Coming off the rollercoaster that has been the last 17 months, we are breathing a collective sigh of relief with most of our staff and patients vaccinated. And, while the pandemic isn’t entirely in the rearview mirror yet, taking that breath sure feels good. As we think about getting “back to business as usual,” it is time to gear up for CMS’ MDS Rule coming October 1, 2021. With a good understanding of the proposed rule and proposed updates to the Patient-Driven Payment Model (PDPM), a solid understanding of their implications, and some hints about where to focus to remain compliant, SNFs can be well-prepared. Jump to the Ten Tips…
Key changes to SNF Medicare Part A in the FY2022 Proposed Rule
As a reminder, the proposed rule issued last April indicates what CMS is planning, and the final rule is issued August/September to go into effect October 1, 2021. While nothing is certain yet, there is some good news. The Proposed Rule suggests an aggregate increase of $444 million or 1.3% of payment. (This does not include Value-Based Payment (VBP) reductions of $184.25 million and a $1.2 million decrease for new exclusion of blood clotting factors from your consolidated billing.)
We don’t see many changes to the PDPM (case-mix classification) apart from some ICD-10 mapping changes. Changes are intended to ensure codes are more appropriate and accurate. As usual, now is the time for all of us to get familiar with the proposed changes, so we’re ready to hit the ground running and code successfully come October 1.
The big change we do see is the parity adjustment. Last year, when CMS changed from RUG IV to PDPM, this change was supposed to be budget neutral. In reality, payments increased by 5%. To help solve this imbalance, CMS proposes to recalibrate case-mix indices (CMIs) across all PDPM components to reduce spend by – you guessed it – 5%.
Within the proposed rule, CMS gave us a few options for how they might accomplish this: a delayed implementation of blanket cuts or a phased implementation with smaller reductions per year. Most providers commented they would prefer a mix of both. We’ll stay tuned for the final rule.
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Prepare for Oct. 1 now to ensure compliance and proper reimbursement
If we take a closer look at where that 5% spending increase came from, we can essentially create a crystal ball and see areas CMS will be focusing on for compliance monitoring in the months ahead. In short, spending increases occurred in Speech-Language Pathology (SLP), nursing, and non-therapy ancillary (NTA) services. These three areas are heavily influenced by how SNFs capture both diagnosis and co-morbidities. The coding of the MDS itself will be key to getting appropriate reimbursement.
Digging into our MDS dataset at PointRight, examining data from Q3/Q4 2019 until Q1 2021, we’ve identified some trends, and this gives us a sense of where auditors might take a closer look in the future. Not surprisingly, most of these trends are related to COVID-19.
Here is a summary and ten quick tips to help stay compliant when October 1, 2021 arrives.
October 1 2021 MDS Updates – Ten Tips to Get Ready
- Depression severity score has risen rather dramatically. CMS will be taking a closer look, so the right documentation for a depression diagnosis is key to your success.
- Use of Extensive Services has risen as well. Correct documentation in care plans will be critical (see Tip #3 below).
- Rates of COVID-19 and isolation have, of course, increased throughout 2020 and early 2021 (though thankfully they are finally declining). For a COVID-19 diagnosis, SNFs should ensure they only code confirmed cases documented by the provider and review related codes (e.g., suspected exposure). When coding for isolation, remember to review to ensure you meet all four criteria. (see: RAI v. 3.0 Manual p. 0-5 for further detail).
- The SLP case-mix drivers have had several changes. Well-documented resident interviews are critical for a cognitive impairment diagnosis. SNFs residents will be well-served when they are closely observed eating to determine a swallowing disorder. SNFs should then review any resident with swallowing disorder for documentation of Speech Therapy evaluation and/or treatment as this has caught the attention of CMS.
- For depression and cognitive impairment, remember that interviews still must be attempted if the resident is at least sometimes understood. If an interpreter is needed but not available, answer “no” to the gateway question. If the interview was not attempted but should have been, code the gateway question “yes” and dash the interview items, but don’t complete the staff assessment. Always follow the RAI Manual instructions, and be sure to note the reason no assessment was done in the record.
- CMS will likely be looking at NTA as it has increased. SNFs will be well-served to closely document any NTA.
- As a reminder, code active diagnosis on MDS and redouble your efforts to follow the rules and capture all other diagnoses.
- For skilling in place (the three-day waiver), SNFs should ensure appropriate documentation, including a physician’s documentation of medical necessity and certification.
- Therapy delivery does not impact PDPM, but CMS is watching this area closely too. Keep your eyes open for inconsistencies between ADL coding and therapy documentation and potential inaccuracies in reporting functional outcomes (e.g., ADL functional score).
- Documentation for daily skilled services has not changed, but again, increase your efforts to make sure your documentation is air-tight. Interdisciplinary input ensures that no skilled needs are missed, and your patients are best served.
Measure correctly: proposed changes to the
SNF Quality Reporting Program (QRP)
There are two proposed new measures in the SNF QRP and one proposed change to an existing measure. Proposed new measures include SNF Healthcare-Associated Infections Requiring Hospitalization (SNF HAI) and COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP). The first is a claims-based measure that has several exclusions and includes risk adjustment. As of April 2022, this is publicly reported. However, in another COVID-related complication, the initial reporting period for this measure has actually passed. But to be ready for the future, now is the time for SNFs to re-examine and shore up infection prevention and control policies and address any issues.
To be ready for the HCP measure, SNFs will want to look at which groups of employees are covered under the measure (including volunteers, students, and trainees) and the reporting time frame. As a reminder, reporting is now mandatory and subject to a fine for those who do not comply.
What are the differences between MDS-based and Claims-based insights?
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With the existing measure, Transfer of Health (TOH) Information to the Patient—Post-Acute Care (PAC), the denominator changed to exclude patients discharged home with Home Health or Hospice services. (As a reminder, TOH Information measure reporting is on hold until at least two fiscal years after the end of the COVID-19 Public Health Emergency).
Due to the Public Health Emergency (PHE), the Skilled Nursing Facility 30-Day All Cause Readmission Measure (SNFRM) will be suppressed for the FY 2022 program year. All participating SNFs will receive a performance score of zero and will receive a 1.2% back from the 2% program withhold (SNFs subject to the Low-Volume Adjustment would receive the full 2%). Data will be reported with the notation that the measure was suppressed due to the PHE.
And CMS isn’t done yet. They are looking for input on future quality measures, and they can add up to nine new VBP measures. We will keep our eyes and ears open so we can weigh in and report back.
At the end of the day, comply, comply, comply
As always, compliance is key and annual updates to the Proposed Rule do not change the Requirements of Participation. Understanding the proposed changes above, now is the time for all SNFs to ensure consistency in compliance programs and that infection prevention and control are top-notch. Having these in order ensures your SNF is only compliant but also realizing your mission: providing the highest quality care to all residents.
Under PDPM, the non-therapy ancillary (NTA) component of reimbursement is tripled during the patient’s first three days.2 NTAs are conditions or comorbidities that add to a patient’s medical complexity, including things like opportunistic infections, HIV, and morbid obesity.
Increased synergy and information sharing between facilities
Presumably, we can all agree that sounds great in theory. But what does it actually mean? What specific ways can business intelligence and data help a SNF succeed? What results can someone realistically expect?
The minimum data set (MDS) assessment is the standardized and federally mandated clinical assessment of patients in your facilities that serves as the basis for the assessment and care planning process. For many patients, it also determines how much you’ll be reimbursed for their care.
PointRight, a Net Health data analytics company serving the skilled nursing industry, recently analyzed the 
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