If you are a therapy or MDS professional in the SNF setting, you know that change comes at least twice a year – January 1st and October 1st.

Why? January 1st is the start of the calendar year and brings with it the changes from the Physician Fee Schedule for Medicare Part B. October 1st is the start of the SNF fiscal year and brings with it the changes for PPS Medicare Part A, which may also include changes to the MDS and reimbursement.

So…. change is nothing new for us! SNF professionals get suspicious when things are quiet for too long anyway!

Let’s take a look at what is coming….

Medicare Part A Changes

The changes impacting Medicare Part A reimbursement that will take effect 10/1/18 fall under a few different umbrellas. Up to this point, therapy managers, therapists and MDS Coordinators may not have focused on all aspects of Part A reimbursement since the primary “umbrella”, the RUG-IV  Prospective Payment System (PPS) has been the hogging the spotlight for years.  However, since it will be lights out for RUG-IV next October when PDPM (Patient Driven Payment Model) kicks in,  it is time to start focusing on the other umbrellas. PDPM will only be a small piece of the puzzle moving forward and it is critical that professionals understand the bigger picture.

1- SNF Value-Based Purchasing Program (SNF VBP)

We have known about the SNF VBP program for a while, but SNFs will only begin to feel the effects starting 10/1/18, when the VBP payment impact kicks in for all SNFs that participate with Medicare Part A.

• So what is SNF VBP?

The SNF VBP Program is the shift CMS is taking toward paying based on quality rather than quantity – or “value over volume.” The program rewards SNFs with incentive payments for the quality of care they give to people with Medicare – based on scoring of  different Measures. For now, there is only 1 measure.

• The Measure that kicks in for payment 10/1/18 is called:    SNF 30-Day Readmission Measure (SNFRM – NQF #2510) 

This  measure looks at all Medicare Part A residents who were discharged from the hospital to a SNF, and then ended up back in the hospital for an unplanned readmission within 30 days of the original hospital discharge. This includes residents that are in your SNF and go back to the hospital AND residents that you have discharged home or to a lesser level of care who then go back to the hospital {Yes, somewhat out of your control!}  Facilities are scored and ranked to determine what their incentive payment will be, if any, based on a particular data collection period.

• How is this program paid for?

EVERY SNF loses 2% off the top of their PPS reimbursement for the year in order to fund this program! But don’t worry…the SNF VBP program allows a chance to earn some or all {or none} of it back. Your Achievement and Incentive Scores will determine your points, score and ranking, which in turn, determines if you receive any of the 2% back. Most won’t.

• Why is SNF VBP important to therapy and MDS professionals?

First and foremost, you are losing 2% off the top and have a chance to get it back by demonstrating the quality care you provide. Staying on top of this measure is somewhat in your control, even after the residents leave your facility. For example, residents admitted to your SNF from the hospital require adequate monitoring of medical stability. It goes without saying that staying on top of each resident’s medical condition is a must. The newer admissions may not be 100% stable – as we know by the revolving door we sometimes see when residents leave the hospital too soon. Therapy may not be the priority when residents arrive – yes, they may not be able to tolerate Ultra minutes – and therapy sure as heck should not be pushing someone lacking stability into distress. Treat wisely. Also, your SNF should have internal measures as to how to handle an acute crisis where sending the resident out to the hospital can be avoided. Availability of qualified PA’s, NP’s, and MD’s on a 24/7/365 basis is a must. The last thing you want if for a doc to say “send them out” when you know the issue is minor enough to be successfully handled internally. Also important to note here is “readiness for discharge.” With the push for decreased length of stay, this measure may give you leverage when fighting for more days of coverage to ensure medical stability before a resident is sent home.

• Important resource links

This is only the tip of the iceberg so if you are interested in more on this topic, check out these links:

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18003.pdf
• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP-FAQs-Final.pdf

2- SNF Quality Reporting Program (SNF QRP)

The SNF QRP program has been around for a few years and has lots of moving pieces, some new each year and some old. Remember MDS Section GG?

• So what is SNF QRP?

SNF QRP  came to us by way of the IMPACT Act of 2014 which, in part, required a movement toward standardizing data between post acute care settings {SNFs, HHAs, IRFs and LTCHs} with a goal of  improving quality of care, communication and coordination of care between settings. [See this article]  A shift toward standardizing data elements in each of the assessment tools used in the different settings began. If you work in multiple setting, you will recognize some of the same questions of the MDS, IRF-PAI, etc. The data collected can be used to “Measure” quality and outcomes.

• What are the Measures? {There are quite a few to keep track of!}

The 3 old measures that kick in for payment 10/1/18 are in the areas of Skin, Falls and Function. These are the Measures we were collecting data for over a year ago which will impact payment in October. Keep in mind that we are still in a collection period now which will determine future payment in 2019 and beyond.

SNF QRP Assessment-Based Measures (From MDS Questions)

NQF Measure ID	Measure Title
NQF #0674	Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
NQF #0678	Percent of Patients or Residents with Pressure Ulcers that are New or Worsened
NQF #2631	Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function

The 3 new claims based measures will also impact payment 10/1/18, though these are not derived from MDS questions.

SNF QRP claims-based measures (From Billing Claims)

Measure	Data Source
Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)	Medicare FFS claims
Potentially Preventable 30-Days Post-Discharge Readmission Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)	Medicare FFS claims
Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure	Medicare FFS claims

The following new Measures start data collection 10/1/18  to 12/31/18 (no dashes!) and will impact payment 10/1/19:

Measure	MDS Section
Drug Regimen Review	Section N
Change in Skin / Pressure Ulcer / Injury	Section M
Change in Self Care	Section GG
Change in Mobility	Section GG
Discharge Self Care Score	Section GG
Discharge Mobility Score	Section GG

 

• How are the Measures used for payment or penalty?

Remember the push for “no dashes” in Section GG??? This was the reason. Any “incomplete” MDS Section GG section for Skin, Falls and Function during the collection period will now come back to haunt you. You will receive a 2% PPS payment reduction if less than 80% of your submitted PPS 5 day and DC MDS’s  were not 100% complete – no missing info or dashes. Collection periods in the past will impact payment now. Remember – once a collection period is over, you will be in a new collection period….so it’s never really “over.”

• Why is SNF QRP important to therapy and MDS professionals?

SNF QRP is HUGE for therapy professionals! These are the outcomes for our Medicare Part A residents…..self care, mobility, successful discharge to the community. All therapy professionals should be keenly aware of the MDS items that contribute to these outcomes. Some therapy software programs incorporate the MDS questions into the therapy initial evaluations and discharge summaries…..but that DOES NOT cut it! Therapists need to look at an MDS directly to get the full scope of the SNF QRP. Therapists need to understand the connection between what they are filling out in therapy software and what may actually populate the MDS. Since MDS Coordinators have the “big picture” in mind, they should be the gate-keepers of what populates to Section GG from therapy software, in addition to being on “dash-patrol.”

• Important resource links
  • https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html
  • https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting.html
  • https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-FAQs-.html
  • https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-Table-for-Reporting-Assessment-Based-Measures-for-the-FY-2020-SNF-QRP-APU.pdf
  • https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QM-Users-Manual-V10-FINAL-5-22-17.pdf

3- MDS 3.0

Every year we see MDS item question additions and/or changes. This October is no exception. There are multiple changes this year to support the SNF QRP Measures described above, as well as to support next years PDPM. MDS changes can also impact State Case Mix.

• What is changing?
  • Section A: New Medicare numbers
  • Section I: Primary Medical Dx for SNF Stay – added in preparation for PDPM
  • Section J: Prior Surgery – added in preparation for PDPM
  • Section M: Skin – added term “injury”
  • Section N: Medications – Added items for Drug Regimen Review
  • Section O: Special Treatments, Procedures – clarified invasive vs non-invasive ventilator
  • **Section GG: Functional Abilities and Goals – Major Changes!
    • Added “Prior Level of Function”
    • Added to Self Care: Shower/Bathe Self; Upper and Lower Body Dressing; Don/Doff Footwear
    • Added to Mobility: Roll; Car Transfer; Walk 10′; Walk 10′ Uneven Surfaces; Step/Curb; 4 & 12 Steps; Pick item from floor
• Why is this important to therapy and MDS professionals?

These new or modified questions will impact the SNF QRP, measured outcomes and reimbursement for years to come. They are also set up to determine PDPM payment. Section GG is growing in leaps and bounds and therapy professionals have the ability to make a direct impact in this area.

4- Medicare Part B

The Proposed Rule out this July was only 665 pages… We will need to wait for the Final Rule which is not typically out until November. However, we can project that the following changes will take place January 1st:

• Value-Based Programs….Yes, Part B has Quality Measures to report on as well! What used to be PQRS transitioned into MIPS, or Merit Based Incentive Payment and is going strong. The good news is….therapists in the SNF setting do not need to worry about these changes as they pertain to therapists in private practice at this time. If you are a therapist that is also a Medicare Provider of Part B in any setting, most of those 665 pages are for you!
• Functional Limitation Reporting:  FLR or G-Code Reporting came to us in 2013 and according to the Proposed Rule, will be history 1/1/19. The FLR requirements for Part B therapy will be removed from Chapter 15 of the Medicare Benefit Policy Manual.
• Therapy Cap: Since the Cap has been repealed, there should not be much discussion on this in the Final Rule with the exception of a possible update to the $ threshold that marks use of the KX Modifier and the potential manual medical review
• PT and OT Evaluation CPT Codes: After a long enough data collection period with the new PT and OT evaluation complexity codes, it was anticipated that a change in payment structure may be released. However, no changes were proposed in the recent Rule.
• New Modifiers for PT and OT Assistants: In preparation for changes to come 1/1/22 with reimbursement reductions in all Part B settings to 85% of the Fee Schedule for services provided by PT and OT Assistants, 2 new modifiers will be mandated starting 1/1/20 to indicate on the billing claim which services were provided “in whole or in part” by an assistant. There will likely be further {intense} discussion on this topic as the Proposed Rule indicates that “any minute” of billable services provided by an assistant must be coded as provided by an assistant.
  • What does this mean? Well, if a resident received 30 minutes of therapy for 1 unit of therapeutic exercise and 1 unit of gait training, if an assistant provided ANY services contributing to either of those units, the unit would be subject to reduced reimbursement. An exception would be if the assistant was helping a therapist…as in this case the therapist would be billing the full time.
  • Remember, this is for Part B only. What we may see is a shift of Assistants providing the Part A and Managed Care treatment and Therapists providing the Part B services. We will have to wait on this for now.

Summary – and a Word About PDPM

Yes, 10/1/19 will be here before we know it and PDPM will bring about major changes for the SNF setting, therapists and MDS Coordinators.

But… let’s slow down for a minute and focus on 10/1/18.

If you truly read the above information on VBP and QRP,  you will see that the Shift toward “value” and the Measures that require reporting rely on the input from therapy professionals.

THIS is the information that you need to master if you plan to stick around the SNF setting after 10/1/19, be successful and really show your worth! The shift to value is NOT going anywhere, unlike PPS.

Therapy in the SNF setting always was…and always will be…about SERVICE to the resident.

Learn everything you can about the “big picture.” Your service will make all the difference…in quality….and in outcomes.

Any questions, please submit them to our Just Ask Q&A Forum.

In Your Corner,

Dolores and the Montero Therapy Team

Rehab and MDS Compliance Experts – www.RehabManagerTraining.com

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Want more details on the changes to come? Join Us for our Upcoming Course – We have designed this course with the busy professional in mind. The course will be released to you on September 19th. You will have 2 full weeks to listen to webinar as many times as needed – and you will then have access to a 1 hour live Q&A Session on 10/3/18 from 2-3 pm EST where we will provide a quick review of the material highlights and then open up the webinar for your questions. Don’t miss out!

Webinar: SNF Therapy & MDS Changes for October 1st 2018 and Beyond – Registration