Soon Section G will cease to exist. Are you prepared?

On Sept. 1, 2022, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS Nursing Home Comprehensive (NC) Item Set version 1.18.11  Nursing homes will be required to implement the v1.18.11 item sets—with their many changes—beginning Oct. 1, 2023.

Some significant changes include:

  1. Section G (Functional Status) will no longer exist! Some Section G items have been updated and incorporated into Section GG including two former Section G items, Functional Limitation in Range of Motion and Mobility devices.  Assessment windows for some item sets will be adjusted.
  2. Section GG takes central stage and  becomes critical to OBRA assessments and Interim Payment Assessments (IPAs).  Those facilities who have relied heavily on therapy to assess and code Section GG are now behind those like Premier Therapy’s partners who have embraced the collaborative effort in coding usual performance and have focused on nursing training on coding of Section GG elements.
  3. Items that will accommodate the Transfer of Health Information QRP quality measures have been added.
  4. Items that will accommodate an additional five categories of Standardized Patient Assessment Data Elements (SPADEs) have been added.
  5. PHQ-9 was changed to PHQ-2 to 9, which could shorten the interview to two questions in some cases.

We will look for the release of the updated RAI manual for further information regarding the changes.

Premier Therapy and our partnering facilities have been training for this since 2017.  We are ready for what’s to come.  Are you?

PEPPER Now Available: Have Concerns About Triggering in the Newly Released PDPM Areas?

The Q4FY21 release of the Skilled Nursing Facility (SNF) Program for Evaluating Payment Patterns Electronic Report (PEPPER) is now available. This newly updated version reflects recent changes made to more accurately highlight PDPM areas of concern.

PEPPER is an educational tool that summarizes provider-specific data statistics for Medicare services that may be at risk for improper payments. SNFs can use the data to support internal auditing and monitoring activities as part of their compliance program. The PEPPER Team does not provide PEPPERs to other contractors, although it does provide a Microsoft Access database to MACs and Recovery Auditors so areas of concern should be addressed.

The above PEPPER target areas were identified by CMS as being potentially at risk for improper Medicare payments. A high target area percent does not necessarily indicate the presence of improper payment or that the provider is doing anything wrong; however, under these circumstances, providers may wish to review their medical record documentation to ensure that the services their beneficiaries receive are appropriate and necessary, as well as to ensure that the documentation in the medical record supports the level of care and services for which they have received Medicare reimbursement.

The SNF PEPPER is available to the SNF’s Chief Executive Officer, Administrator, President, Quality Assurance and Performance Improvement Officer, or Compliance Officer through a secure portal on the website.

If you are concerned about outliers on your SNF PEPPER, ensure:

  • therapy/nursing staff have the skills necessary to provide          and document medically necessary treatments.
  • a triple check system is in place that monitors therapy, MDS and billing for accuracy

2022 Skilled Nursing Facility Prospective Payment System Proposed Rule

2022 Skilled Nursing Facility Prospective Payment System Proposed Rule

2022 Skilled Nursing Facility Prospective Payment System Proposed Rule Overview

On April 8, 2021, CMS issued a proposed rule that would update Medicare payment policies and rates for skilled nursing facilities under PPS for fiscal year (FY) 2022. In addition, the proposed rule includes proposals for the SNF Quality Reporting Program (QRP), and the SNF Value-Based Program (VBP) for FY 2022.

FY 2022 Proposed Updates to the SNF Payment Rates

On 10/1/21, the rates for Part A have a proposed increase of 1.3%, which equates to approximately $444 million more in payments to SNFs. These are the unadjusted rates that when multiplied by the case mix index values, determine each PDPM Case Mix Group rate.

Methodology for Recalibrating the PDPM Parity Adjustment

When finalizing PDPM, CMS stated that this new payment model would be implemented in a budget neutral manner.. Since PDPM implementation, currently available data suggest an unintended increase in payments of approximately 5 percent, or $1.7 billion in FY 2020. As with past payment model transitions, CMS has conducted the data analysis to recalibrate the parity adjustment used to achieve budget neutrality under PDPM. However, CMS also acknowledges that the COVID-19 PHE could have affected the data used to perform these analyses.

New Blood Clotting Factor Exclusion from SNF Consolidated Billing

The proposed rule includes establishing an additional category of excluded codes, specific to certain blood clotting factors and services for the treatment of hemophilia and other bleeding disorders, from consolidated billing requirements. This exclusion affects the Part A rates as the money from Part A to Part B, and as such, proposed adjustments to the Part A rates from the NTA and Nursing Components of PDPM are included.

Proposed changes in PDPM ICD-10 Code Mappings

PDPM utilizesICD-10 codes to assignpatients to clinical categories used for categorization under several PDPM components, specifically the PT, OT, SLP and NTA components. CMS is proposing several changes to the PDPM ICD-10 code mappings affecting the areas of sickle-cell disease, esophageal conditions, multisystem inflammatory syndrome, neonatal cerebral infarction, vaping-related disorder, and anoxic brain damage.

Skilled Nursing Facility Quality Reporting Program (SNF QRP) update

The SNF QRP is a pay-for-reporting program where SNFs who do not meet reporting requirements may be subject to a two-percentage point (2%) reduction in their annual update. CMS is proposing to adopt two new measures and update the specifications for another measure.

Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAI) Requiring Hospitalization Measure

The proposed measure uses claims data to estimate the rate of HAIs acquired during SNF care and result in hospitalization.  Some of the HAIs identified in this measure include sepsis, urinary tract infection, and pneumonia. The goal of the measure is to be able to assess and compare SNFs that have notably higher rates of HAIs acquired during SNF care and result in hospitalization. Implementation of the SNF HAI measure provides information about a facility’s adeptness in infection prevention and management and encourages improved quality of care.

COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure

This measure would require SNFs to report on COVID-19 HCP vaccination in order to assess whether SNFs are taking steps to limit the spread of COVID-19.. Under this proposal, SNFs would report the vaccination data through the Centers for Disease Control and Prevention National Healthcare Safety Network beginning October 1, 2021.

Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program

Proposal to suppress the SNF readmission measure in the SNF VBP Program

CMS is proposing to suppress the SNF 30-Day All-Cause Readmission Measure for the FY 2022 SNF VBP Program Year due to the significant effects of COVID-10 on the measure.

  • Under this proposed suppression policy, for all SNFs participating in the FY 2022 SNF VBP program, CMS would use the previously finalized performance period and baseline period to calculate each SNF’s risk-standardized readmission rate for the SNFRM, followed by assigning all SNFs a performance score of zero, resulting in identical performance scores and identical incentive payment multipliers.
  • CMS would provide each SNF with its SNF readmission measure rate in confidential feedback reports so that the SNF is aware of the observed changes to its measure rates, and rates would be publicly reported with appropriate caveats noting the limitations of the data due to the PHE.
  • CMS also outlines consideration for additional VBP measures, including: functional status, patient safety, and care coordination, as well as including measures expanded to all residents, not only Part A, and is requesting public comment.

HERE is a link to the CMS Fact Sheet.

Value-based care is here to stay

Value-based care is here to stay

Value-based care is here to stay … If you’re still in the fee-for-service boat, you’re going to drown,” said Tanner, also chief operating officer of Arkos Health

Excerpted from McKnights by Kimberly Marselas

Skilled nursing providers looking to take on risk for long-term viability need to start getting creative, warn two executives in the business of connecting payers and providers in value-based partnerships.

Any new payment alternatives offered by the federal government may offer too little, too late to help post-acute providers thrive after the pandemic, Brian Fuller, CEO of Integrated Care Solutions, said Tuesday. Instead of waiting for a lifeline, he urged providers to seek out and create shared-risk programs within their own networks.

“Whatever comes out of CMMI (The Centers for Medicare & Medicaid Services innovation branch) is highly likely to be directed either at the physician group model, where you’ve got to control a group of TINs (tax-payer identification numbers), which, of course, most SNF operators do not, or it’s going to be a payer-like model dressed up in fee-for-service clothing,” predicted Fuller, whose care management company supports a network of post-acute and hospital providers. “If that’s the trend, then you say, how do we find a way to play? I think it’s some of these creative, sub-cap risk arrangements…. There’s nothing preventing those kinds of relationships — you’ve just got to find the right partner.” 

His comments came during the 2021 Synergy Summit executive retreat held in Utah this week. Fuller was joined at a “Fireside Chat” by Eric Tanner, CEO of OnPointe, a skilled nursing operator that has transitioned into a broader company pursuing value-based options across the post-acute continuum.

Tanner referenced an earlier Synergy presentation by former CMS Administrator SeemaVerma, whom he described as saying healthcare was “desperate” for SNF providers willing to take on risk.

“Value-based care is here to stay … If you’re still in the fee-for-service boat, you’re going to drown,” said Tanner, also chief operating officer of Arkos Health, a new risk-bearing medical group integrating managed care, technology and clinical services. “Value-based care has been very difficult for our industry primarily because, as the CMS administrator mentioned today, the savings have come on the backs of post-acute.”

Navigating without strong VBP options

To better position themselves over the next five to 15 years, post-acute providers should focus on local and regional partnerships, which have become even more important as the number of truly national skilled nursing providers dwindles, Tanner said. His companies aim their efforts on specific states, with services designed to meet needs of the populations there. 

Fuller, meanwhile, suggested two specific strategies providers could use when offering to take on risk: shortening length of stay, in part by starting earlier the discharge planning process, which can add at least a day to resident stays; and building well-defined clinical service lines around conditions including congestive heart failure, pneumonia, sepsis and COPD.

Providers shouldn’t hold out for a bundle in which they can control Medicare or Medicaid dollars, Fuller reiterated. While some providers are successfully pursuing the ability to control Medicare lives through Institutional Special Needs Plans, other options remain limited. The Direct Contracting Model, for instance, previously offered a Medicaid Managed Care option, but CMS is not taking applications in 2022. 

That said, if a high-needs track for dual-eligibles comes back, it “could be a path forward for SNF operators to take risk,” Fuller said.

Pressure is growing on and within CMS to empower providers with more value-based payment opportunities as a way of ensuring they can continue to operate.

CMMI director Liz Fowler said last week that she expects her agency to lean heavily on value-based care, raising the possibility of making some models mandatory in the near future.

And a May report by Duke’s Margolis Center for Health Policy found that few VBP models “have been specifically developed for SNFs or with the goal of specifically improving both quality and costs at facilities.”

“VBP models have potential to supply more reliable revenue and support high-quality care, but more opportunities for SNFs to participate in VBP are needed if that potential is to be realized,” the authors reported, noting that a change as simple as streamlining the 3-day waiver process could encourage more providers to participate. “Most prior SNF-focused payment reforms have been pay-for-performance models, which have had modest results. There may be opportunities for more advanced VBP models, such as identifying how SNFs can be part of Medicaid ACO models. Any Medicaid VBP model has to be carefully designed so as to attract SNF participation given the expressed concern about Medicaid rates for long-stay residents.”

In the meantime, Tanner, making a “Hamilton” reference, told providers it’s critical they get into the room where “it” happens. That means bringing the right metrics to payers more concerned with medical loss ratios than MDS data — and then offering to share the risk of caring for high-cost populations.

Executing successfully could provide a cushion against occupancy that may never fully rebound, he added.

“From a performance perspective, if they have a portion of your risk … you’d certainly feel more confident if they had skin in the game and you’d utilize them more, which is sort of the win-win we’re going for,” Tanner said. “I believe that truly getting in front of your payers, the people that have money in their pocket and can put it into yours, and saying that you’re willing and able to get into a risk-type arrangement with them, that will make some noise.”