Skilled nursing facilities (SNFs) throughout the U.S. pay close attention to the Minimum Data Set (MDS) for good reason—it’s a key component in a federally mandated process for reproducible clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes.
That said, some anticipated changes to the MDS have been delayed due to the coronavirus (COVID-19) pandemic, while others have been implemented and will impact how SNFs in many states must undertake MDS assessments moving forward.
If you or your staff is involved in completing MDS assessments, here’s what you need to know heading into 2021:
Changes to Quality Measures Delayed
In October 2020, the Centers for Medicare and Medicaid Services (CMS) had planned to add several questions to the MDS related to quality measures in order to collect relevant data in that area—particularly around staffing. Given COVID-19, it has been delayed until October 2021.
Section GG Now Required for Most States
Section GG, which was enacted Oct. 1, 2019 with the onset of the Patient Driven Payment Model (PDPM), was initially used only for Medicare Part A and C residents. While it was not previously required for Omnibus Budget Reconciliation Act (OBRA) assessments, it now is for most states—and in 2021, it will be the basis for reimbursement for OBRA assessments. This means you will be able to generate a HIPPS code from an OBRA assessment which will decrease the number of assessments for your insurance payers (note that this does not apply to MCR replacement plans).
Removal of Section G Delayed
Likewise, CMS had planned to remove Section G from the MDS at the start of the coming federal fiscal year on October 1. (Section G is used to calculate quality measures, including those related to function (short-stay function) and Percent of Residents Whose Ability to Move Independently Worsened (long-stay).) As the COVID-19 pandemic continues to unfold, that too has been put on hold, and industry watchers predict it could happen in the next update…perhaps in 2021…perhaps later.
PDPM Added to Overall Assessment
For case-mix states, PDPM fundamentally changes the method by which SNFs in many states are reimbursed for services. In the past, facilities were reimbursed based on the Resource Utilization Groups (RUG) model for long-term assessments. On October 1, 2019, the switch to PDPM occurred for Medicare and managed care, but the long-term assessment hasn’t yet changed.
Where therapy volume served as the basis for reimbursement under the RUG methodology, a resident’s acuity is now emphasized under PDPM. Facilities must still do quarterly assessments and OBRA assessments as before (e.g., admission, quarterly and annual); but now, if a resident is transferred to a hospital and returns to your SNF, you can perform an additional assessment to capture any change in condition—e.g., sickness, wounds, medication additions or changes. The assessment, therefore, now revolves around nursing and nursing acuity rather than therapy.
So, what’s the takeaway here? It’s as simple as knowing what your state requires in terms of assessments (i.e., PDPM or RUG) and understanding how your state pays you. If the state says it requires a PDPM assessment, but it still pays you based on a RUG assessment, you must be aware of that. A higher PDPM assessment rate is certainly desirable, but it won’t be necessary if your state doesn’t use it as the basis for reimbursement.
Regardless, things still can get confusing. Your facility’s EHR software could generate both a HIPPS code and a RUG score. If the state still pays by RUG but requires a PDPM assessment, that assessment may not change your reimbursement—in fact, it may not be relevant at that particular moment. Yet, it will be someday, so you need to do it regardless. It can be a juggling act in these already uncertain times.
The bottom line is this: Although current changes to the MDS are minimal, this is not a time to let your guard down—particularly with regard to quality measures. Original changes to quality measures slated for 2020 have been delayed until at least October 2021. While this means your SNF won’t be able to boost its quality measures until the freeze is lifted, CMS continues to gather data—and that data could be used to the benefit or detriment of your facility when quality measures resume. As a result, it’s essential to capture all data correctly and thoroughly. It’s a best practice for all times—and in the current COVID-19 pandemic, even more so.