Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P)

On April 19, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1718-P] for Fiscal Year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). This proposed rule is part of our continuing efforts to strengthen the Medicare program by better aligning payment rates for these facilities with the costs of providing care and increasing transparency so that patients are able to make informed choices.  Additionally, effective October 1, 2019, CMS will begin using a new case-mix model, the Patient Driven Payment Model (PDPM), which focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment.

This fact sheet discusses three major provisions of the proposed rule: the proposed changes to SNF payment policy under the SNF Prospective Payment System (PPS), the SNF Value-Based Purchasing Program (VBP), and the SNF Quality Reporting Program (QRP).  This proposed rule includes policies that would continue a commitment to shift Medicare payments from volume to value, with the continued implementation of the PDPM, SNF VBP, and SNF QRP to improve program interoperability, operational quality and safety.

CMS created the Five-Star (5-Star) Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Updated twice in April 2019.

Fact Sheets

This section includes fact sheets on a variety of PDPM related topics.

• Administrative Level of Care Presumption under the PDPM
• PDPM Payments for SNF Patients with HIV/AIDS
• Concurrent and Group Therapy Limit
• PDPM Functional and Cognitive Scoring
• Interrupted Stay Policy
• MDS Changes
• NTA Comorbidity Score
• PDPM Patient Classification
• Variable Per Diem Adjustment

PDPM Frequently Asked Questions

This section contains frequently asked questions (FAQs) related to PDPM policy and implementation. The PDPM FAQs were updated on 4-4 and then again on 4-11.

To date, the accuracy of section GG (functional abilities and goals) hasn’t mattered from a payment perspective. Section GG doesn’t affect payment under the RUG-IV case-mix classification system, and the Skilled Nursing Facility Quality Reporting Program (SNF QRP) only penalizes providers financially for failing to meet the data submission threshold for required MDS data elements, including section GG items. In other words, completeness—not accuracy—is what allows providers to avoid the SNF QRP’s 2% payment cut every fiscal year.

As a result, many SNFs have relied exclusively on therapy to complete section GG, says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH. “However, CMS always intended section GG to be a collaboration that includes both nursing’s perspective and therapy’s perspective. PDPM will require providers to make good on CMS’s intent because section GG will affect three of the five case-mix-adjusted PDPM payment components: nursing, physical therapy (PT), and occupational therapy (OT).”

A significant percentage of nursing homes don’t take advantage of their CASPER (Certification And Survey Provider Enhanced Reports) reports, says Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.

“Almost every week when I walk into a new facility and ask for some of their CASPER reports, no one can provide them,” she explains. “For example, I may ask, ‘What does your Skilled Nursing Facility Quality Reporting Program (SNF QRP) Review and Correct Report show?’ Or ‘Can you get me a copy of your MDS 3.0 Facility-Level Quality Measure (QM) Report?’ And it’s surprising how common it is for providers not to have even heard of the reports I ask for—or if they know what the reports are, they either don’t know how to obtain them or just never do.”

Both new and seasoned directors of nursing services (DNSs) should pay attention to CASPER reports, says Maher. “The DNS job is so difficult. Using these tools that the Centers for Medicare & Medicaid Services (CMS) provides can make it a little easier to know where to focus your resources.”

PDPM Training Presentation

This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.

PDPM Resources

This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

Topics covered include:

• What is the Skilled Nursing Facility Value-Based Purchasing Program?
• What SNFs are included in the SNF VBP Program?
• What measure is currently being used in the SNF VBP Program?
• What is the difference between a planned readmission and an unplanned readmission?
• When does the SNFRM 30-day period begin and end?
• Are the measures in the SNF VBP Program the same as the measures in the SNF Quality Reporting Program (QRP) and on the Nursing Home Compare website?
• How are performance scores calculated?
• Will SNFs be able to calculate their achievement and improvement points?
• How are incentive payments determined?
• How will SNFs be notified of their performance in the Program?
• What is Phase One of the Review and Corrections process?
• How can I correct an error in my patient-level data?
• What is Phase Two of the Review and Corrections process?
• Where can I find more information or ask questions about the SNF VBP Program?

The enhanced Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) review and correct reports are now available, on demand in the Certification and Survey Provider Enhanced Reporting (CASPER) application. In addition to enhanced sorting functionality, this report now includes patient level data and automated CSV file creation functionality that contains patient level results. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage.

NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.

In addition to the sorting enhancements and inclusion of resident level data, these reports:

• Contain quality measure information at the facility level
• Allow providers to obtain aggregate performance for the past four quarters (when data is available)
• Include data submitted prior to the applicable quarterly data submission deadlines
• Display whether the data correction period for a given CY quarter is “open” or “closed.

On April 5, the new Q4FY18 Skilled Nursing Facility (SNF) PEPPER was released. Find information here: https://pepper.cbrpepper.org/About-PEPPER/Distribution-Schedule-Get-Your-PEPPER

The CMS contractor will also hold a web session to review the release.

A new Question and Answer (Q+A) document is now available. The Q+A document reflects frequently asked questions that were received by the SNF QRP Help Desk during the fourth quarter (Oct - Dec) of 2018.

·        SNF QRP Quarterly FAQ Update Q4 2018 [PDF, 268KB]

From https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-FAQs-.html

April 5 update: An errata (V3.00.1) was posted for the DRAFT version (v3.00.1) of the MDS 3.0 Data Specifications, which will go into effect on October 1, 2019. Twenty-one issues were identified. One new item (X0570A) was added. Five existing items were added to additional item sets. Nine new edits were added, and eight existing edits were revised.

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A new version (V3.00.0) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there are many significant changes, including the removal of eight item sets (NS, NSD, NO, NOD, SS, SSD, SO, SOD), the addition of two new item sets (IPA and OSA), and item additions in Sections A, GG, I, J, O and Z. These specs accommodate the utilization of the PDPM grouper, which also begins on October 1, 2019.

In addition, a new version (V1.04.0) of the MDS 3.0 CAT Specifications was posted. This version is also scheduled to become effective October 1, 2019. The specification for CAT 12 (Nutritional Status) has been updated in accordance with the changes in V3.00.0 of the MDS 3.0 Data Specifications.