The Critical Role of Section GG in Nursing Home Medicaid Reimbursement
For skilled nursing facilities (SNFs), precise and comprehensive documentation isn’t just a regulatory requirement—it’s a driver of financial stability. One essential piece of this puzzle is Section GG of the Minimum Data Set (MDS). This section directly influences reimbursement rates under the Patient-Driven Payment Model (PDPM) as well as Case-Mix for many state Medicaid programs.
What Is Section GG?
Section GG, titled “Functional Abilities and Goals,” evaluates a resident’s capacity to perform self-care and mobility tasks. It captures the level of assistance required for activities such as:
- Self-Care: Eating, grooming, bathing, and toileting.
- Mobility: Lying to sitting, transferring, walking, and wheelchair use.
Each task is scored on a scale from 1 (dependent) to 6 (independent), with higher scores indicating greater functional independence.
Section GG’s Impact on Medicaid Reimbursement
Thirty-five states either plan to or already use a version of PDPM for Medicaid rate setting – the majority of which utilize the Nursing component alone. This means that much like late loss ADLs under RUG III or RUG IV, the Nursing function splits now play a significant role in state-based case-mix calculations, which directly determine a facility’s reimbursement rates.
How the Nursing Function Score Is Calculated
The nursing function score is determined by summing or averaging specific self-care and mobility tasks:
- Self-care: Eating
- Self-care: Toileting hygiene
- Mobility: Average of “Sit to lying” and “Lying to sitting on side of bed”
- Transfers: Average of “Sit to stand,” “Chair/bed-to-chair transfer,” and “Toilet transfer”
| Section GG items | Score | |
| GG0130A | Self-care: Eating | 0-4 |
| GG0130C | Self-care: Toileting hygiene | 0-4 |
| GG0170B | Mobility: Sit to lying | 0-4 (avg. of 2 bed mobility items) |
| GG0170C | Mobility: Lying to sitting on side of bed | |
| GG0170D | Mobility: Sit to stand | 0-4 (avg. of 3 transfer items) |
| GG0170E | Mobility: Chair/bed-to-chair transfer | |
| GG0170F | Mobility: Toilet Transfer | |
These scores categorize residents into different PDPM Nursing groups, each with a corresponding Case Mix Index (CMI). The function splits help classify residents into the appropriate reimbursement tier, directly impacting payment rates. For example, the state of Washington has published the following weights.
| Nursing Group | Function Score | Nursing CMI |
| ES3 | 0-14 | 3.84 |
| ES2 | 0-14 | 3.29 |
| ES1 | 0-14 | 2.77 |
| HDE2 | 0-5 | 2.27 |
| HDE1 | 0-5 | 1.88 |
| HBC2 | 6-14 | 1.76 |
| HBC1 | 6-14 | 1.52 |
| LDE2 | 0-5 | 1.97 |
| LDE1 | 0-5 | 1.64 |
| LBC2 | 6-14 | 1.63 |
| LBC1 | 6-14 | 1.35 |
| CDE2 | 0-5 | 1.77 |
| CDE1 | 0-5 | 1.53 |
| CBC2 | 6-14 | 1.47 |
| CA2 | 15-16 | 1.03 |
| CBC1 | 6-14 | 1.27 |
| CA1 | 15-16 | 0.89 |
| BAB2 | 6-14 | 0.98 |
| BAB1 | 6-14 | 0.94 |
| PDE2 | 0-5 | 1.48 |
| PDE1 | 0-5 | 1.39 |
| PBC2 | 6-14 | 1.15 |
| PA2 | 15-16 | 0.67 |
| PBC1 | 6-14 | 1.07 |
| PA1 | 15-16 | 0.62 |
Example of Reimbursement Impact
Consider a case with a function score of 15-16 and a nursing group of a PA1 with a weight of 0.62. If that same case was more dependent and had a function score between 6-14, they would qualify into PBC1, which carries a much higher case-mix weight of 1.07—substantially increasing reimbursement.
Additionally, function scores influence eligibility for specific nursing components. For instance:
- A resident receiving IV fluids may qualify for Special Care High, but if their function score is 15 or 16, they would be categorized under Clinically Complex instead, resulting in a lower case mix index.
- Conditions like cerebral palsy, multiple sclerosis, or Parkinson’s disease must have a function score of 10 or lower to qualify for Special Care Low; otherwise, they fall into the Clinically Complex category.
Best Practices for Maximizing Reimbursement Accuracy
To ensure optimal reimbursement, SNFs should:
- Establish clear documentation policies: Develop standardized procedures for MDS data collection, ensuring all staff, including CNAs, understand the importance of accurate Section GG documentation. Training and periodic audits can help identify inconsistencies and maintain compliance.
- Conduct strategic interim assessments: If a resident’s functional status changes significantly between scheduled assessments, facilities should perform interim assessments to reflect the most accurate case mix classification. This practice is particularly important in daily weighted CMI states (Kentucky, Iowa, Maryland, Tennessee, and more) where timely updates can have a major impact on acuity capture and reimbursement.
- Leverage daily point-of-care (POC) charting to support care planning and CMI optimization. While CNA documentation can be inconsistent and add workload, the ability to identify meaningful, yet subtle shifts outweighs the challenges. You can’t manage what you don’t track and enhancing documentation with training and automation can improve data reliability.
- Use technology to enhance data tracking: Implementing software solutions like MedaSync that integrates daily point of care charting along with real-time clinical documentation analysis and AI-audits can automate the process of identifying patterns, progress, subtle changes and discrepancies. This helps clinical teams proactively adjust interventions, care plans, and assessment timing in a timely manner.
Conclusion
Accurate documentation of Section GG functional scores is critical for optimizing Medicaid reimbursement in skilled nursing facilities. Given the direct impact of function scores on case-mix calculations, clinical reimbursement teams must implement clear documentation policies, closely monitor assessment windows, and strategically capture resident function changes. Small variations in functional independence can significantly alter case-mix scores, making it essential for MDS coordinators and care teams to track and document resident abilities consistently. By leveraging daily point-of-care charting and proactive assessment strategies, facilities can ensure they receive appropriate reimbursement while maintaining compliance with state Medicaid guidelines.
To learn more about MedaSync’s automated functional analysis software features, contact us here to request a product demonstration.
