Q&A: We had to dash a few GG items on the PPS Discharge assessment, is this going to count against us for SNF QRP?

Posted By: Carol Maher, RN-BC, CPC, RAC-MT
Post Date: 03/06/2019

Question: I have a resident who triggered in the CMS quality measure Application of Percent of Residents in LTCH with an Admission and Discharge Functional Assessment and Care Plan. Reviewing his 5-day assessment, section GG admission performance was completed, he had discharge GG goals coded and care planed.  But on his PPS Discharge assessment, some of the GG performance items were dashed. Did these dashes cause him to trigger this measure?

Answer: Yes, that SNF QRP Measure is a process measure.  If there are dashes in any of the admission performance items on the 5-day or the discharge performance items on the NPE, it will not trigger that the process was correctly completed.  Dashes in risk adjustment items, like height and weight can also cause the measure to show that the MDS was invalid for calculating the SNF QRP measures.  Sometimes, like those very quick admission/discharge or quick admission/death situations there will be items that will need to be dashed, because they had not been assessed.  Your facility is at risk for losing 2% of the annual Medicare payment update if over 20% of your assessments contain dashes in necessary items.

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