise in function and activities of daily living.

Some important notes:

  • Bathing: does not include washing hair.
  • Upper Body Dressing: bra, dress, LTSO, abdominal binder, etc. Cannot be scored on the use of hospital gown
  • Lower Body Dressing: includes donning lower limb prosthesis, knee braces, and shrinkers
  • Toileting: Includes the ability to clean and use ostomy but does not include changing the ostomy bag. If they have an indwelling catheter, score on assist required for BM.
  • Footwear: AFO, compression stockings

Check out these trainings from CMS

Image is from the CMS OASIS-D Manual but descriptions are the same in all settings except LTCH.

GG0170. Mobility

These are the mobility items below. Images are from the OASIS-D Manual, but the descriptions are the same in all settings except LTCH. Occupational therapists can score the mobility section. Section GG is not assessing gait pattern or any other item that may seem more physical therapy focused (although assessing gait is still in the OT Scope of Practice).

Occupational therapists often observe many of the mobility items while completing a functional assessment. That said, this is an interdisciplinary assessment so it is good to take data from multiple clinicians in order to gather the most accurate score for the client’s average status.

Here are some of the mobility item-specific training for mobility from CMS.

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Does Section GG have anything to do with the FIMTM?

Yes! Section GG replaced the Functional Independence Measure (FIMTM) in inpatient rehab facilities (IRF). The FIMTM was not utilized in all post-acute settings.

Additionally, the FIMTM had different scoring from similar assessments in other settings, and many practitioners complained about the lack of sensitivity or the grouping of certain activities together.

Removing the FIMTM when adding Section GG helps ensure CMS is not adding unnecessary regulatory burden by having practitioners score both assessments.

Section GG is a standardized assessment implemented by CMS in post-acute care. The assessment measures a patient’s need for assistance with self-care and mobility while also documenting the patient’s prior level of function. OT is vital for accurate scoring. Learn why.

The Role of Occupational Therapy in Scoring Section GG

Understanding the relationship between Section GG, reimbursement, and occupational therapy is critical in advocating for occupational therapy’s involvement early in the case.

If the OT practitioner is not the clinician completing the initial assessment, the practitioner should still share their findings with the reporting clinician. Occupational therapy practitioners are experts in self-care and functional mobility. Therefore, they are the perfect professionals to assess Section GG in collaboration with other professionals.

Why You Need an OT for Accurate Scoring of Section GG

Occupational therapy practitioners are generalists by trade. They are experts in task analysis, problem-solving, and plan development. All OT practitioners (OTP) have training in self-care, activities of daily living, instrumental activities of daily living, functional cognition, vision, mobility, falls, mental health, and so much more.

If you’re looking for the perfect practitioner to meet all of your patient’s needs, an occupational therapy practitioner is the way to go.

So, if your employer or company is struggling to meet quality benchmarks or is consistently falling short regarding reimbursement, give OT a seat at the table.

If you’re an OTP in one of those settings, speak with your managers and use the information in this article to explain why OT is the solution to their issues. You can view a facility’s quality scores online for free and see how your employer shapes up to others in the area.

OT’s Influence on Reimbursement and Outcomes

Accurate scoring at evaluation and discharge is important for accurate outcome reporting and revenue.

  • The patient is scored as more functional than their usual performance at the evaluation
    • Patient has little space to make progress.
    • Facilities will not receive adequate reimbursement for the services the patient needs.
    • Negatively impact quality outcome reporting.
  • The patient is scored as less functional than usual performance at discharge.
    • Pay may appear to have declined in function.
    • A patient may appear to have not improved at all.
    • Negatively impact quality outcome reporting.

All of the above outcomes are not ideal and can have serious consequences for revenue and outcome reporting if happening on numerous patients.

Employing and utilizing an occupational therapist can help eliminate many of the above scenarios as they are experts in assessing self-care and functional mobility.

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hi there,

I’m  Clarice

Occupational therapist & medicare specialist helping practitioners understand policy, engage in advocacy, and own their value!

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