SNF A Guide to Regulation and Legislation

CLA’s Regulatory Advisor: 2020 proposed SNF rule offers a concise summary of the proposed rule and highlights key changes to payment and policy standards, the QRP, and the VBP program.

Navigating health reform

CMS Releases Proposed SNF Rule for 2020

  • Jennifer Boese
  • 5/21/2019

On April 19, the Centers for Medicare & Medicaid Services (CMS) released the fiscal year (FY) 2020 proposed skilled nursing facility (SNF) rule. The following includes a high level overview of key provisions of the proposed rule (CMS-1718-P). The comment deadline is June 18.

SNF payment and policy updates

CMS indicates the proposed FY 2020 SNF PPS rule would increase payments rates to SNFs in the aggregate by $887 million, and decrease payments to SNFs under the Valued-Based Payment program by $213.6 million.

Marketbasket update

There is a 3 percent update, which is reduced by a mandatory 0.5 percent productivity adjustment, resulting in a 2.5 percent net payment increase.

Wage index

CMS is soliciting comments on SNF PPS wage index value calculations. CMS seeks comments from stakeholders regarding the wage index used to adjust SNF PPS payments and suggestions for possible updates and improvements to the geographic adjustment for those payments.

Patient-Driven Payment Model (PDPM)

CMS is moving forward with the PDPM model as finalized in last year’s final SNF rule. There are not substantive changes to the model in this rule. The new PDPM payment model begins October 1, 2019.

Group therapy definition

CMS proposes to redefine group therapy in the SNF Part A setting as follows: a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities. Therapists must continue to document why group therapy is appropriate to meet patient needs.


To ensure that the ICD-10 mappings and lists used under PDPM reflect the most up-to-date codes possible, CMS proposes to update any ICD-10 code mappings and lists used under PDPM, as well as the SNF GROUPER software and other such products related to patient classification and billing, through a subregulatory process. CMS would post updated code mappings and lists on the PDPM website. Nonsubstantive changes would be done through the subregulatory process while substantive changes would continue through the notice and comment process.

Five-day assessment clarification

CMS notes that even though this assessment is commonly referred to as the 5-day assessment, an additional three-day grace period has always been available beyond that window for its actual completion. The additional three days will be directly incorporated into the assessment window itself, effective October 1, 2019. Additionally, CMS will change “patient assessments” to “initial patient assessment.” The revision is: “the assessment schedule must include performance of an initial patient assessment no later than the 8th day of posthospital SNF care.

SNF Quality Reporting Program (QRP)

CMS proposes well over 100 pages of changes to the SNF QRP. The following are elements of those changes, but closer review of the proposed rule for details is recommended.

  • CMS proposes to adopt two process measures to the SNF QRP for FY 2022. The two measures are:
    • Transfer of Health Information to the Provider — Post-Acute Care (PAC). This measure would assess whether or not a current reconciled medication list is given to the subsequent provider when a patient is discharged from the current PAC setting.
    • Transfer of Health Information to the Patient — Post Acute Care (PAC). This measure would assess whether or not a current reconciled medication list was provided to the patient, family, or caregiver when the patient was discharged from a PAC setting to a private home or apartment, a board and care home, assisted living, a group home, transitional living or home under care of an organized home health services organization, or a hospice.
  • For FY 2020, CMS proposes to update specifications for the Discharge to Community-PAC SNF QRP measure to exclude baseline nursing facility (NF) residents from the measure. CMS defines baseline NF residents as SNF residents who had a long-term NF stay in the 180 days preceding their hospitalization and SNF stay, with no intervening community discharge between the NF stay and hospitalization.
  • CMS seeks input on the importance, relevance, appropriateness, and applicability of the future measures, concepts, and standardized patient assessment data elements (SPADEs) under consideration (see table 13).

Table 13: Future Measures, Measure Concepts, and Standardized Patient Assessment Data Elements (SPADEs) Under Consideration for the SNF QRP

Assessment-based quality measures and measure concepts
Functional maintenance outcomes
Opioid use and frequency
Exchange of electronic health information and interoperability
Health care-associated infections in skilled nursing facility (SNF) – claims-based
Standardized patient assessment data elements (SPADEs)
Cognitive complexity, such as executive function and memory
Bladder and bowel continence including appliance use and episodes of incontinence
Care preferences, advance care directives, and goals of care
Caregiver status
Veteran status
Health disparities and risk factors, including sex education, sex and gender identity, and sexual orientation
  • SPADEs. CMS proposes a variety of changes with respect to SPADEs. CMS proposes to move forward with adopting additional SPADEs, beginning with the FY 2022 SNF QRP. Under the proposal, SNFs would be required to report data with respect to SNF admissions and discharges that occur between October 1, 2020 and December 31, 2020 for the FY 2022 SNF QRP. For the FY 2023 SNF QRP, SNFs must report data with respect to admissions and discharges that occur during the subsequent calendar year (e.g., CY 2021 for the FY 2023 SNF QRP, CY 2022 for the FY 2024 SNF QRP).

    CMS proposes the following data elements would meet the definition of standardized patient assessment data for use in the SNF QRP.
    • Cognitive Function and Mental Status Data
      • Brief Interview for Mental Status (BIMS)
      • Confusion Assessment Method (CAM)
    • Patient Health Questionnaire-2 to 9 (PHQ-2 to 9)
    • Special Services, Treatments, and Interventions Data
      • Cancer Treatment: Chemotherapy (IV, oral, other)
      • Cancer Treatment: Radiation
      • Respiratory Treatment: Oxygen Therapy (intermittent, continuous, high-concentration oxygen delivery system)
      • Respiratory Treatment: Suctioning (scheduled, as needed)
      • Respiratory Treatment: Tracheostomy Care
      • Respiratory Treatment: Non-invasive Mechanical Ventilator (BiPAP, CPAP)
      • Respiratory Treatment: Invasive Mechanical Ventilator
      • Intravenous (IV) Medications (antibiotics, anticoagulants, vasoactive medications, other)
      • Transfusions
      • Dialysis (hemodialysis, peritoneal dialysis)
      • Intravenous (IV) Access (peripheral IV, midline, central line)
      • Nutritional Approach: Parenteral/IV Feeding
      • Nutritional Approach: Feeding Tube
      • Nutritional Approach: Mechanically Altered Diet
      • Nutritional Approach: Therapeutic Diet
      • High Risk Drug Classes: Use and Indication
    • Medical Condition and Comorbidity Data
      • Pain Interference (pain effect on sleep, pain Interference with therapy activities, and pain interference with day-to-day activities)
    • Impairment Data
      • Hearing
      • Visions
    • Social Determinants of Health (SDoH). The SDoH is a newly proposed category.
      • Proposed SDoH Data Collection to Inform Measures and Other Purposes. Data would be collected on race, ethnicity, preferred language, interpreter services, health literacy, transportation, and social isolation.
      • Standardized Patient Assessment Data.

SNF Valued-Based Purchasing Program

The performance period for the FY 2022 program year will be FY 2020, and the baseline period will be FY 2018. In addition, CMS proposes to adjust how and when it will suppress data on Nursing Home Compare for SNFs that have fewer than 25 eligible stays. CMS solicits comments on its proposed approaches.

In place of the March 31 deadline, CMS proposes to adopt a 30-day deadline for phase one review and correction requests, and notes that this proposal would align the phase one review and correction process with the phase two process. In other words, SNFs would have 30 days from the date that CMS issues its report to review the claims and measure rate information and to submit a correction request to CMS if the SNF believes that any of that information is inaccurate.

How we can help

CMS continues forward with PDPM implementation, which begins October 1. Interested in understanding how PDMP and the proposed changes in this rule may impact your organization? You can rely on CLA for our insights and analysis of the financial, policy-related, and operational impacts of an ever-changing health care landscape. We promise to know you and help you.