The Centers for Medicare and Medicaid Services (CMS) released the Code of Federal Register (CFR) on August 3, 2022 that includes several changes and clarifications. In the CFR released in 2021, CMS reported that budget neutrality had not been obtained with the change from the skilled nursing facility (SNF) RUG-IV payment model to the Patient Driven Payment Model (PDPM) implemented on October 1, 2019 as expected. The table below reflects what CMS estimated the average case mix index (CMI) or overall patient acuity in each payment component for FY 2020 and the actual CMI average, even after removing beneficiaries using a Public Health Emergency-related waiver or with a COVID-19 diagnosis from the data set.

One could make the argument that for the first time since the inception of the Prospective Payment System (PPS), nurses and the services they provide are now a consideration in the reimbursement methodology under PDPM, and the lack of focus on the importance of nursing services under RUG-IV may have contributed to an underestimation of the CMI’s for the SLP, nursing, and NTA components.

Based on the difference between the 2019 estimated CMI’s and the 2020 actual CMI’s, the Centers for Medicare and Medicaid Services went forward with their proposed parity adjustment to ensure budget neutrality. To achieve this, CMS will make the adjustments equally across all PDPM components. They also finalized that the parity adjustment will be accomplished through a two-year phase-in period resulting in a 2.3% reduction in FY 2023 and a 2.3% reduction in FY 2024.

MDS Coding IsolationICD-10 Updates

During COVID many questions arose regarding the documentation and rules for coding isolation. Although there was a cry to change the requirements, CMS continues to maintain “The significant increase in payment associated with this item is intended to account for the increase resources…” Therefore, assure when isolation is reported on the MDS that nursing documentation supports the isolation coding requirements.

Code for “single room isolation” only when all the following conditions are met:

1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
2. Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g., rehabilitation, activities, dining, etc.).

ICD-10 Updates

The good news is that many of the gastric codes are no longer “return to provider” and map to medical management. On the other hand, several changes to the PDPM ICD-10 code mappings that could be used are now “return to provider” codes. It is important to note that CMS expects specificity when assigning ICD-10 codes, particularly when the primary diagnosis is entered as MDS item I0020B. Below are the return to provider codes, the related diagnosis, and CMS’ reason for the change.

The Quality Reporting Program

Currently for the Health Care Personnel (HCP) COVID–19 vaccine measure, SNFs use the COVID–19 vaccination data collection module in the CDC National Healthcare Safety Network (NHSN) to report the number of HCP eligible to work at the facility for at least one day during the reporting period, excluding persons with contraindications. To meet the minimum data submission requirements for the HCP COVID–19 vaccine measure, SNFs submit COVID–19 vaccination data through the NHSN for at least one week each month. Data collection for the HCP influenza measure will begin October 1, 2023. To avoid a 2% payment reduction for a given FY, the facility must reach the 100% threshold for reporting HCP COVID-19 vaccinations through the CDC NHSN system.

Coming soon: The Transfer of Health Care Information (TOH) and six Standardized Patient Assessment Data Elements (SPADES) will be added to the MDS item sets with the October 1, 2023 RAI Manual revision 1.18.11. The item sets are currently located on CMS’ MDS3.0 RAI manual website. The SPADES are cross-setting measures, meaning the same items will be reported by inpatient rehab facilities (IRF), long-term care hospitals (LTCH), skilled nursing facilities (SNF), and home health (HH). We will be familiar with some of the SPADES since they have been part of the MDS for the past few years, but there will new MDS items to report on as well.

SNF Value-Based Purchasing

Based on the significant and continued decrease in the number of patients admitted to SNFs, which likely reflects shifts in utilization patterns due to the risk of spreading COVID–19 in SNFs, CMS finalized their proposal to suppress the Skilled Nursing Facility Readmission Measure (SNFRM) for the FY 2023 SNF Value-Based Purchasing (VBP) program year. As with the suppression policy adopted in the FY 2022 SNF VBP Program, the performance period (FY 2021) and baseline period (FY 2019) will be used to calculate each SNF’s risk-standardized readmission rate (RSRR) for the SNFRM. SNFs will receive a performance score of zero in the FY 2023 SNF VBP program year, meaning all participating SNFs will receive an identical performance score, as well as an identical incentive payment multiplier. A risk adjustment variable will be added to the SNRM beginning FY 2023 to address patients diagnosed with COVID-19 during the prior proximal hospital stay and patients with a history of COVID -19 due to the growing evidence of “long” COVID-19.

However, CMS removed the low-volume adjustment policy beginning in the FY 2023 program year, and instead, SNFs that do not report a minimum of 25 eligible stays for the SNFRM for the FY 2023 program year will not be included in the SNF VBP Program for that program year. As a result, the payback will remain at 60%.

As with the Quality Reporting Program, begin preparing for future SNFVBP expansion to include:

• Healthcare-associated infections (HAI), which by definition will measure infections acquired while receiving care at a healthcare facility that was not present or incubating at the time of admission
• Total nursing hours per resident day staffing (total nurse staffing)
• Discharge to the community (DTC)
  

Regulatory Considerations 

§483.60(a)(2)(i) will be revised to add experience as one of the ways to qualify as the director of food and nutrition services. Specifically, an individual who has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management by no later than October 1, 2023, along with the other requirements set out at § 483.60(a)(2), is qualified to be the director of food and nutrition services.

Physical environment was also addressed in §483.90(a)(1)(iii). CMS noted that facilities using the Fire Safety Evaluation System (FSES) were no longer able to achieve a passing score because of changes in scoring.

Enhance Outcomes with Richter

Richter will continue to keep you informed of updates and changes as soon as the manual revisions are released. As the industry’s leading LTPAC performance advisors, we listen, analyze, strategize and implement customized solutions to Enhance Outcomes in every facet of your organization. To learn more about how Richter can provide customized clinical consulting services for your challenges, contact us here or call us at 866.806.0799.

References:

United States, Department of Health and Human Services Centers for Medicare and Medicaid Services. FY 2023 42

CFR Parts 413 and 483 Vol. 87 No. 148 (August 3, 2022) retrieved 10/4/2022 from: Federal Register :: Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; Changes to the Requirements for the Director of Food and Nutrition Services and Physical Environment Requirements in Long-Term Care Facilities