Each year The Centers for Medicare and Medicaid Services updates the final rules for the Skilled Nursing Facility (SNF) Medicare Program. Payment, ICD-10 codes, quality programs and any other changes are included in the Code of Federal Register released in late July or early August. The changes take effect for the upcoming fiscal year that begins on October 1st of the current year.

As of October 1, 2023 certain ICD-10 codes will be added, removed or remapped.  Five codes have been reassigned; D75.84 [platelet-activating anti-platelet factor 4 (PF4)], G90.A [postural orthostatic tachycardia syndrome (POTS)] and K76.82 [Hepatic encephalopathy] will map to Medical Management. Prolonged grief disorder F43.81 and F43.89 other reactions to severe stress will be return to provider. Along with these changes, six substance abuse codes will map to return to provider, meaning these codes cannot be used as a primary diagnosis for the purposes of MDS coding in I0200B but can still be used as secondary codes.

The Quality Reporting Program (QRP) should not be confused with the Survey Quality Measures or the 5-Star Quality Measures. The QRP is part of governmental efforts to measure quality across the Post-Acute (PAC) settings and CMS has plans to add, remove and update these measures over the next several years. The QRP measures are unique in their difficulty for SNFs to keep up with the data collection periods and timelines for submission. Failing to meet these periods and timelines results in a 2% point payment reduction in the applicable fiscal year. The challenge exists because the data collection periods may begin months or years prior to when the actual penalty is incurred. Therefore, SNFs must be vigilant in assuring the information required by the Centers for Disease Control reported through the National Safety Network is timely and specifically that the sections of the Minimum Data Set (MDS) that impact the QRP measures are supported in the medical record. When there is no information in the medical record to support an MDS item the “no information code” (dash) is entered for that MDS item. At this time, 100% of the QRP items on at least 80% of the MDS assessments submitted to CMS is required to prevent the 2% penalty. Beginning January 1, 2024 the requirement will increase to 100% of the items affecting the QRP measures on 90% of the MDS assessments submitted to CMS. SNFs failing to meet this requirement will be penalized 2% points on October 1, 2025 for the FY 2026 APU. For a better understanding of the QRP deadlines see the attached FY2025 QRP Data Submission Timelines.

Fiscal year 2025 will bring a change to the CDC’s COVID-19 Vaccination among Healthcare Personnel (HCP). Data collection begins October 1, 2023 and will be publicly reported in October of 2024. The definition will change from personnel who “complete vaccination course” to personnel whose vaccinations are “up to date.” “Up to date” is defined as healthcare personnel who meet one of the following criteria: 

1.    Individuals who received an updated bivalent booster dose, or
2.    HCP who received their last booster less than 2 months ago, or
3.    Individuals who completed their primary series less than 2 months ago.

We will see another change with this measure beginning for FY 2026 when SNFs will be required to submit data for the entire calendar year.

FY 2026 will bring the assessment-based Patient/Resident COVID-19 Vaccine that reports the percent of resident stays in which the resident is “up to date” on their COVID-19 vaccinations. In this instance assessment-based means a few more questions will be added to the MDS.

The application of the IRF functional assessment and care plan that addresses function as well as the IRF change in function and mobility scores will be replaced in FY 2025 with an outcome measure based on the patient’s usual function the last 3 days of the Part A stay. The Discharge Functional Score measures the percentage of Part A SNF residents who meet or exceed an “expected” discharge score during the reporting period. The “expected” discharge score is calculated using a risk adjustment methodology based on age, admission functional status and clinical characteristics. 

The CMS proposed the CoreQ Short Stay Discharge questionnaire that would require SNFs to contract with an independent CMS-approved survey vendor to administer the questionnaire to residents discharged in a 6-month period from a SNF within 100 days of admission. After public comment, CMS decided against finalizing this rule for FY 2026. Nevertheless, do not think this subject has been permanently set aside. CMS stated, “However we remain committed to the timely adoption of a meaningful measure that addresses resident satisfaction or resident experience for the SNF QRP.”

The SNF Value Based Payment Program (VBP) continues to evolve as well. The crossover among the different quality measure programs is staggering; some measures, such as falls with major Injury, are part of the 5-Star and the QRP measures. It is no wonder facilities find it challenging to keep up with the various periods involved and the requirements to meet each measure. Table 1 below includes the current measures and those planned for the future. It is important to keep in mind that data collection for these measures occur at least 2 years prior to the end of the program year. Therefore, a proactive approach to the Skilled Nursing Facility Value Based Purchasing Program is paramount to success. 

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Table 1: Currently Adopted and Measures for Future Years

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