Section GG Functional Coding Audit

Targeted audit template for reviewing Section GG self-care and mobility coding for consistency with usual performance rules, three-day observation expectations, and supporting documentation.

Audit Scope and Record Identification

• Resident and assessment identifiers match the record under review
• Assessment type and target Section GG items are clearly identified
• Look-back or assessment period reviewed is documented
• Source documentation reviewed is listed

Usual Performance Rule

• Coding reflects usual performance rather than best or worst performance
• Documentation supports the coded level across the observation period
• Assistance level is consistent across similar tasks and shifts
• Any variance in performance is explained and clinically reasonable
• Auditor notes on usual performance rationale

Three-Day Observation Rule

• At least three days of observation or documentation were available for review when applicable
• Observations from the three-day window were used to determine the code
• Observation dates fall within the relevant assessment window
• Number of observation days reviewed

Section GG Self-Care Coding Review

• Eating and oral hygiene codes are supported by documentation
• Toileting hygiene and shower/bathe self codes are supported by documentation
• Upper body dressing, lower body dressing, and putting on/taking off footwear codes are supported by documentation
• Self-care coding errors identified

Section GG Mobility Coding Review

• Sit to lying, lying to sitting on side of bed, and sit to stand codes are supported by documentation
• Chair/bed-to-chair transfer, toilet transfer, and car transfer codes are supported by documentation
• Walk 10 feet, walk 50 feet with two turns, and walk 150 feet codes are supported by documentation

Coding Accuracy, Deficiencies, and Closeout

• Overall Section GG coding is accurate
• Deficiencies identified
• Corrective action / education plan