The next CMS Skilled Nursing Facilities (SNF)/Long Term Care (LTC) Open Door Forum scheduled for:  

Date:  Thursday, December 12, 2019

Start Time:  2:00 PM – 3:00 PM Eastern Time (ET);

Please dial-in at least 15 minutes before call start time.

Conference Leaders: Todd Smith & Jill Darling

**This Agenda is Subject to Change**

I.  Opening Remarks

Chair – Todd Smith (Center for Medicare)

Moderator – Jill Darling (Office of Communications)

II.   Announcements & Updates

*PDPM Update

*Fiscal Year 2020 SNF VBP Facility-Level Dataset and SNF VBP Aggregate Performance

III. Open Q&A

**DATE IS SUBJECT TO CHANGE**

Next ODF: TBD

Mailbox: SNF_LTCODF-L@cms.hhs.gov

jRAVEN (version 1.7.2) is now available for download which contains the following updates:  

• A defect has been corrected that was causing the HIPPS score that is calculated in jRAVEN to not match the score calculated by the Submission System
• Changes in support of the MDS Data Specifications Errata V3.00.3
• The new MDS VUT, version 3.2.0, also updated in support of the Errata V3.00.3
• All enhancements included with jRAVEN V1.7.0 & V1.7.1:

As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), we are holding a limited number of Skilled Nursing Facility (SNF) claims while we make further refinements to our claims processing system.

PDPM is a historic reform of the SNF prospective payment system. PDPM focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. PDPM was effective on October 1, 2019.

Specifically, CMS is holding claims with:

• Dates of service October 1, 2019 or later and
• Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF Patient Driven Payment Model (PDPM) and
• Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).

Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. We anticipate releasing the remaining held claims in late November, once CMS completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.

In addition, we underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. We are automatically reprocessing those claims; no provider action is needed.

Directors of nursing services (DNSs) often take a largely hands-off approach to Medicare Part A coverage issues, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “In many facilities, DNSs more or less delegate the entire Medicare program to the MDS coordinator or the Medicare consultant. This ability to delegate is important because DNSs have such a demanding job. However, DNSs ultimately are responsible for all aspects of resident care. The MDS is a part of that, as are Part A skilled services.”

Consequently, DNSs still need to provide oversight—to be a member of the Medicare Part A team and to be aware of how well facility systems work by either auditing medical records or reviewing the results of delegated audits, suggests Harvey. “A DNS who just says, ‘The MDS coordinator handles that,’ could run into unexpected problems during medical review.”

“The implementation of the Patient-Driven Payment Model (PDPM) changed the payment system used for traditional Part A residents,” notes Harvey. “It did not change the coverage policies for skilled services.”

CMS has revised SNF-focused chapters in the following manuals in the online manual system to account for the Patient-Driven Payment Model (PDPM):

• Medicare Benefit Policy Manual;
• Medicare Claims Processing Manual; and
• Medicare General Information, Eligibility, and Entitlement Manual.

Therapy utilization will no longer be a payment driver under the Patient-Driven Payment Model (PDPM) in the Skilled Nursing Facility Prospective Payment System (SNF PPS), but skilled therapy services still have a key role to play. Liz Barlow, RN, CRRN, RAC-CT, DNS-CT, senior director of quality for RehabCare in Louisville, KY, offers five ways that directors of nursing services (DNSs) can work with the interdisciplinary team to get the most bang for their buck with therapy:

Under the Patient-Driven Payment Model (PDPM), resident outcomes will be key to avoiding medical review, said officials with the Centers for Medicare & Medicaid Services (CMS) during the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training session, Patient-Driven Payment Model: What Is Changing (and What Is Not). Note: Find the session slides here.

The goal of PDPM is for SNFs to provide value-driven care, said officials. “Fundamentally, it comes down to a balance. A high-value and efficient provider is one that is able to achieve high-quality outcomes at low cost.”

CMS measures SNF quality of care in three main ways:

• The SNF QRP;

• The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program; and

• The Five-Star Quality Reporting System on Nursing Home Compare.

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.

Under the Patient-Driven Payment Model (PDPM) that goes into effect this October 1 for the Skilled Nursing Facility Prospective Payment System (SNF PPS), restorative nursing plays two key roles, just as it did under RUG-IV:

1.  It is a qualifier for two payment classification categories in the nursing component of PDPM:

a. Behavioral Symptoms and Cognitive Performance, and

b. Reduced Physical Function.

Note: See the chart at the end of this article for an overview of restorative nursing’s role in the nursing component of PDPM.

2.  It also can serve as the daily skilled service required to meet a skilled level of care for Medicare Part A patients (e.g., upon admission when skilled therapy isn’t medically necessary, in conjunction with skilled therapy that doesn’t meet the daily requirement, or after the patient is discharged from skilled therapy). Section 30.6, Daily Skilled Services Defined, in Chapter 8, “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” of the Medicare Benefit Policy Manual offers insights into its role as a daily skilled service:

“In instances when a patient requires a skilled restorative nursing program to positively affect his functional well-being, the expectation is that the program be rendered at least 6 days a week. (Note that when a patient’s skilled status is based on a restorative program, medical evidence must be documented to justify the services. In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration.)”