Quality Measures

QM User’s Manual GG Footnotes Clarified 

The Centers for Medicare & Medicaid Services (CMS) provided guidance on which section GG column will be used for new measures in the MDS 3.0 Quality Measures User’s Manual (v17.0), effective Jan. 1, 2025. The measures affected are also the four measures that were frozen (i.e., held constant) from April 2024 until January 2025:
  

• Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased

• Percent of Residents Whose Ability to Walk Independently Worsened 

• Percent of Residents With New or Worsened Bowel or Bladder Incontinence 

• Percent of Residents With Pressure Ulcers 

The following guidance was provided in the footnotes of each of the affected measures:

The GG item column (e.g., Admission, Discharge, OBRA/Interim) used for measure calculation is determined by the qualifying [reason for assessment] RFA of the target/prior assessment. If an assessment has more than one qualifying RFA, apply the hierarchy outlined below:
 

1. If A0310F = [10, 11], use Discharge items (e.g., GG0170B3).

2. Else, if A0310A = [02, 03, 04, 05, 06] and A0310B = [99], use OBRA/Interim items (e.g., GG0170B5). 

3. Else, if A0310A = [01] or A0310B = [01], use Admission items (e.g., GG0170B1). 

This footnote explains which GG item column (admission performance, discharge performance, or OBRA/interim performance) will be used based on the target and/or prior assessment’s qualifying RFA. Additionally, the footnote provides a hierarchy if the assessment is combined and has more than one GG column completed on the target or prior assessment. The guidance states to first look at A0310F; if this item is coded 10 or 11 for an OBRA Discharge, then the measure will use the discharge performance in column 3. If this assessment is not an OBRA discharge but is coded at A0310A as 02, 03, 04, 05, or 06, then column 5, OBRA/interim performance, is used. Lastly, if none apply and A0310A = 1 (OBRA Admission) or A0310B = 1 (PPS 5-Day), then use the admission performance in column 1.