Blog by:  Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC-A, Director of Regulatory Services, Proactive Medical Review and Jessica Cairns, RN, RAC-CT, CMAC, Clinical Consultant, Proactive Medical Review

July 29th, 2021, the Skilled Nursing Facility (SNF) prospective payment system (PPS) final rule was released. The rule, which goes into effect October 1, 2021, contained several updates, including factors affecting the usual payment rates, changes to diagnosis code mapping under the Patient Driven Payment Model (PDPM), and updates to both the SNF Quality Reporting Program (QRP) and SNF Value-Based Purchasing (VBP) Program. In addition, there was discussion surrounding the much-debated future PDPM parity adjustment which considers how SNFs will pay back the estimated $1.7 Billion “overpayment” for the first year of PDPM. In this blog, we will take a look at some of the biggest takeaways affecting our business and how to prepare.

Medicare Part A Rates

The Federal Per Diem rates are updated annually and take effect every October 1st. The typical “raise” SNFs receive is over 2%. This October, CMS anticipates a 1.2% rate increase, which equates to approximately $411 million more in PPS reimbursement as compared to 2021. This is based on an unadjusted increase of 2.7% reduced by both a 0.08% forecast error and a 0.07% productivity adjustment. The unadjusted per diem components of the rates for FY 2022 are listed below for both urban and rural providers. Of these rates, 70.4% of each component is adjusted by the wage index, which varies for each core-based statistical area. Listed below are the unadjusted rates for October 1st, 2021.

Unadjusted Federal Rate Per Diem-Urban

Unadjusted Federal Rate Per Diem-Rural

To give you an idea of the daily rate changes [urban] from FY2021 to FY2022, the PT component will increase $0.78/day, OT component to $0.73/day, SLP to $0.29/day, Nursing to $1.35/day, NTA to $1.02/day and the Flat Rate $1.22/day.

Delayed PDPM Parity Adjustment

SNF’s can celebrate this small victory. The parity adjustment was the top concession that CMS made in response to feedback on the proposed rule. This proposed rule left us with the potential of $1.7 billion (5%) parity reduction as CMS data supported that PDPM was not budget neutral as it intended. Said differently, depending on the different component combinations, the rate could have been $10-48.00 per day lower. While we get a pass this year, the rate recalibration will be re-examined in the Proposed Rule for FY2023.

ICD-10-CM code mappings for PDPM classification

The final rule contained updates to the mapping of several diagnoses and where they are classified under the PDPM. Some of the conditions affected include the following:

The FY 2022 PDPM ICD-10 Mapping file is available at https://www.cms.gov/files/zip/fy-2022-pdpm-icd-10-mappings.zip

HIV Add-On

The add-on for HIV was renewed and remains unchanged from prior years, including a 12.8 percent increase to the nursing component and an additional add-on of 8 points to the non-therapy ancillary (NTA) component. This add-on is based on claims data containing a diagnosis code for HIV or AIDS (B20).

VBP Program

CMS is suppressing the use of SNF readmission measure data for purposes of scoring and payment adjustments in the FY 2022 SNF VBP Program Year as a result of the PHE. They will use the previously finalized performance period (4/1/2019-12/31/2019 and 7/01/2020-09/30/2020) and baseline period (FY 2019) to calculate each SNF’s RSRR for the SNFRM and assign all SNFs a performance score of zero in the FY 2022 SNF VBP Program Year, resulting in all SNFs receiving an identical performance score and incentive payment multiplier. SNFs will not be ranked for the FY 2022 SNF VBP program.

CMS will reduce each participating SNF’s adjusted Federal per diem rate for FY 2022 by 2 percentage points and award each participating SNF 60 percent of that 2 percent withholding, resulting in a 1.2 percent payback for the FY 2022 SNF VBP Program Year. Those SNFs subject to the Low-Volume Adjustment policy (fewer than 25 eligible stays during the performance period) would receive 100 percent of their 2 percent withhold.

For FY2024, the performance period will be FY 2022 and the baseline period will be FY2019.

Currently, the SNF VBP program only includes the readmission measure. CMS is considering adding additional measures in the future. The table below shows the additional measures under consideration, in addition to these measures, CMS is also considering adding a measure related to staff turnover.

(SOURCE: Federal Register)

Consolidated Billing

Effective with items and services furnished after 10/01/2021, CMS has established an additional category of excluded codes for certain blood clotting factors for the treatment of patients with hemophilia and other blood clotting disorders, which includes those identified by HCPCS codes J7170, J7175, J7177-J7183, J7185-J7190, J7192-J7195, J7198-J7203, J7205, and J7207-J7211. The latest list of excluded codes can be found on the SNF Consolidated Billing website at https://www.cms.gov/​Medicare/​Billing/​SNFConsolidatedBilling.

QRP

The SNF QRP currently has 13 measures for the FY 2022 SNF QRP:

  • MDS Assessment-Based
    • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
    • Application of Percent of Residents Experiencing One or More Fall with Major Injury (Long Stay) (NQF #0674)
    • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    • Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF#2634)
    • Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF#2636)
    • Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF#2633)
    • Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF#2635)
    • Drug Regimen Review Conducted with Follow-Up for Identified Issues- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
    • Transfer of Health Information to the Provider Post-Acute Care
    • Transfer of Health Information to the Patient Post-Acute Care
  • Claims-Based
    • Medicare Spending Per Beneficiary (MSPB) – PAC SNF QRP
    • Discharge to Community – PAC SNF QRP (NQF #3481)
    • Potentially Preventable 30-day Post-Discharge Readmission Measure for SNF QRP

CMS will adopt two new SNF QRP measures beginning with the FY 2023 SNF QRP:

  • SNF Healthcare-Associated Infections Requiring Hospitalization measure –
    • Will use FY 2019 claims data to calculate this measure for the FY 2023 QRP.
    • This measure will be publicly reported beginning with the April 2022 Care Compare refresh.
  • COVID-19 Vaccination Coverage among Healthcare Personnel measure –
    • Will use data submitted to NHSN by SNFs to calculate this measure with an initial data submission period from 10/1/2021-12/31/2021.
    • Starting in CY 2022, SNFs will be required to submit data for the entire calendar year beginning with the FY2024 SNF QRP.
    • This measure will be publicly reported beginning with the October 2022 Care Compare refresh or as soon as technically feasible using data collected for Q4 2021 and the most recent quarter of data will be reported during each advancing Care Compare refresh.

In addition, CMS is also updating the denominator for the Transfer of Health Information to the Patient PAC measure to exclude residents discharged home under the care of home health or hospice service.

How to Prepare

Make plans to share this information and assess the impact on your facility over the next two months in preparation for the October 1 effective date.

Quick list of action items:

  • Review the rate changes including modifications to VBP adjustments, to determine the financial impact they will have on your organization
  • Incorporate updated rates into your budget and plan accordingly
  • Ensure the billing office is up to date on the current components that affect Medicare rates. This includes ensuring updates to billing software.
  • Discuss the changes in the ICD-10 mapping with the appropriate staff and include the new consolidated billing exclusions related to blood-clotting factors in that conversation.
  • Provide education to clinical staff on changes to VBP and QRP and verify you have processes in place to report all required information.
  • Ensure the infection control nurse has a process in place to report required vaccine information to the CDC.
  • Continue to monitor facility readmission rates and ensure a process is in place to mitigate unnecessary rehospitalizations.

References

 

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About Proactive Medical Review
HTS partners with Proactive Medical Review, a third party company who specializes in ensuring compliance with regulatory standards and promoting measurable care excellence. The team includes SNF experienced nurse, MDS, Health Facility Administrator, therapist and reimbursement specialists with experience serving in multi-site contract therapy operations, as corporate directors of quality, clinical program specialists, and Compliance Officers. Proactive is uniquely positioned to assist in managing the many changes and challenges facing providers partnered with HTS. Learn more about our commitment to compliance here.

On April 9, 2021, CMS issued a new Memo to State Survey Agencies (QSO-21-17-NH) resulting in an end to a few waivers which were granted under the PHE.

The below flexibilities will end effective 5/10/2021:

  • The emergency blanket waivers related to notification of resident room or roommate changes, and transfer and discharge notification requirements
  • The emergency blanket waiver for certain care planning requirements for residents transferred or discharged for cohorting purpose
  • The emergency blanket waiver of the timeframe requirements for completing and transmitting resident assessment information Minimum Data Set (MDS)

Changes in QSO-21-17-NH were updated on April 8, 2021 and made available to providers via this link: COVID-19 Emergency Declaration Blanket Waivers for Health care Providers. Please note, waivers that will end effective 5/10/2021 are found on pages 18-19 of the linked document are in red, strikethrough font

On April 8, 2021, CMS released the new Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Proposed Rule which, once finalized, is effective October 1, 2021. This proposed rule updates Medicare payment policies for facilities under SNF PPS for fiscal year 2022. The proposed rule also includes information for the SNF Quality Reporting Program (QRP) and SNF Value-Based Program (VBP) for FY 2022.

See below for the most significant areas of updates:

  1. FY 2022 updates to the SNF payment rates
  2. Methodology for recalibrating the PDPM parity adjustment
  3. Rebase and revision of the SNF market basket to improve payment accuracy under the SNF PPS
  4. New Blood Clotting Factor Exclusion from SNF Consolidating Billing
  5. Changes in PDPM ICD-10 Code Mappings – The ICD-10 code mappings and lists used under PDPM are available on the PDPM Website at: https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/SNFPPS/PDPM
  6. SNF QRP update – modification to the public reporting SNF quality measures
  7. SNF VBP Program proposal to suppress the SNF readmission measure

For more information on this proposed rule, please visit the Federal Register’s Public Inspection Desk under “Special Filings,” at http://www.federalregister.gov/inspection.aspx.

 

Blog by Cassie Murray, OTR, MBA, QCP, Chief Operating & Clinical Officer

As you may already be aware, CMS has finalized cuts in reimbursement for our Med B therapy codes (physician fee schedule codes). These reduced payments are set to begin ‪on‬ ‪1/1/2021‬. We have a short time to appeal to our lawmakers to ask them to support a delay in these cuts while we are in the midst of the PHE. The population that our team serves is the most vulnerable to decline and the impacts of COVID-19. Please consider the implications of how reduced reimbursement for important therapy services may reduce access to care for many Medicare beneficiaries. The cuts are expected to result in 9% reduction in PT/OT reimbursement and 6% reduction in ST reimbursement. These cuts are significant and will create a hardship nationwide for providing therapy services, especially in rural areas that already experience therapist shortages and difficulties with access to care. Reducing the reimbursement of critical therapy services only increases the challenges of providing quality services to our most vulnerable patients.

ACT NOW! Please reach out to your representative to request support for therapy services. We, at HTS, are an active member of the National Association for Support of Long-Term Care (NASL). NASL has prepared a letter for you to email your lawmakers to fix this policy through legislative action. We only have a few days to act! This is very time-sensitive and requires all of us to act as advocates for our patients, as well as our professions!

Please follow this link to reach out to your representatives:
https://app.govpredict.com/portal/grassroots/campaigns/dd7scnxz/take_action

Thank you in advance for your advocacy! This is a critical situation that requires all rehab professionals’ attention.
Please share this information with colleagues and family/friends. Now is the time that we need to come together to ask our representatives to support our services!

Cassie Murray, OTR, MBA, QCP
Chief Operating Officer, Chief Clinical Officer
Healthcare Therapy Services, Inc.

Blog by:  Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Director of Regulatory Services, Proactive Medical Review

On 08/17/2020 CMS announced that they are revising guidance on the expansion of survey activities to authorize onsite revisits and other surveys, and guidance was provided to State Survey Agencies (SA) on resolving previously “on hold” enforcement cases. A temporary expansion to the desk review policy was also announced.

Background & Recent Updates

On June 1, 2020 CMS issued survey reprioritization guidance to transition States to more routine oversight and survey activities once a State has entered Phase 3 of the Nursing Home Reopening Guidance. At that time, states were authorized to expand beyond conducting only IJ, Focused Infection Control, and Initial Certification survey, and were permitted to resume the following types of surveys, at the state’s discretion:

  • Complaint investigations that are triaged as Non-Immediate Jeopardy-High;
  • Revisit surveys of any facility with removed Immediate Jeopardy (but still out of compliance);
  • Special Focus Facility and Special Focus Facility Candidate recertification surveys; and
  • Nursing home and Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) recertification surveys in facilities where it has been over 15 months since the last standard survey.

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About Proactive Medical Review
HTS partners with Proactive Medical Review, a third party company who specializes in ensuring compliance with regulatory standards and promoting measurable care excellence. The team includes SNF experienced nurse, MDS, Health Facility Administrator, therapist and reimbursement specialists with experience serving in multi-site contract therapy operations, as corporate directors of quality, clinical program specialists, and Compliance Officers. Proactive is uniquely positioned to assist in managing the many changes and challenges facing providers partnered with HTS. Learn more about our commitment to compliance here.

On July 24, 2020 CMS released a SNF QRP COVID-19 Tip Sheet. Here’s what you need to know:

  • Starting on July 1, 2020, SNFs are expected to resume timely quality data collection and submission of measure and patient assessment data for the MDS/RAI.
  • Specific quarters requiring reporting of data for the QRP program for CYs 2019 and 2020 are listed below:October 1, 2019–
    • December 31, 2019 (Q4 2019)
    • January 1, 2020–March 31, 2020 (Q1 2020)
    • April 1, 2020–June 30, 2020 (Q2 2020)
  • The MDS should be submitted for all new admission records and discharge records that occur on or after July 1, 2020.
  • Timely submission and acceptance requirements of MDS data to meet the 80-percent threshold are unchanged. SNFs are required to submit at least 80 percent of the necessary data to calculate the SNF QRP quality measures.
  • Before QM data is publicly reported on Nursing Home Compare, SNFs have the opportunity to review and correct and/or preview their data. A quarterly Provider Preview Report can be accessed via the Certification and Survey Provider Enhanced Reports (CASPER) application which is accessible from a SNF’s “Welcome to the CMS QIES Systems for Providers” page. Full instructions are available here.

 

Did You Know?

As part of the HTS Partner Plus Program you get access to multiple MDS specialists and nursing consultants to assure your coding is accurate which not only impacts PDPM reimbursement but also QRP? Contact HTS Director of Clinical Outcomes today for more details at sheena@htstherapy.com.

On July 31, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates the Medicare payment rates and the quality programs for SNFs.

These updates include routine technical rate-setting updates to the SNF PPS payment rates, as well as finalizes adoption of the most recent OMB statistical area delineations and applies a 5 percent cap on wage index decreases from FY 2020 to FY 2021.

CMS is also finalizing changes to the ICD-10 code mappings that would be effective beginning in FY 2021, in response to stakeholder feedback. CMS projects aggregate payments to SNFs will increase by $750 million, or 2.2 percent, for FY 2021 compared to FY 2020.

Updated Base Rates for PDPM Components

For FY 2021, the unadjusted federal rate per diem for urban and rural will be as follows, prior to adjustment for case-mix.

TABLE 3: FY 2021 Unadjusted Federal Rate Per Diem – URBAN

Table 4: FY 2021 Unadjusted Federal Rate Per Diem – RURAL

Click here to view the SNF PPS Final Rule Fact Sheet.

Link to the Final Rule – http://www.federalregister.gov/inspection.aspx

Source: Centers for Medicare & Medicaid Services, www.cms.gov

CMS posted initial data analytics on COVID-19. Data was collected from nursing home reports to the CDC’s National Healthcare Safety Network. Data will be updated on a weekly basis moving forward.

COVID-19 Focused Survey Items for Nursing Homes to be Completed by July 31, 2020

Indiana COVID-19 Updates and Resources

Kentucky COVID-19 Updates and Resources

What can providers do?

For questions or additional information, contact your Regional Director or Cassie Murray.

Blog by Cassie Murray, OTR, MBA, QCP, Chief Operating & Clinical Officer

During the May 12th CMS Office Hours broadcast, CMS provided guidance for SNF therapists to include the time spent donning and doffing PPE in the MDS Section O minutes. Therapists should begin including this time in the total treatment time for each session. This topic is covered in the recorded podcast between time markers 3:02 and 3:54. The link below is to the recording and written transcript.

Tuesday, May 12, 2020, CMS Office Hours (ZIP)

For questions or additional information, contact your Regional Director or Cassie Murray.

Blog by:  Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Director of Regulatory Services, Proactive Medical Review

As part of President Trump’s Guidelines for Opening Up America Again, the Centers for Medicare and Medicaid Services (CMS) announced new nursing home reopening recommendations for state and local officials. These recommendations detail criteria for relaxing certain restrictions and mitigating the risk of resurgence, visitation and service considerations, and restoration of survey activities.

The guidance encourages state leaders to collaborate with the state survey agency and state and local health departments to decide how these criteria or actions should be implemented in their state and provides examples of how a State may choose to implement the recommendations, which includes options of states to require that all facilities go through each phase at the same time, allowing facilities in a certain region within the state to enter each phase at the same time, or permitting individual facilities to move through each phase based on their status for meeting the criteria for each phase.

Click here to continue reading this blog.

 

About Proactive Medical Review
HTS partners with Proactive Medical Review, a third party company who specializes in ensuring compliance with regulatory standards and promoting measurable care excellence. The team includes SNF experienced nurse, MDS, Health Facility Administrator, therapist and reimbursement specialists with experience serving in multi-site contract therapy operations, as corporate directors of quality, clinical program specialists, and Compliance Officers. Proactive is uniquely positioned to assist in managing the many changes and challenges facing providers partnered with HTS. Learn more about our commitment to compliance here.