What CMS changes to MDS sections G and D will impact SNF care planning and reimbursement this fall?
by Pam Kaiser, MSN, RN
Okay, I will admit that this one almost got by me. Caught up in the Patient-Driven Payment Model (PDPM) whirlwind, I was focused on the post mortem of the first full quarter and just glanced at the email noting availability of the CMS version 1.18.0 of the MDS Item Set. Then, my colleagues started talking about it so I shook off my PDPM focused lenses and pulled up the new 10/1/2020 assessment file. Of course, these versions are drafts and subject to change, but looking at them always shines a light on the potential direction CMS is planning to take in the future. [ My colleague Jennifer Gross recently explored the impact of these changes in a live webinar. ]
Section G Goes Bye-bye
First big change: Section G Functional Status goes away, and Section GG Functional Ability and Goals takes center stage. With this change, CMS is clearly indicating that the Quality Reporting Program (QRP) will be the measure of quality outcomes. This shift should surprise no one. CMS has been moving towards measures of quality that cover the entire continuum of care and that knock down the silos of individual provider quality measurements. The ultimate goal is to have the ability to identify which provider does the best in managing outcomes for different patient cohorts.
If anything, providers should be pleased that the 2 tiers of functional measures will vanish. Anyone that has tried to get staff to correctly document functional status using MDS definitions understands that pleasure. It is nearly impossible to get staff to record the highest burden of care and now there is this other measure to capture? What is usual performance anyway? With different look-back periods and definitions? Much better to move to one measure of function… anyway, skilled nursing facilities (SNFs) were the outlier; other providers already use prior functional status as a baseline.
There are other obvious consequences to the change. States that use Section G in their Medicaid case mix will need to make some adjustments and of course, there will be changes to Five-Star that will need to be explained to stakeholders.
Section D Gets Split
Another change: Section D Mood is split into the PHQ-2 and PHQ-9. This section informs the Nursing component of PDPM that uses the end splits for Depression and can trigger the Mood State Care Area Assessment (CAA). Some have suggested that depression is under diagnosed in SNFs and that reducing the Mood interview to potentially two questions would further reduce identification. While depression might be under diagnosed in SNFs, using the coding of this section would not be the way to evaluate the issue.
Firstly, the coding is based on an interview of the resident. There are many variables that come into play like how the questions are asked, when they are asked, and who asks them.
Second, a patient can have a diagnosis of depression, score as not depressed on the PHQ-9, and therefore, not get the depression end split. This does not mean the resident was not diagnosed as depressed; it just means that the symptoms are controlled, and less nursing time is needed to care for that individual. Really, the PHQ-9 should identify potential symptoms of poorly managed or undiagnosed depression and not as a broad measure of depression in SNFs.
If using the PHQ-2 allows for an efficient screening of depressive symptoms, using it streamlines the interview and prompts probes only when needed. This saves our most precious resource: time.
Focused Data and Advanced Analytics
That the MDS drives care planning and reimbursement is well known; also well known, but sometimes overlooked, is the vast amount of data completed MDSs generate for research. Since it is a standardized, required assessment that is completed systematically, new data points can quickly amass to a significant database in a fairly short period of time.
Clearly, CMS is interested in social determinants of care. Based on the amount of discussion that has happened on this topic, many others are interested in the impact these determinants have on care outcomes as well. Likely to help answer these questions, the draft MDS expands the Ethnicity and Race sections; first by uncoupling them, and second, by adding more specific coding options. Also added to the draft MDS are areas linked to poor outcomes and increased expense like transportation, medication reconciliation, social isolation and health care literacy. When this data becomes available, analysis can be done to determine the impact these elements have on care and care outcomes in the SNF setting.
Eventually, this information will be combined with the standardized data that will be collected from all post-acute providers. CMS will be able to track which provider along the continuum produces the best outcomes with the least cost. When that happens, expect more payment reform regulations to follow.
Save the Date – Live Webinar on MDS Changes 2/20/2020
Join Pam Kaiser on Thursday, February 20, for a CEU webinar covering the expected impact on Skilled Nursing Facility reimbursement, quality reporting, and care planning.
Pam Kaiser, MSN, RN
Vice President, Provider Services, PointRight
Pam has enjoyed 27 years in the healthcare field. A second career for her, she worked her way from a certified nursing assistant through the long term care ranks to become a leader in clinical reimbursement and compliance for several large long term care providers. She has a B.A in Advertising from Michigan State University and an MSN in Community Health Nursing from the University of Southern Maine.