The SNF QRP Reporting User’s Manual Version 3.0.1 has been updated. These updates will be effective October 1, 2020.
Specification updates
All four SNF Functional Outcome Measures
Exclusion criteria: The age exclusion criterion for these measures has been updated from 21 years to 18 years, such that any resident younger than 18 years of age will be excluded from measure calculations.
SNF Discharge to Community Measure:
Exclusion criteria: This measure has been updated to exclude residents who had a long-term nursing facility (NF) stay in the 180 days preceding their qualifying hospitalization and SNF stay, with no intervening community discharge between the long-term NF stay and qualifying hospitalization.
Data Refresh
Early in the public health emergency, CMS made reporting requirements “optional” or “excepted” based on quarter. CMS indicated that data submission for Q4 2019 was optional and that any data submitted would be used for reporting purposes. Since data submission for Q4 2019 was strong, the data will be included in measure calculations for the Nursing Home Compare site refresh scheduled for October 2020. Because data from Q1 and Q2 is not included in the category or group specified for reporting, the data will be held constant following the October 2020 refresh.
CLICK HERE to view the SNF QRP User’s Manual Version 3.0.1
Beginning, October 1, 2020, MDS version 1.17.2 will be instituted. Updates include assessment changes that will support the calculation of PDPM payment codes for state Medicaid programs and on OBRA assessments when not combined with the 5-day SNF PPS assessment.
This will specifically affect the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.
Sections GG, I, and J
The updated item sets will not have a revised RAI manual released. As of 9/18/2020, AANAC is reporting 31 states have indicated they will be gathering PDPM data for state Medicaid programs and on OBRA assessments.
Section GG
Items GG0130 and GG0170 headers updated to read “Start of SNF stay or State PDPM”
Completion instructions include: If state requires completion with an OBRA assessment, the assessment period is the ARD plus 2 previous days. Complete only column 1.
Section I
Item I0020 instructions for completion are revised: Complete only if A0310B=01 or if state requires completion with an OBRA assessment.
Section J
Item J2100 instructions for completion are revised: Complete only if A0310B=01 or if state requires completion with an OBRA assessment.
The Centers for Medicare & Medicaid Services (CMS) issued new guidance for visitation in nursing homes during the COVID-19 public health emergency. The guidance below provides reasonable ways a nursing home can safely facilitate in-person visitation to address the psychosocial needs of residents.
Visitation can be conducted through different means based on a facility’s structure and residents’ needs, such as in resident rooms, dedicated visitation spaces, outdoors, and for circumstances beyond compassionate care situations.
Regardless of how visits are conducted, certain Core Principles of Infection Control must be maintained:
Screen all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms
Hand hygiene (use of alcohol-based hand rub is preferred)
Face covering or mask
Social distancing at least six feet between persons
Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene)
Clean and disinfect high frequency touched surfaces in the facility often, and designate visitation areas after each visit
Appropriate staff use of Personal Protective Equipment (PPE)
Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care)
Resident and staff testing conducted as required in 42 CFR 483.80(h)
Guidance is provided for indoor, outdoor, and compassionate care situations.
Outdoor Visitation
Outdoor visits pose a lower risk of transmission due to increased space and airflow. Therefore, outdoor visitation is preferred, and all visits should be held outdoors whenever practicable.
Indoor Visitation
Should be accommodated and supported based on the following guidelines:
No new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing;
Visitors adhere to the core principles and staff adherence;
Limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space);
Consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and
Limit movement in the facility.
Facilities should use the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data site to determine how to facilitate indoor visitation:
Communal Activities and Dining
While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur.
Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person).
Facilities should consider additional limitations based on status of COVID-19 infections in the facility.
Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering.
Facilities may be able to offer a variety of activities while also taking necessary precautions.
For example, book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission.
For additional guidance concerning compassionate care visitations, refer to the full article here.
Falls can put you at risk of serious injury. Prevent falls with these simple fall-prevention measures, from reviewing your medications to hazard-proofing your living spaces.
Remove tripping hazards such as books, papers, shoes and boxes from hallways, and secure area rugs.
Install grab-bars in the bathroom, both around the toilet and the shower.
Keep frequently used items within easy reach, so you don’t have to climb or strain for them.
Make sure that both the inside and outside the home has adequate lighting so you can see your path while walking.
Alert your care or maintenance team of any damage or repairs that need to be made to walkways or steps and.
Wear sensible shoes with nonskid soles and a proper fit.
Poor vision is a major factor in falls. Get an eye exam at least once a year to keep prescriptions current and eyes functioning their best.
Consider adding extra personal by using a mobile alert system with GPS to access emergency help at any time.
Medication errors are one of the main catalysts for falls. Talk with your caregivers about any potential side effects of the medications you take to see if any may increase dizziness or impact balance and ways to mitigate this
Stay active! Even gentle exercise can increase strength and balance, healing to reduce the risk of falls.
CMS has released guidance outlining details on how to comply with the new interim final rule requiring COVID-19 testing of staff and residents.
Testing Guidance
CMS is requiring facilities to conduct three types of testing:
Symptomatic Testing: Test any staff or residents who have signs or symptoms of COVID-19 (facility must continue screening all staff, residents and other visitors).
Outbreak Testing: Test all staff and residents in response to an outbreak (defined as any single new infection in staff or any nursing home onset infection in a resident) and continue to test all staff and residents that tested negative every 3-7 days until 14 days has passed since the most recent positive result. An admit already confirmed does not constitute a facility outbreak.
Routine Testing: Test all staff based on the extent of the virus in the community, using CMS’ published county positivity rate under “COVID-19 Testing”, in the prior week as the trigger for staff testing frequency as outlined in the table below:
Facilities are guided to monitor their county positivity rate every other week (e.g. first and third Monday of every month).
Staff and residents who have recovered from COVID-19 and are asymptomatic do not need to be retested for COVID within 3 months after symptom onset.
CMS provided guidance on staff who refuse to test:
Staff who refuse and have signs or symptoms must be prohibited from entering until the return to work criteria are met. CLICK HERE to review the CDC Criteria for Return to Work.
Asymptomatic staff who refuse testing should follow occupational health and local jurisdiction policies.
Facilities must maintain records of all testing for compliance and must be able to provide to surveyors.
Facilities that do not comply with the testing requirements will be cited for noncompliance with new F-tag, F-886.
CMS has also revised the focus surveys for nursing homes to ensure compliance with testing requirements, infection prevention standards, and compliance for infection preventionists.
With frequently updated guidance from federal and state agencies, we are continuously hearing the most current information on how to protect our residents from COVID-19 with best practice infection control. Keeping all members of the team informed of the most recent processes may appear to be a daunting task; however, with the uptick in COVID-19 cases in nursing homes and CMS administrator Seema Verma stating concern, it’s a great time to review how we can keep our residents, staff, and selves safe.
Reliant has created a 4-step approach to Take CARE with Infection Control:
When considering implementation, identify appropriate hand hygiene frequency, PPE based on type of precautions, and items and equipment that need routine cleaning and disinfection. Be attentive to sequenced steps and processes for hand hygiene, donning and doffing PPE, and cleaning. In order to ensure reliability, commit to self and peer accountability and implementing PPE peers using return demonstration. To monitor effectiveness of implementation, assess and adjust processes as necessary.
By working together as an interdisciplinary team and holding each other accountable for best practice infection control practices, we can minimize the spread of COVID-19 within our facilities. Practice extreme diligence and caution with infection control and prevention processes.
CLICK HERE for more information on Reliant’s Take CARE with Infection Control initiative.
Mrs. Mabary was admitted to Care Nursing and Rehab in Brownwood, TX, after a fall led to a hip fracture on her right side which also had a prior transtibial amputation. Prior to her injury, Mrs. Mabary walked up and down the 20 stairs to her bedroom with her prosthesis. However, due to weight bearing restrictions, the therapy team had to get creative with a technique for going up and down the stairs. At first, Mrs. Mabary was unable to hop up and down even one step without her prosthesis. After working hard in therapy, she is now more than halfway to her goal of 20 steps as she is able to hop up and down a step 13 times!
Her drive and determination didn’t stop there! When Mrs. Mabary arrived at Care Nursing and Rehab, she had a great deal of pain and required moderate assistance for bed mobility and transfers. Now she can perform bed mobility and transfers with someone just standing nearby for assistance, and with decreased pain.
Luckily for Mrs. Mabary, communication and training with her son (with whom she lives ) is easily achievable as her son is a certified nursing assistant at the facility. Mrs. Mabary has a follow up appointment next week, and the team is hoping for great news regarding her weight bearing restrictions. In the meantime, she will continue working hard to improve her strength and balance.
Thank you, Mrs. Mabary, for being a great example of perseverance while also encouraging the other residents to strive hard in therapy. You are an inspiration to us all!
The Office of Civil Rights (OCR) issued an alert on August 6, 2020 reporting postcards are being sent impersonating the OCR to coerce compliance officers into visiting a website regarding HIPAA risk assessments. This is a marketing ploy to trick the victim into engaging in services under the guise of a directive from OCR. A risk assessment is a requirement of HIPAA as defined in §164.308(a)(1); however, it does not specifically state how often it is needed or how it is to be done. Best practice is to conduct risk assessments annually or when significant changes or threats occur within or to the environment.
It is recommended by OCR that all covered entities alert their workforce about this misleading communication. For more information and an example of the postcard, CLICK HERE.
In the August 6, MLN, CMS announced Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs resumed with post-payment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.
Although medical review has not been initiated at this time for dates of service during the public health emergency, future RAC and MAC reviews are forthcoming. According to an article posted on RAC Monitor on 8/25/20, high priority audits may include claims with
Positive COVID-19 diagnoses to ensure testing results are accurately documented.
Remote patient monitoring codes
Providers should be reviewing claims and supportive documentation now to identify potential areas of improvement.
Additionally, the introduction of remote audits is anticipated. The remote audits allow for the current work-from-home, travel-restricted business climate.
CMS projects that aggregate Medicare program payments to SNFs will increase by $750 million, or 2.2 percent, for FY 2021 compared to FY 2020. This estimated increase is attributable to a 2.2 percent market basket increase factor, adjusted by a 0.0 percentage point productivity adjustment.
Updates to PDPM Clinical Diagnosis Mappings
In this final rule, in response to these stakeholder recommendations, CMS is finalizing changes to the ICD-10 code mappings, effective October 1, 2020.
SNF Value-Based Purchasing (VBP) Program
CMS made no changes to the measures, SNF VBP scoring policies, or payment policies in this final rule. CMS announced performance periods and performance standards for the FY 2023 program year.
With the budget neutrality adjustment to account for changes in Resource Value Units (RVUs), CMS reports the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09. CMS’ increases in RVU for Evaluation and Management (E/M) services codes in CY 2020 final rule are to take effect 1/1/2021. These increases are a positive for primary care physicians and some physical therapy and occupational therapy evaluation codes. However, the significant cuts to frequently used therapy intervention codes result in an overall 7-9% decrease in reimbursement for therapy services. CMS proposes these cuts to therapy as well as other critical care provisions in order to meet the budget neutrality requirements.
Advocacy efforts are underway to #fightthecut and protect our beneficiaries’ access to therapy, especially during this health care emergency.
Contact your congressman through your respective association below:
Additionally, comments can be sent directly to CMS here by October 5, 2020.
Medicare Telehealth
CMS is proposing to make permanent some telehealth provisions related to physician visits that have been extended as part of the public health emergency. Currently, a finite list of therapy services is reimbursable when provided via telehealth for as long as the public health emergency exists, and there is no proposal to make these therapy telehealth provisions permanent.
CLICK HERE to view the Physician Fee Schedule CY 2021 Proposed Rule.
CLICK HERE to view the Physician Fee Schedule Proposed Rule Fact Sheet.
On Oct 1 MDS version 1.17.2 will be used. Updates include assessment changes that will support the calculation of PDPM payment codes for state Medicaid programs and on OBRA assessments when not combined with the 5-day SNF PPS assessment. This will specifically affect the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.
The updated item sets will not have a revised RAI manual released. Contact your state’s RAI coordinator for item set questions.
Watch for more information from CMS regarding possible additional waivers for beneficiaries in Louisiana and Texas due to Hurricane Laura and in California due to the wildfires following declarations of public health emergency in those locations.
CLICK HERE for more information on the waivers when they become available.
CLICK HERE to read the press release regarding Hurricane Laura relief.
Providers have begun receiving non-medical additional document requests for claims utilizing the benefit period waiver in response to the COVID-19 public health emergency. These reviewers are being flagged with a “7COVD” code and have primarily been reported under Wisconsin Physician Services (WPS).
These suspended claims may be the result of a billing issue. As such, review the proper guidelines below for how claims involving the waiver for the 60-day wellness period should be billed.
Loneliness and social isolation might seem like conditions that are just “in your head,” but it’s important to recognize the signs and help those who might be impacted.
Types of Loneliness
Emotional
When someone feels the lack of intimate relationships possibly due to the loss of a close partner or friend.
Grief and bereavement support can help provide the tools needed to cherish that relationship and move forward to exploring new ones.
Incorporate activities to honor their loved one (e.g., make a scrap book or photo album).
Social
Lack of satisfying contact with family, friends, neighbors and other community members
Engaging in social activities can help mitigate this one. Encourage the person to dine with others and find activities that inspire them to interact including music, games and other activities hobbies.
If appropriate for the resident(s), incorporate education in the use of smart phones or computers for communication with family and friends.
Collective
Feeling of not being valued by the broader community
Lend a listening ear.
Coordinate a small support group within the community where participants can share their stories, encourage each other and identify opportunities for community involvement.
Facilitate activities that engage the resident and the community in which residents assist the community (e.g., shelling peas for a local farmer).
Existential
The sense that life lacks meaning or purpose
Often older adults feel they have moved from providing for their family to being becoming a burden on them. Help them find a new meaning and purpose such as the following:
Explore small chores in the facility such as:
Helping with a pet therapy animal
Watering or tending plants/gardens
Feeding the birds
Delivering mail or paper
Shower them with lots of appreciation for their contributions – no matter how big or small.
Despite the many adaptations and additional considerations that have been adopted in the battle against COVID-19, healthcare providers in skilled nursing facilities (SNFs) maintain their primary focus of quality patient rehabilitation and care. In the midst of planning and delivering care in a pandemic, some may ask, Does data collection really matter right now? What’s GG got to do with it? The answers are Yes and everything!
CMS has indicated the value of data collection of our patient’s functional abilities (i.e. Section GG) by signaling it as a key comparison of quality across post-acute settings, an indicator of resource use impacting reimbursement, and critical to guiding patient-centered care planning. Although CMS stated exceptions and extensions were granted because data collection may be greatly impacted by the response to COVID-19, beginning July 1, SNFs are expected to report their quality data to meet the SNF QRP requirements for the third quarter of 2020. (Download CMS’ SNF QRP Tip Sheet)
Knowing this data eventually will be publicly posted, the question now becomes Does it reflect our exhausting efforts to deliver care during this public health emergency? That answer is yet to be determined, but it is never too late for a review and refresh of Section GG content as well as considerations for coding and patient identification in the current environment.
Accuracy of Section GG coding depends not only upon the healthcare professional’s familiarity with the objective scales, but also with each item’s definition, intent and parameters for coding. For example, walking items may be completed within separate sessions. A single walking item may include a brief rest, as long as the resident does not sit down. These considerations may assist in completing a thorough assessment in isolation. CMS provides training videos on the SNF QRP Training webpage for instructional purposes.
Facilities can use Section GG data to capture potential changes in function that may require skilled intervention by completing interim assessments. It is the role of the interdisciplinary team to identify potential impacts of isolation on a patient’s biopsychosocial wellbeing and intervene as appropriate.
Finally, review the submission requirements for the SNF-QRP, so a technicality does not overshadow the successful outcomes your teams are creating. Avoid dashes, utilize the activity not attempted codes as necessary, incorporate at least one goal into the patient’s care plan and submit the completed data for at least 80% of your Medicare A claims.
The interdisciplinary team should champion the role of data collection, even in a pandemic, to ensure that we are facilitating the appropriate plan of care, capturing the true picture of the resident’s needs and maintaining the highest quality of rehabilitation and care. Our patients are counting on us!
CMS reports a new issue is affecting some inpatient hospital and skilled nursing facility (SNF) claims when an interrupted stay is billed at the end of the month. The system incorrectly assigns edits U5601-U5608 (overlapping a hospital claim).
If you billed the interrupted stay correctly, and your claim is rejected, modify your billing so the claim spans past the last day of the interrupted stay:
Bill two months at a time, or
Bill a month plus the days in the following month that span the interrupted stay plus 1 day
According to CMS, adjusting the statement covered from and through dates to encompass the entire interrupted stay will allow your claim to process and pay correctly. Medicare Administrative Contractors will finalize any suspended claims that meet the criteria, so you can make corrections and resubmit your claim.
If CMS rejected an inpatient hospital claim, the hospital should ask the SNF to modify their claim. Until October 5, a SNF cannot submit an adjustment to a paid claim; they must cancel the paid claim and all subsequent claims in the same stay and resubmit them in sequential order.
External reviewers have begun targeting Section GG as a focal point of pre/post-pay medical review audits. Because the PDPM function score is derived from Section GG data, and that score correlates to a case mix group for payment, reviewers will seek supportive documentation for decision making related to coding on the MDS.
Therapy evaluations, recertifications, and discharge documents serve as clinical support of that decision making.
Section GG coding should be reflective of the patient’s clinical characteristics.
Objective data within the therapy evaluation/discharge should correlate to the section GG scores.
Example: Bathing noted as Min assist by OT would be scored as 3 – Partial/Moderate Assistance.
Ensuring accurate data information at the beginning of the stay is the first key to successful outcomes. Accurate coding on sections I, C, and K of the MDS are critical. This clinical classification serves as a predictor of resource needs (therapy needs) from CMS and establishes an admission (baseline) for the patient that may be used as parameters in the future for patient progression.
Consider implementing proactive internal audits that review supportive documentation for MDS coding and continue to educate staff on proper coding to strengthen medical review success.
To access our tools for success, please CLICK HERE.
The U.S. Department of Health and Human Services (HHS) has provided more detailed Provider Relief Fund (PRF) reporting guidance. HHS reports they will be releasing more detailed reporting instructions by August 17, 2020.
These reporting instructions will provide directions on reporting obligations applicable to any provider that received a payment from the following CARES Act/PRF distributions:
General Distributions:
Initial Medicare Distribution
Additional Medicare Distribution
Medicaid, Dental & CHIP Distribution
Targeted Distributions:
High Impact Area Distribution
Rural Distribution
Skilled Nursing Facilities Distribution
Indian Health Service Distribution
Safety Net Hospital Distribution
According to HHS, the reporting system will become available to recipients for reporting on October 1, 2020.
All recipients must report within 45 days of the end of CY 2020 on their expenditures through the period ending December 31, 2020.
Recipients who have expended funds in full prior to December 31, 2020 may submit a single final report at any time during the window that begins October 1, 2020, but no later than February 15, 2021.
Recipients with funds unexpended after December 31, 2020, must submit a second and final report no later than July 31, 2021.
Detailed PRF reporting instructions and a data collection template with the necessary data elements will be available through the HRSA website by August 17, 2020.
