Now available! New Provider Data Catalog makes it easier to search and download publicly reported data. Also, Medicare’s Compare sites have been improved.

Notice of Upcoming SNF QRP Measure Removals – January 2024

The Centers for Medicare & Medicaid Services (CMS) is alerting Skilled Nursing Facility (SNF) providers of upcoming measure removals from the SNF Quality Reporting Program (QRP). The following quality measures are planned for removal from the iQIES Review and Correct Reports, Facility-Level Quality Measure (QM) Reports, and Resident-Level QM Reports in January 2024:

  • Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
  • Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients
  • Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients

Once removed from reports, users will no longer have access to any data or measure results for these measures.

Click here to read more.

Blog by: Stacy Baker, OTR/L, CHC, RN, RAC-CT, Director of Audit Services, Proactive Medical Review

MACs have begun rolling out the mandated 5-Claim Probe and Educate audit and will eventually review claims for every eligible SNF in their jurisdiction. SNF certifications and recertifications are important elements of SNF Medicare stay compliance and will be considered as part of this review. In this blog, we’ll delve into the essential aspects of the SNF certification / recertification process, and share guidance and insights for assessing your process and ensuring compliance.

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.

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

 

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.

HTS has identified the top 5 therapy clinical outcome focus areas for 2021 based on our experiences from 2020 which makes us better equipped to overcome COVID-19 related obstacles. Furthermore, after attending a 15-hour training and certification process, HTS management staff have all become “PDPM Masters.” These additional “feathers in our cap” allow us to uniquely champion process improvement initiatives alongside your interdisciplinary team. As HTS continues to identify opportunities for clinical growth, a key process improvement area will be discussed each month.

 

This month’s clinical outcome focus area is:

Section GG Outcomes

Analysis of outcomes comes in many different forms. For CMS, outcome data is derived from coding in Section GG of the MDS. As we begin to see more medical review of PDPM claims, we have seen first-hand that section GG and documentation of collaboration of the patient’s usual functional performance is the golden ticket to defend our claims. As information and regulatory standards continue to evolve, HTS has concentrated therapist efforts and education to assure training and documentation standards of care align with Section GG regulations and standards.

Improving communication and processes between departments produces the best Section GG accuracy. The top three ways to improve Section GG Coding include:

1) Therapy use of the HTS Business Intelligence functionality via Net Health’s (formerly known as Optima) operating system provides a detailed analysis of the Section GG Daily Dashboard. This information is then used at the site level to identify facility-specific process improvement initiatives. The dashboard also allows the user to drill to the patient level, identify trends and/or outliers, and action plan as clinically indicated.

2) Facility staff rounding for OBRA ARD communication between the MDS and therapy department will be fine-tuned to assure best GG coding practices across all payors. To meet the state requirements for GG collection for OBRA assessments, processes to collect this information should be effectively communicated. We recommend that all IDT work together when possible, to code usual GG performance. When the therapy assessments align with the ARD, therapists can then contribute GG information for Med B, MGD B, Medicaid, and Private Pay so that collaborative coding is achieved.

3) Review of RAI item set definitions to master the intent of each GG item being coded. HTS encourages all section GG contributors to familiarize themselves with the item set definitions so that coding is as accurate as possible. This review is important because it helps secure proper reimbursement for the care being provided by your team.

  • For example, per the RAI, the admission assessment for wheelchair items should be coded only for residents who used a wheelchair prior to admission. If the patient did not use a wheelchair at prior level of function and declined in the hospital which then required the use of a wheelchair in the SNF, section GG0110 (prior device use) would be coded as “no.” This is coded as such since GG0110 is indicative of use prior to the current illness, exacerbation, or injury. Then, if during the SNF stay the resident is not learning how to self-mobilize using a wheelchair, the 5-day assessment for wheelchair use would also be coded as “no.” This then elicits a skip pattern on the MDS, no goal would be applied, and the answer would remain “no” on the discharge assessment.
As we continue to learn more about medical review focus areas, denials based on lack of supportive GG documentation continues to be an area for improvement. Good communication and processes are imperative to support your coding decisions.

Need a Powerful Therapy Partner? Contact Amanda Green, Executive Director of Strategic Development amanda@htstherapy.com for information about our contract therapy partnerships.

The fourth quarter fiscal year 2020 Program for Evaluating Payment Patterns Electronic Reports (PEPPER) are now available for skilled nursing facilities (SNFs) to download through the PEPPER Resources Portal. These reports summarize provider-specific data for Medicare services that may be at risk for improper payments. This data can be used to support internal auditing and monitoring activities.

To obtain your SNF PEPPER report, please follow the following steps:

  1. Visit the PEPPER Resources Portal
  2. Complete all the fields; and
  3. Download your PEPPER report

Click here to visit the PEPPER Resources Portal.

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

Now that routine surveys are beginning to take place in most states, it is important that vigilant infection prevention and control practices do not take a backseat to other survey-ready quality assurance activities. Notably, HHS announced a $2.0 billion payment incentive program (VBP) with $500 million per month for four months Sept. -December 2020 paid based on SNF performance in managing the rate of COVID-19 infections each month and the COVID-19 mortality rate for the month as compared to other facilities with similar community infection rates. Details are forthcoming on the specific formula to be used for distribution of funds, but it is anticipated that a facility may be excluded from receiving a portion of these funds if performing significantly worse than peers on these measures.

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.

SNF PEPPER summarizes data statistics which are obtained from paid SNF Medicare UB-04 Claims for SNF episodes of care that end in the most recent three federal fiscal years (the federal fiscal year spans October 1-September 30). The current version of PEPPER now available reviews episodes of care through quarter 4 of FY2019 including statistics for 2017, 2018, and 2019. SNFs are compared to other SNFS in three comparison groups: nation, MAC, and state. These comparisons enable a SNF to determine if their results differ from other SNFs and whether it is an outlier and/or at risk for improper payments.

Target Area Updates

The following RUGs focused target areas will be phased out for FY2020 as a result of PDPM: Therapy RUGS with High ADL, Nontherapy RUGs with High ADL, Change of Therapy Assessment, & Ultrahigh Therapy RUGS. These target areas are included in the current FY2019 report along with the target areas: 20-day episodes of care, 90+ day episodes of care, and a new target area: 3-5 day readmissions which reviews readmissions to the SNF following a 3-5 calendar day gap. Please note this target area will not reflect claims until FY2020 and is intended to give providers information on readmission practices before and after PDPM implementation in order to assess the level to which facilities “may attempt to circumvent interrupted stay rules.”

Please click here for a table of target area definitions and suggestions.

The July 2020 Nursing Home Compare refresh, including quality measure results based on SNF QRP data submitted to CMS, is now available.

The following SNF QRP measures will displayed on NH Compare during the July 2020 refresh.

  1. Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay). Q4 2018 – Q3 2019 (10/01/18 – 09/30/19)
  2. Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function . Q4 2018 – Q3 2019 (10/01/18 – 09/30/19)
  3. Medicare Spending Per Beneficiary-PAC SNF QRP. Q4 2016 and Q3 2018(10/01/16 – 9/30/18)
  4. Discharge to Community-PAC SNF QRP. Q4 2016 and Q3 2018(10/01/16 – 9/30/18)
  5. Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP. Q4 2016 and Q3 2018(10/01/16 – 9/30/18)

Visit the NH Compare website to view your updated quality data.

Article by Cassie Murray, OTR, QCP, IASSC CYB, Chief Operating & Clinical Officer, Healthcare Therapy Services, Inc.

On Friday 4/19, CMS released the pre-publication of the FY 2020 Skilled Nursing Facility Prospective Payment System Proposed Rule. As expected, the Patient-Driven Payment Model is confirmed to go into effect October 1, 2019.
SNF Proposed Payment Updates for FY 2020:

  • Proposed SNF payment update is 2.5% (increase of $887 million from FY2019)
  • The proposed updated Base Rates for the PDPM Components (unadjusted federal per diem rates for urban and rural):

TABLE 3: FY 2020 Unadjusted Federal Rate Per Diem–URBAN

TABLE 4: FY 2020 Unadjusted Federal Rate Per Diem-RURAL

SNF Quality Reporting Program:

  • For FY 2022, CMS proposes the adoption of two process measures:
    • Transfer of Health Information to the Provider-Post-Acute Care.
    • Transfer of Health Information to the Patient-Post-Acute Care.
  • CMS proposes to update specifications for Discharge to the Community SNF QRP Measure to exclude baseline nursing facility residents from the measure.
  • CMS proposes to collect standardized patient assessment data using MDS for all patients regardless of payer source.

PDPM Changes:

  • CMS proposes to change the SNF group therapy definition to match the IRF group therapy definition. This would allow for qualified therapists or assistants to treat two to six patients in a group performing the same or similar activities.
  • CMS proposes that non-substantive updates to ICD-10 codes used in PDPM be made through the PDPM website. Substantive changes would continue to be made through traditional notice and rulemaking processes. Non-substantive updates are to maintain consistency with the most recent ICD-10 code set.
  • CMS proposes updates to the regulation text to coincide with the assessment changes under PDPM:
    • Initial patient assessment regulation would state: “assessment schedule must include performance of an initial patient assessment no later than the 8th day of post-hospital SNF care”.
  • The Optional Interim Payment Assessment would be included in the regulation.

Stakeholder comments will be accepted until June 18, 2019.

Click here to view the CMS Fact Sheet.

Click here to view the FY 2020 Proposed Rule Pre-publication.