Centers for Medicare and Medicaid Services (CMS) released the Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) FY2026 Final Rule containing the components that will go into effect 10/1/25.
The information in this article is structured as a resource and teaching tool for SNF therapy and MDS professionals, outlining where the changes come from and what they mean in plain language.
The information is divided into the 3 main topics of the Rule tied to Medicare Part A and incorporates the changes for each:
- Part A Rates, PDPM and the MDS
- SNF Quality Reporting Program (SNF QRP)
- SNF Value Based Purchasing (SNF VBP)
A solid foundation in each of these areas will allow you to help your facility succeed. Take it 1 piece at a time….
Medicare Part A Rates, PDPM Changes & MDS Changes
Medicare Part A Rates
The Federal Per Diem rates are updated annually, and for Part A, we typically see an increase, unlike the Part B yearly therapy reductions. On 10/1/25, the rates for Part A have a net increase of 3.2%, which equates to an overall increase in payment to SNFs in FY2026 of $1.16 billion distributed between the 15,000+ SNFs today. As a reference point, last years’ increase was 4.2%.
To put the $1.16 billion increase in perspective, if all 15,000+ SNFs received equal “raises” this would equate to approximately $77,333 more this year than last.
Changes to the rates each year depend on multiple variables, which are explained in great detail in the Rule. The final rate of 3.2% was determined as follows:
- [(Market Basket increase of 3.3% + Forecast Error Correction of 0.6%) – 0.7% Productivity Adjustment (MFP)] = -3.2%.
Below are the final Unadjusted Federal Per Diem rates used to calculate each Patient Driven Payment Model (PDPM) Case Mix Group (CMG) rate, up slightly from the Proposed Rule.
Now that we have daily per diem rate information, let’s put this together with changes to the Case Mix Index values in the next section to outline the individual rate for each Case Mix Group.
Medicare Part A PDPM Changes – Case Mix Index Values
Case Mix Index (CMI) values for each of the PDPM Components, PT, OT, Speech, Nursing and Non-Therapy Ancillary, reflect “resident acuity” and are updated annually as needed. These values are important as they assign “weight” to each of the CMGs, and when multiplied by the daily per diem rates in the prior section, determine the rate for each individual CMG.
The CMI values for each of the 5 components for 10/1/25 will remain the same as last year. The dollar values will be different, of course, due to the rate changes, but the CMI values will remain the same.
Here are the final “adjusted” daily rates for each of the case mix groups (CMG), derived by multiplying the Unadjusted Federal Per Diem Rate with the CMI value assigned to each CMG. These are the pieces needed in order to calculate the total daily rate.
Total Daily Rate = PT + OT + SLP + Nursing + NTA + Non-Case Mix Rate
The chart below shows the CMI values for each group and the resulting rate once multiplied by the Unadjusted Federal Per Diem Rates above.
Final FY2025 (Urban and Rural)
As a reminder, all of the CMG scores are derived based on how the MDS “trigger questions” are answered. The Non-Case Mix Group Rate is a “flat rate,” not tied to the MDS.
For example, using the Urban chart above, a HIPPS Code of KACD1 represents TK [PT $109.05] + TK [OT $102.92] + SA [SLP $18.10] + ES1 [Nursing $365.64] + ND [NTA$125.48] + Non-Case Mix Rate [$118.21]. The total base rate for this HIPPS Code would be $839.40 per day.
The total rate per day fluctuates based on what “PPS day” it is. Days 1-3 see a higher rate due to the NTA Component paying triple, and days 21-100 see a rate reduction as the PT and OT Components slowly decrease in value throughout the stay. The base rate reflects payment for days 4-20, when there are no variables that impact the rate involved.
Changes In Wage Index – Geographical Locations – For part a rate calculation
In the section above, we demonstrated how to calculate the national daily per diem rate. To take this rate and transform it into the rate that your SNF will receive, requires another piece of the puzzle…. the Wage Index (WI).
CMS categorizes SNFs as Urban or Rural and assigns a unique WI value to each county or state. This WI is a variable used to take the Total Daily Per Diem Rate and adjust it up or down based on where you live.
The total daily rate explained in the section above is comprised of a Labor Portion and a Non-Labor Portion. The WI is used to adjust the Labor Portion to get your location-specific rate.
Total Daily Rate = Labor Portion + Non-Labor Portion
Your SNFs Total Daily Rate = (Labor Portion x Your SNFs Wage Index) + Non-Labor Portion
CMS updates these WI values each year. The final Wage Index Tables for FY 2026 can be found here:
- Wage Index Home Page – All Wage Index Tables Here
- SNF wage index file (ZIP) – Final Rule
In each Final Rule, CMS includes a calculation example for a mock SNF. To get a better understanding of how the daily rate is calculated, see pages 14-16 of the Rule.
Make note of whether your SNF is Urban or Rural, and your area WI. Not sure if your SNF is classified as urban or rural? Use the Wage Index Look Up Tool HERE and plug that into the PDPM Calculator to get your rates.
Medicare Part A PDPM Changes: ICD-10 Code Mapping For PT, OT + Speech Components
There is 1 question/item on the MDS where an ICD-10 code is entered to tell CMS what the primary reason for SNF Part A covered care is. This item in Section I, I0020B, is also responsible for setting part of the HIPPS Code by determining the case mix classification under PDPM. This is a Code that should be determined with intention.
What does that mean? The ICD-10 Code entered for that MDS item will be compared to the ICD-10 “Mapping File” established by CMS, to determine which of the 4 categories it will fall under. The reimbursement ranges for each of the categories differ.
Each ICD-10 Code is mapped to 1 of 4 PT and OT Clinical Categories as shown here. If the ICD-10 Code is not listed in 1 of the 4 categories, it will be identified as a Return to Provider (RTP) code, meaning….. the code can’t be used in Item I0020B (because it is likely not a worthy code to represent the primary reason a resident would require Part A coverage).
The 4 Clinical Categories seen in the right column are the “headings” for the PT and OT Case Mix Group Categories, setting the 1st letter of the HIPPS Code on the MDS “score.” For example, Medical Management Case Mix Groups are TI, TJ, TK and TL, and ICD-10 Code “mapping” to Medical Management would have a HIPPS Code that starts with I, J, K or L. If the resident’s ICD-10 Code mapped to Acute Neuro, the potential Case Mix Groups are narrowed to TM, TN, TO or TP, with a HIPPS Code that starts with M, N, O or P. The Code determines the category.
It is important to note, Section I0020B is the only place where RTP codes can’t be used. These RTP codes can be placed in Section I8000 of the MDS or on the billing claim if they accurately represent an active diagnosis for the resident.
Each year, CMS makes modifications to the mapping of certain ICD-10 Codes. Codes can switch categories, be added to the list, or deleted. This year, CMS finalized changing the clinical category assignment for the following thirty-four ICD–10 codes, essentially deleting 33 codes and changing the mapping of 1.
Mapping is Changing from Medical Management to Return to Provider (33)
- E10.A0 (Type 1 diabetes mellitus, pre-symptomatic, unspecified),
- E10.A1 (Type 1 diabetes mellitus, pre-symptomatic, Stage 1)
- E10.A2 (Type 1 diabetes mellitus, pre-symptomatic, Stage 2)
- E10.9 (Type 1 diabetes mellitus without complications)
- E16.A1 (Hypoglycemia level 1)
- E16.A2 (Hypoglycemia level 2)
- E16.A3 (Hypoglycemia level 3)
- E16.0 (Drug induced hypoglycemia without coma)
- E16.1 (Other hypoglycemia)
- E16.2 (Hypoglycemia, unspecified)
- E16.3 (Increased secretion of glucagon)
- E16.4 (Increased secretion of gastrin)
- E16.8 (Other specified disorders of pancreatic internal secretion)
- E16.9 (Disorder of pancreatic internal secretion, unspecified)
- E66.811 (Obesity, class 1)
- E66.812 (Obesity, class 2)
- E66.89 (Other obesity not elsewhere classified)
- E66.01 (Morbid (severe) obesity due to excess calories)
- E66.09 (Other obesity due to excess calories)
- E66.1 (Drug induced obesity)
- E66.3 (Overweight)
- E66.9 (Obesity, unspecified)
- F50.010 (Anorexia nervosa, restricting type, mild)
- F50.020 (Anorexia nervosa, binge eating/purging type, mild)
- F50.021 (Anorexia nervosa, binge eating/purging type, moderate)
- F50.21 (Bulimia nervosa, mild)
- F50.22 (Bulimia nervosa, moderate)
- F50.810 (Binge eating disorder, mild)
- F50.81 (Binge eating disorder, moderate)
- F50.83 (Pica in adults)
- F50.84 (Rumination disorder in adults)
- F98.21 (Rumination disorder of infancy and childhood)
- F98.3 (Pica of infancy and childhood)
Mapping is Changing from Acute Neurologic to Medical Management (1)
- G90.81 (Serotonin syndrome)
Below is the new ICD-10 Mapping File for all PDPM ICD-10 Mapping. The mapping files are needed to determine the Case Mix Group for the PT/OT, Speech and NTA Components. Your EMR may have some of this information built in, however, using the source documents from CMS is your best bet.
- PDPM CMS Home Page – All Mapping Files Here
- PDPM ICD-10 code mapping (ZIP) – Draft Version
- CMS has not posted the Final Version though no changes will be made from the Draft
Changes to the Non-Therapy Ancillary (NTA) Component
Potential changes to the NTA Component were the highlight of the Rules last year. In those Rules, CMS solicited information about potential future NTA changes, and gave examples of what the NTA Component may look like in future Rules.
This year’s Rule….. crickets.
However, CMS spent way too much time outlining those changes to drop this discussion for good. Something to keep an eye on!
If you are interested in the potential NTA changes CMS discussed, we explained them in detail in our review last year.
mDS Changes Coming 10/1/25
The Final MDS Item Sets for 10/1/25 have been released, though we are still waiting on the Final RAI Manual.
Until the Final RAI Manual is posted, the Draft RAI Manual should be reviewed to identify major changes. All items in red identify what’s new. The best way to familiarize yourself with the changes (assuming you were familiar with the Manual before the changes) is to scroll and read all the “red” and then go to the end of the Manual and look at all the track changes where you can see what was added and crossed out for each section.
Draft_MDS-3.0-RAI-Manual-v1.20.1_October_2025 (1) (PDF) [Final RAI not yet released]
Final MDS Item Set Links below:
- 5-Day PPS
- Comprehensive (Admission, Annual, Significant Change)
- Final_MDS-3.0-Item-Sets-v1.20.1v3_October_2025 (All Sets in a ZIP File)
- Final_MDS-3.0-Item-Matrix-v1.20.1v3_October_2025 (PDF)
- For all others, visit our MDS 3.0 Toolbox
There are some minor changes in the Final Item Sets, as well as a major change for Section O: Therapy Days and Minutes.
Let’s start with the minor changes.
- A0800 & X0300 Gender removed and replaced with A0810 & X0310 Sex on all assessments
- A2000 Discharge Date was removed from the End of PPS MDS
- A2400 Medicare Stay No/Yes change in skip pattern for End of PPS MDS
- B0100 Comatose change in skip pattern based on answer for End of PPS MDS
- I7900 Active Diagnoses “None of the Above” added to Quarterly, OBRA DC, 5 Day
- A new Section of the MDS, “Section R” was set to roll out on 10/1 with 4 new Social Determinants of Health questions (Food, Utilities, Living Situation….). However, the Final Rule confirmed that Section R was scrapped. The 4 new questions were not added to the MDS and the existing Transportation item A1250 that was going to join Section R now finds its’ way back to Section A as A1255. *Of note, Section R is in the Draft RAI Manual and should be removed when the Final Manual is released. The Final Item Sets show the removal of Section R.
Now for the major changes. Section O: Therapies
The release of the Final MDS Item Sets (ie: Admission, Quarterly, Annual, PPS 5 Day, etc.) confirm the changes to Section O. These changes not only impact Medicare Part A, but also impact therapy data collection for all residents, and potentially ties into how your State is reimbursed by Medicaid going forward.
As a refresher, there are 2 types of MDS assessments: OBRA and PPS. The 10/1 changes impact both types:
- OBRA MDS Assessments are required for all residents at specific intervals regardless of payor source. (Admission, Quarterly, Annual, Significant Change, OBRA Discharge Return Anticipated / Return Not Anticipated)
- PPS MDS Assessments are required for traditional Medicare Part A residents only, and convey information to CMS for payment or quality measure purposes. (Initial PPS 5-Day, IPA, End of PPS Discharge)
Section O0400, “Therapies,” currently present on all MDSs, which includes data collection for Physical, Occupational and Speech Therapy, as well as Respiratory, Psychological and Recreational Therapy, will be removed from ALL MDSs, with the exception of Item O0400D2 “Respiratory Therapy Days,” which is needed for PDPM HIPPS Code calculations. Section O0420 Distinct Calendar Days of Therapy will also be removed for ALL non-Medicare Part A resident assessments.
Removal of O0400 includes items all to familiar for therapists such as Therapy Start Date, Therapy End Date, Type or Mode of Therapy (Individual, Group, Concurrent, Co-treatment), Total Days and Total Minutes. Mind you, this is a veteran section, that has been on the MDS for decades.
We were teased with this change in October 2023, when the accidental (?) removal of these items occurred in conjunction with the MDS overhaul at that time (when GG replaced G….). However, CMS added the collection of these items back later that year. “Is It Really Bye-Bye Therapy”.
How will therapy service detail be monitored going forward? These 2 ways, discussed here:
- Medicare Part A Resident Monitoring will occur at the end of the Medicare Stay
- All residents, regardless of payor, will use a new therapy question added 10/1/25
- Medicare Part A Resident Monitoring
Section O0425: Part A Therapies collected at the END of a Medicare stay will remain “as is” for Medicare Part A data collecting, and will continue to collect total Therapy Days and Minutes (including Individual, Concurrent, Group and Co-treatment) for the entire Part A stay. Section O0430: Distinct Calendar Days of Part A Therapy will also remain, and together, this information will calculate the amount and type of therapy provided over the course of a Part A stay, and will be used to track the % of Group and Concurrent services to monitor SNFs over the 25% threshold.
This is what Section O0425 looks like now…. and it will not change on 10/1/25.
Section O0400, which looks identical to the above section, has been collected at the start of Medicare (ie: 5-Day PPS MDS), as well as on OBRA assessments, and is the Section that will be retired.
What has been collected at the START of the Medicare Part A stay will now only be collected at the END.
It is important to point out that this level of detail will be collected by CMS for Medicare Part A residents only….. for all other residents, which are the majority in the SNF setting, the details about therapy delivery, going forward, will not be on the MDS AT ALL.
2. New Therapy Question on all MDS Assessments
A new question [O0390] has been added to the OBRA Admission, Quarterly, Annual, Significant Change and the PPS 5-Day to indicate [via a “check mark”] when any of the therapy services have been provided for at least 15 minutes on any 1 day during the 7-day look-back window.
No Start Date, no End Date, no Mode of therapy (Individual, Group, Concurrent, Co-Treatment), and no Calendar Days.
This new item will only tell us if therapy was provided, and does not give real usable information in terms of frequency and intensity. For example, a therapy evaluation completed with a treatment and discharge in the same day (a.k.a “Eval Only”) will be answered on the MDS in the same way as a resident who received 5 days of therapy in the look-back.
- 15 minutes of “something” = Checkmark
The new question looks like this:
The list includes all the types of therapy services from the current MDS with the exception of Recreational Therapy, which has been completely removed from the MDS.
Which therapy will be next?
In last year’s Final Rule, CMS responded to the multiple comments submitted identifying concern with removing the Therapy Days and Minutes items. CMS indicated these MDS items are not needed to determine PDPM payment, and removal of the items decreases the “burden” on those completing the MDS by “6.6 minutes.”
The therapy practice pattern data we have been collecting for decades is worth the 6.6 minutes.
How does this impact Medicaid Reimbursement?
Medicaid reimbursement varies from State to State. Some states use the MDS to contribute to Medicaid reimbursement rates, some states do not. States that were using “old payment models” like RUG-IV or RUG-III, used therapy information from the MDS Section O Therapy Days and Minutes. Since this part of Section O will be removed from the MDS 10/1/25, these states need to shift to a different model. The PDPM model is now the “only model” that the MDS currently uses, and produces a HIPPS Code that includes the Case Mix Group Scores for the 4 PDPM Components: PT/OT, Speech, Nursing and NTA. States can now opt to use the PDPM Model as a whole, or chosen Components (ie: using only Nursing, or using Nursing and NTA) to establish how their Medicaid reimbursement will be determined. Many states already made this transition between 2019 and 2024, and now 10/1/25 will force the remainder of SNFs to transition.
As we know, the PDPM Model does not use therapy days and minutes to contribute to the HIPPS Code, or “score.” Therefore, states that are used to the RUG Model and the need to attain a minimum of 5 calendar days and 150 minutes of therapy in the look-back window for the lower RUG Level, may see a shift in therapy delivery models for the long-term care residents (ie: Part B).
Take a deep breath. This change should not be the “end of therapy in the SNF as we know it.”
There are Federal regulations in place that require SNFs to ensure residents attain and maintain their highest level of function. Therapy departments will need to ensure that they continue to monitor and assess residents on a regular basis to meet this requirement. Though the pattern or therapy days may see a change, the purpose and importance of therapy for the long term care residents will not change.
Moving forward….
Changes To CMS Medicare Part A Quality Measure Programs
If you are not already heavily involved in your SNF Quality Measure Program processes, NOW is the time. As these Measure Programs grow and grow, don’t get left behind. By understanding the Measures and Programs, SNF therapy and MDS professionals can be a godsend to their facility. Here, we break down each program and what will be changing in the 2 CMS Medicare Part A QM programs:
- SNF Quality Reporting Program (SNF QRP)
- SNF Value Based Purchasing Program (SNF VBP)
- SNF Quality Reporting Program – SNF QRP
The SNF QRP is the program that started small over 9 years ago [remember when Section GG was new?] and has now ballooned into the program with the most measures. This is a pay for reporting program, meaning, SNFs are required to report measure data on specific MDS items, and if not reported, facilities can be subject to a 2% Part A payment penalty.
The penalty occurs when information is missing, not for poor outcomes. [yet]
Here is a link to all the MDS questions that, if not filled out, will trigger the payment penalty if the threshold is met. This list is in effect for Q4 2025.
CMS will release the FY2028 table soon. You can monitor this page for its release.
The list of item sets (MDS questions) continues to grow, making the attainment of submitting 100% of the required quality measure data collected on at least 90% of all PPS Part A assessments to avoid the penalty a challenge!
Make sure MDS staff have the list of MDS items above. These are the MDS items being collected NOW that will potentially impact FY 2027 & 2028 Annual Payment Update (APU) Determination.
The SNF QRP works in 2 time tables. The collection of data NOW will impact your payment in the FUTURE. Though the payment penalty is deferred, the SNF Measure status is publicly reported on the CMS Care Compare website for all to see.
In addition to submitting 90% of all Part A MDS assessments with no missing data, there are 2 other ways in which SNFs can loose that 2%:
- Required submission of100% of data for the COVID-19 and Influenza Vaccination for Healthcare Personnel to the CDC National Healthcare Safety Network (NHSN). If info is missing on the MDS or vaccination info is not sent timely to the CDC, the penalty will apply.
- Failure to respond to new MDS Validations Audits *Starting in September
- See discussion prior to Summary Section
SNF QRP Changes for FY2026
There are no “new Measures” for the SNF QRP in the Final Rule. But that does not mean we can sit back and relax. Below are the 15 current Measures in place for 10/1/25 (FY2026). The 1st 9 are solely dependent on how the MDS questions are answered, followed by 4 measures based on billing claims, and 2 regarding vaccinations.
Easy Come, Easy Go
Last year, CMS finalized the addition of 4 new item sets / MDS questions, or standardized patient assessment data elements (SPADES) in the Social Determinants of Heath (SDOH) category, that would correlate to the SNF QRP program, as well as the potential Part A “penalty” for not answering the questions. Set to make their debut on the 10/1/25 MDS, these questions were officially scrapped in the Final Rule. (Living Situation, Food, Utilities)
CMS stated “we acknowledge the burden associated with these items at this time….and look for ways to balance the need for data collections regarding quality care and burden of these data collections on health care providers.” CMS will work towards a better way to capture this data going forward.
CMS is all about “minimizing the burden” this year, mentioned 84 times in this Rule!
Other SNF QRP Changes
The Final Rule outlined additional changes to the Reconsideration Policy and Process. The Reconsideration Process is when SNFs are not in agreement that they did not comply with reporting requirements, and are notified of a pending 2% payment penalty for their SNF.
The Final Rule includes 2 new items in this area:
- Allowing SNFs to Request and Extension to File for Reconsideration based on extraordinary circumstances (natural disaster, etc.)
- Modifying existing reconsideration policy to provide that CMS will grant a timely request and reversal
Future SNF QRP Measures
In the Proposed Rule, CMS sought comments, or Requests for Information (RFI) in 3 areas. This information is used to solicit feedback for future rule making. The Final Rule reviewed comments and feedback received in these areas:
- Future measure concepts for: Interoperability, Well-being, Nutrition and Delirium
- Potential revision to the data submission deadlines for assessment data collected for the SNF QRP from 4.5 months to 45 days, with the goals of having more current data available to the public to make informed decisions on where to receive care, as well as providing data to SNFs for their quality improvement efforts sooner.
- Advancing digital quality measurement in the SNF – Seeking feedback on the current state of health information technology in the SNF setting
On to the last Quality Measure Program….
2. SNF Value-Based Purchasing Program (SNF VBP)
The SNF VPB Program is a “pay for performance” program and works by withholding 2% of all SNFs’ Medicare Part A payments to fund the program, and then allows for an opportunity for SNFs to recoup part of the 2% by demonstrating “success” with the established Measures. CMS redistributes approximately 60% of this back to SNFs as “incentive payments” to encourage improvements in the quality of care provided to Medicare beneficiaries (and yes, CMS keeps the remaining 40%).
Current SNF VBP Measures
Though there are no new measures in this year’s Final Rule, we are all impacted by the multitude of new measures added over the past few years that are slowly kicking in.
Since the start of this Program, there has only been 1 Measure: The SNF 30-Day-All-Cause Readmission Measure, which looks at residents readmitted back to the hospital within 30 days of entering the SNF from the hospital. However, 10/1/25 marks the FY2026 Program Year where 3 additional Measures will have a payment impact.
The timeline of all the VBP Measures are listed below.
It is important to note that the Program Year is synonymous with “payment impact year,” which follows 2 years after the “Performance Year. So even though some of these dates feel a bit “far off,” we need to pay attention, as the “data collection start date” is 2 years prior.
Once the Program Year hits, it’s too late to do anything about the data.
- The 4 Measures in the FY2026 Program Year will impact the SNF score and payment on 10/1/25 from data that was collected in FY2024.
- The additional 4 Measures in the FY2027 Program Year will impact the SNF score and payment on 10/1/26 based on data collected in FY2025 (now). This includes Discharge to Community, Falls with Major Injury, Discharge Function Score and Hospitalizations per 1000 Long Stay Resident Days.
Jumping ahead…..data collection for the FY2028 Program Year Measures will begin FY2026, or 10/1/25.
SNF VBP Measure Performance Standards
The Final Rule released the Achievement Threshold and Benchmark for each of the VBP Measures as shown below, showing changes from the Proposed Rule. These figures are essentially used to rank SNF performance.
other sNF VBP changes
Change in Scoring Methodology
CMS finalized removing the Health Equity Adjustment (HEA) that was supposed to kick in 10/1/25, before it had a chance to start. The HEA was set to reward top tier performing SNFs that served higher proportions of dual eligible residents (Medicare/Medicaid). Removing the HEA avoids a change in the variable payback rate and will maintain the 60% payback method that SNFs have been accustomed to since 2022. CMS contributes the removal of the HEA to program “simplicity and regulation streamlining,” …… or maybe….. burden?
Adopting a Reconsideration Process
CMS finalized adoption of a reconsideration process that will allow SNFs to seek reconsideration of a “review and correction” request if they are not satisfied with the CMS decision. This process would provide SNFs an opportunity to review information that is to be made public prior to publication.
New SNF Data Validation Process (For QRP and VBP)
See below for details about this new proces
New SNF Data Validation Process for SNF QRP + SNF VBP
Coinciding with the timing of the FY2026 Final Rule, we can’t forget about the new SNF Data Validation Process that was outlined in the FY2024 and FY2025 Rules…. the process to validate the MDS responses with the medical record.
…. and another way to lose 2% from the Medicare Part A APU if SNFs are not on top of it!
The time is here and CMS auditing should begin in the next few weeks, prior to 10/1/25. The purpose of the audit is to assess the accuracy of the MDS-based Quality Measure questions that are used in the SNF QRP and the SNF VBP. You can reference the charts in the previous sections to identify the MDS-Based Measures, 9 Measures in the QRP and 2 in the VBP (Long Stay Falls with Major Injury and Discharge Function Score).
How will SNFs know if they are selected?
- SNFs notified ONLY via iQIES MDS 3.0 Provider Preview Reports Folder
- Look for item labeled “SNF Data Validation Process – Initial Selection Notification”
- *Ensure someone is assigned to check this folder daily
- 10 random records with required data submission response within 45 days from notice…. or lose 2%
What is the response time to avoid losing 2%?
- 10 random records with required data submission response within 45 days from notice
- There are lots of rules on where and how to respond
What are the best resources to learn more about this process?
- Save / Print the 8 page FAQ Document just released by CMS. It has all the answers and is in an easy to read format.
- Here is CMS new Validation Website with additional info
….. well, this data submission is surely not a burden. Glad we have the extra 6.6 minutes.
In Summary…
October 1st is always about change for SNF therapy and MDS professionals… and it hasn’t killed us yet! This resource was surely the “long answer” to what’s changing 10/1/25.
So what’s the “short answer?”
- Part A rates will go up 3.2%, which is a minimal increase per SNF
- Case Mix Group CMI values will stay the same as last year
- PDPM Mapping changes…. 33 codes convert to Return to Provider, 1 from Acute Neuro to Medical Management
- Major MDS Changes include:
- Removal of Section O0400 Therapy Days, Minutes, Calendar Day on all MDS assessments
- Keeping Section O0425 Therapy Days, Minutes and Calendar Days collected when Medicare Part A ends on the Part A DC MDS only
- New Therapy Section O0390 collecting yes/no for 15 minutes of therapy involvement
- New Section R 4 SDOH questions scrapped
- SNF QRP 15 Measures are in play with no new ones proposed, 9 from the MDS
- There is a much greater chance to incur a Medicare Part A 2% payment penalty as the list of requirements keeps growing, and now includes failure to timely respond to a MDS QM audit
- Are you checking your iQIES folder daily for your random audit notification?
- SNF VBP has no new measures, however, 4+ Measures kick in for data collection on 10/1/25 that will impact future Part A payments in FY2028.
Important Resources to Bookmark:
HERE is a link to the Final Rule PDF Version
HERE is a link to the Federal Register Final Rule
HERE is a link to the CMS Fact Sheet
PDPM Calculators and Resources HERE
That’s the long AND the short of it!
Print it, save it, and go enjoy the last few weeks of Summer!
Thank you for the care you provide our SNF residents every day!
If you have any questions, send them to our Just Ask Q&A Team and we will get your questions answered.
In your corner,
Dolores
Dolores Montero, PT, DPT, RAC-CT, RAC-CTA
President | Montero Therapy & MDS Resource Team
Join Us: September 24th @ 12 pM: SNF Rule Changes For Medicare Part A & Part B 10/1/25-12/31/26
Every October 1st the Medicare Part A Rules change…..PDPM, Reimbursement, MDS….
Every January 1st the Medicare Part B Rules change…. Reimbursement, Coding, Modifiers….
Change is inevitable in the SNF!
Stay up to date on rule changes that impact your practice.