As with most things that happened before COVID-19, it seems like the MDS item set updates for October 1, 2020 (FY 2021) happened in the mists of the far-away past. In fact, it was just December 20, 2019, and even in my webinar on upcoming MDS changes back in February, I warned that things could change. Little did I know how much! To briefly recap the original plan, it included the elimination of Section G and addition of Section GG to OBRA item sets, as well as additional items related to high risk medications, social determinants of health, and numerous updates to existing MDS sections. These updates were all put on hold by the Centers for Medicare and Medicaid Services (CMS) on March 27, citing stakeholder concerns about the changes.
While this delay gave skilled nursing facilities (SNFs) one less thing to think about as the impact of the pandemic hit facilities hard, October 1 brings with it a new Fiscal Year – and with the Patient Driven Payment Model (PDPM) approaching its first birthday, at least some changes were to be expected. CMS announced the revised update (v. 1.17.2) on May 15. While not the major change originally planned, this update will potentially have a significant impact on how your SNF manages the MDS assessment process – depending on what state you’re in.
MDS Updates – Know Your State’s Plan
Here’s the gist: Effective October 1, states will have the option to collect PDPM data on OBRA Comprehensive and Quarterly item sets. This data collection will enable the states to compare PDPM case mix classification with their current RUG-based case mix grouper, so that they can develop future PDPM-based Medicaid models. What this means from a practical standpoint is that the MDS items that are used for PDPM calculation will be added to the OBRA item sets. This includes Section GG, the primary diagnosis in Section I, and surgical procedures in Section J.
The tricky part: knowing whether or not your state will be requiring these additional items starting in October. On the MDS Vendor Call on June 11, CMS discussed the planned changes and released a Q&A document. From the Q&A:
“States are responsible for notifying and educating their providers if implementing these changes. In addition, states are responsible for notifying the vendor community so vendors may make the required changes to their software products for their state providers. CMS will provide vendors with updated technical data submission specifications to allow the calculation of PDPM along with updated and new edits. CMS will not be providing vendors with a list of states opting to calculate the PDPM.”
In other words, there will be no communication from CMS regarding which states have opted to collect PDPM data. While the states are responsible for communicating their plans to providers and vendors, the method of notification may vary from state to state. Our recommendation: be proactive; October 1 always seems to arrive more quickly than we think it will.
Here’s what providers should do sooner rather than later:
- Go to the source. Find out your state’s plan for FY 2021. Contact your State RAI Coordinator; they are the go-to person in your state for MDS related questions and should be able to direct you to the information you need. Be sure to download the current list of state contact information in the MDS 3.0 RAI Manual (Appendix B, in the Downloads section of the CMS web page). If you haven’t already, sign up for your state’s email list so you will be alerted when an update is released.
- Contact your Electronic Health Record (EHR) vendor. The vendors are already planning just as they do every year so that they can have their system updates ready to go live on October 1. Reach out to your EHR’s account representative to find out if they have received notice that your state will be opting to collect PDPM data. Your vendor may also have information on their website customer support portal or in regular blog posts and e-newsletters (just like PointRight does!).
- When in doubt, you could err on the side of caution and assume that your state will be opting for the new item set. Begin to educate your interdisciplinary team on the proper coding of these items anyway. This will also reinforce the accuracy of your PDPM assessments.
If your state uses the PDPM MDS items…
If your state opts to use the PDPM MDS items, remember that this doesn’t necessarily mean that your Medicaid case mix system will change starting in October. The process to switch Medicaid systems is a long and complicated one, and rest assured that the state will provide communication of any changes in enough time to address stakeholder comments and allow for adequate training. States will begin to collect PDPM data on the same MDSs that are being used to set RUG-based case mix. This will help them to analyze the effect of PDPM on the current nursing home Medicaid population, and plan their rate setting accordingly.
Submissions Today Affect Medicaid Rates Tomorrow
Since your MDS data submitted now will affect your Medicaid rates in the future, accuracy is especially important. Make sure you develop processes to collect PDPM related documentation on your long-term residents, and practice ahead of time in the following areas:
Your CNAs and other direct care staff over all shifts will need to get accustomed to capturing the resident’s usual performance for the 3 days ending with the Assessment Reference Date.
Sections I & J
Begin to discuss with your physicians, nurse practitioners, and physician’s assistants about each resident’s primary medical condition as well as any recent surgeries that continue to require care related to the procedure.
Restorative Nursing Programs
Remember that restorative nursing programs play a role in PDPM as they do in RUGs. If this area has gone by the wayside in your center (or has never gotten off the ground), this may be a great opportunity to take another look at restorative for your long-term residents and get a renewed program in place.
Get Ready for Oct. 1 Today
The key take-away: Don’t delay! We said this last year with the Medicare transition to PDPM, and it’s just as true today. Proactive planning (or at least knowing what to expect) will save time and stress come October.
P.S. If you are in a state that doesn’t currently use a RUG-based case mix system for Medicaid, don’t automatically assume you’re off the hook for these MDS additions. Your state just might decide to begin collecting PDPM data for analysis anyway, if their plan is to eventually transition to an MDS-based case mix system. Find out what your state’s plan is just in case!