CLA’s Regulatory Advisor offers a concise summary of the final SNF rule and highlights key changes to payment and policy standards, the QRP, and the VBP program.
On July 30, 2019, the Centers for Medicare & Medicaid Services (CMS) released the fiscal year (FY) 2020 final skilled nursing facility (SNF) rule.
The following includes a high level overview of key provisions of the final rule (CMS-1718-F).
SNF payment and policy updates
CMS indicates the final FY 2020 SNF PPS rule will increase payments rates to SNFs in the aggregate by $851 million, and decrease payments to SNFs under the Valued-Based Payment program by $213.6 million.
Marketbasket update
There is a 2.8 percent update, which is reduced by a mandatory 0.4 percent productivity adjustment, resulting in a 2.4 percent net payment increase.
Use CLA’s 2020 Skilled Nursing Facility PDPM PPS Rate Calculator to see your facility’s payment rates.
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 finalized redefining group therapy in the SNF Part A setting. Effective October 1, 2019, group therapy will be defined as a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities. Also effective October 1, 2019, CMS will establish a 25 percent cap for concurrent and group therapy. This is to monitor and help prevent an overutilization of group therapy under PDPM.
ICD-10
To ensure that the ICD-10 mappings and lists used under PDPM reflect the most up-to-date codes possible, CMS finalizes that updates to 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, will be done through a subregulatory process. CMS will post updated code mappings and lists on the PDPM website. Nonsubstantive changes will be done through the subregulatory process, while substantive changes will continue through the notice and comment process. In response to a commenter’s questions, CMS defines “substantive” as “any change to the mappings and lists that goes beyond the intention of maintaining consistency with the most current ICD-10 medical code data set. Any change that constitutes a change in policy, including changes to PDPM clinical category assignments or to the assignment of a code to the comorbidities list.”
Five-day assessment clarification
CMS finalizes that the “five-day assessment” will now be referred to as the “initial Medicare assessment” going forward. CMS furthers clarifies its reference to eight days (five-day assessment plus three day grace period) to “require the performance of an initial Medicare assessment with an assessment reference date that is set for no later than the 8th day of posthospital SNF care.”
SNF Quality Reporting Program (QRP)
The following are elements of finalized changes, but closer review of the final rule for details is recommended.
- CMS finalizes adoption of 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 assesses 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 assesses 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 updates specifications for the Discharge to Community-PAC SNF QRP measure by excluding 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 finalizes a variety of changes with respect to standardized patient assessment data elements (SPADEs). CMS moves forward with adopting additional SPADEs, beginning with the FY 2022 SNF QRP. SNFs will 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.
- CMS finalizes the following:
- 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)
- 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 finalized category.
- 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.
- Cognitive Function and Mental Status 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 finalizes adjustments to how and when it will suppress data on Nursing Home Compare for SNFs that have fewer than 25 eligible stays.
In place of the March 31 deadline, CMS finalizes a 30-day deadline for phase one review and correction requests. 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 PDPM and the final 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.