What Leaders Need to Know: MDS Updates

In December, the Centers for Medicare and Medicaid Services (CMS) posted a new DRAFT version of the 2020 MDS item sets (v1.18.0). This version is scheduled to become effective October 1, 2020.

Click here to review and download recent MDS updates from CMS.

In FY 2020, CMS implemented PDPM for Medicare Part A along with the MDS item set changes associated with this change. There are now specific MDS item sets that will calculate a 38 or 48-RUG category and specific item sets that only calculate PDPM payments.

For FY 2021 there will only be one item set that can calculate a 38 or 48-RUG category. All other item sets will not contain the Section G ADL data used for RUGs category calculations. The 5-day MDS became the MDS to set the payment rate for an entire Medicare Part A stay.

What follows are a few insights from our Reimbursement and Clinical Consulting team experts.

What MDS changes happened in December 2019?

CMS announced federal MDS assessments would no longer have Section G as of October 1, 2020. CMS released draft item sets, however, Pathway Health experts will review the RAI Manual’s final instructions to know what will happen for certain.

Currently, the following is what we can determine from the draft item sets:

  • No Section G for the following:
    • Any OBRA assessments – Admission, quarterly, annual, significant change in status, significant correction to prior comprehensive, or significant change to prior quarterly
    • Any PPS assessments – 5-day, interim payment assessment, or PPS discharge assessment
    • Any Tracking forms – entry, death in facility (Section G has not been a part of these “non-assessments.”)
  • Section G will continue to be part of the Optional State Assessment, however, G0110 Activities of Daily Living (ADL) Assistance for resident self-performance and staff support for only the four late loss ADLs (bed mobility, transfer, eating, and toilet use) will be included.
  • Two Section G items will be moved to Section GG on federal assessments:
    • G0400 Functional Limits in Range of Motion will become GG0115.
    • G0600 Mobility Devices will become GG0120.
  • Two Section G items will be eliminated on federal assessments:
    • G0300 Balance During Transitions and Walking.
    • G0900 Functional Rehabilitation.
  • The lookback period for Section GG items on OBRA federal assessments will be seven days.
  • Two Section GG items have been added to OBRA federal assessments:
    • GG0130I Personal Hygiene has been added to Self-Care.
    • GG0170FF Tub/Shower transfer has been added to Mobility.
  • Six Section GG Mobility items have been eliminated on OBRA federal assessments:
    • GG0170G Car transfer.
    • GG0170L Walking 10 feet on uneven surfaces.
    • GG0170M 1 step (curb).
    • GG0170N 4 steps.
    • GG0170O 12 steps.
    • GG0170P Picking up an object.


How does this impact skilled nursing providers?

The entire data collection process for the 5-day MDS is now “front-loaded.” LTC facilities need to collect and clarify all resident diagnoses and comorbidity information as well as obtain provider clarification as necessary to optimize PDPM reimbursement. Therapy time treating the resident no longer affects the Medicare payment rate.

The 2021 changes to the MDS item sets mean that State Medicaid agencies that use RUG reimbursement categories for Medicaid payments will need to make significant changes to their software or require providers to complete two MDSs each time an OBRA MDS is required, the OBRA assessment and the Optional State Assessment.

States that use RUG-III or RUG-IV Medicaid reimbursement systems will still need to code Section G on the Optional State Assessment (or other state-designated form) at the state-designated times to receive appropriate Medicaid reimbursement.

  • The OSA requires coding only for the four late-loss ADLs (bed mobility, transfers, eating, and toilet use). Individual states may require coding for additional ADLs.
  • Facilities will no longer need to code nor to obtain supporting documentation for any early-loss, mid-loss, or late-loss ADLs found in G0110 for any federal assessments beginning October 1, 2020. This will significantly reduce the documentation time for CNAs and staff nurses and the coding time for MDS nurses.
  • Facilities will need to code and obtain supporting documentation for Section GG Self-Care and Mobility for OBRA assessments beginning October 1, 2020. This will not only offset the time reductions related to Section G noted above but will also increase the coding time for MDS nurses.
  • Since introducing Section GG to the MDS 3.0, CMS’ intent has been that the coding would be based on the usual performance of the resident that would be assessed by an interdisciplinary team of qualified clinicians using direct observation as well as resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the three-day assessment period.
  • The RAI Manual defines a “qualified clinician” as a healthcare professional practicing within their scope of practice and consistent with Federal, State, and local law and regulations.
  • Self-care and mobility definitions and performance coding for Section GG differ greatly from Section G.
    • There will be a steep learning curve for CNAs and staff nurses if they are not already providing supporting documentation.
    • The MDS nurse will need to provide additional education and auditing.


How will the changes impact quality measures?

Quality measures will not be impacted by the FY 2020 changes to MDS data elements but the elimination of Section G for FY 2021 will have a significant impact on CASPER quality measures as the ADL items in Section G are the primary topic of or a risk adjustment factor for many quality measures.

There are five SNF Quality Measure programs – MDS 3.0 Quality Measures, Nursing Home Compare Quality Measures, SNF Quality Reporting Program (QRP) Measures, SNF Value-Based Purchasing (VBP) program measures, and the Five Star Quality Rating program on Nursing Home Compare.

Section G currently provides numerators, covariates, high-risk determinations, and exclusions for ten Quality Measures in three of the five quality measure programs. (See chart below.)

In calculating Quality Measures after October 1, 2020, CMS may substitute certain Section GG items for Section G items when possible, may place a one-quarter or longer “hold” on calculating some or all of the measures until sufficient data is available, may remove some measures, may introduce new measures.


QMs that Use
Section G ADLs
How Section G Is Used in the QM
QM Program
Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay)
NQF #0678
MDS 3.0 QM
Five-Star Quality Rating System
Percent of Residents Who Made Improvements in Function (Short Stay)
NQF: None
Numerator and covariate
MDS 3.0 QM
Five-Star Quality Rating System
Percent of High-Risk Residents With Pressure Ulcers (Long Stay)
NQF: 0679
High-risk determination
MDS 3.0 QM
Five-Star Quality Rating System
Percent of Low Risk Residents Who Lose Control of Their Bowel or Bladder (Long Stay)
NQF #0685
MDS 3.0 QM
Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay)
NQF #0688
MDS 3.0 QM
Five-Star Quality Rating System
Percent of Residents Whose Ability to Move Independently Worsened (Long Stay)
NQF: None
Numerator and covariates
MDS 3.0 QM
Five-Star Quality Rating System
Number of Hospitalizations per 1,000 Long-Stay Resident Days
NHC Claims-Based QM Five-Star Quality Rating System
Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
NHC Claims-Based QM Five-Star Quality Rating System
Percentage of Short-Stay Residents Who Have had an Outpatient Emergency Department Visit
NHC Claims-Based QM Five-Star Quality Rating System
Percentage of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission
NHC Claims-Based QM, Five-Star Quality Rating System


Leadership Considerations:

For now, facilities need to focus on diagnosis coding, and following the various rules that affect diagnosis sequencing and management, such as the RAI manual, the Medicare Claims processing manual, The Medicare benefit Policy manual and the ICD-10 CM Official Coding Guidelines.

  1. In states that use RUG-III or RUG-IV for Medicaid reimbursement, pay close attention for announcements from the state Medicaid agency and the state RAI Coordinator regarding any changes.
  2. Look at current supporting documentation systems for Sections G and GG and use a QAPI process for identifying strengths, weaknesses, and opportunities for improvements.
  3. The Interdisciplinary Team should be fluent regarding MDS coding instructions, documentation requirements, quality measure impact, and reimbursement. Invest in the education of the staff.
  4. The Leadership Team should be fluent regarding federal and state regulatory requirements associated with assessments and care planning as well as the provider and public QMs and their data sources.
  5. Follow the news for your State with your local nursing home professional organization. Feel free to reach out to your State MDS Coordinator with your questions.
  6.  Stay tuned to Pathway Health communication for educational opportunities as CMS releases more information about the coming changes.

NOTE: When CMS released the DRAFT version of the 2020 MDS item sets on December 20, 2019, they also stated the MDS 3.0 Item Set Change History for October 2020 report would be posted to their website shortly.  On January 23, 2020, a CMS press release announced the 43-page DRAFT document was ready.

Providers can download the sets and the change history at keeping in mind both are DRAFT documents.

Pathway Health consulting services provide your organization the expertise to enhance reimbursement, minimize risk and ensure quality clinical outcomes to reach your desired goals.

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Karolee Alexander
Director of Reimbursement and Clinical Consulting

Louann A. Lawson
BA, RN, RAC-CT Clinical Reimbursement Team Leader/Clinical Educator