Q:
I have a resident who was discharged from Medicare A services, but then had a renewed skilled need and will receive skilled speech therapy services. How do I code section GG if we are not addressing ADL needs (no PT or OT services)?
A:
All column 1 – Admission Performance questions in section GG must be assessed to establish the “usual performance”, whether you are addressing them or not. As far as goal setting is concerned, goals can be set for improvement, maintenance, or even decline in each area as applicable to the resident. Remember, while establishing discharge goals for multiple activities is encouraged, you are only required to select 1 self-care or mobility goal and care plan it.
Blog by Eleisha Wilkes, RN, RAC-CTA, Proactive Medical Review
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