SNF QUALITY REPORTING - BKD · • Calculation of measure example – A facility has a total of 250 SNF Part A stays during a 12-month-period (denominator) – Of these stays, there

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SNF QUALITY REPORTINGRefresh Your Understanding of SNF QRP

Justin ThompsonManaging [email protected]

Deborah Lake, RN, RAC-CT® Senior Managing Consultant

[email protected]

September 13, 2017

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• Participate in entire webinar• Answer polls when they are provided• If you are viewing this webinar in a group Complete group attendance form with

• Title & date of live webinar• Your company name• Your printed name, signature & email address

All group attendance forms must be submitted to [email protected] within 24 hours of live webinar

Answer polls when they are provided

• If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar

TO RECEIVE CPE CREDIT

• Describe & understand the components of SNF Quality Reporting

• Understand current & future quality reporting measures & how information for each is obtained

• Identify processes for successful management & monitoring of quality reporting

LEARNING OBJECTIVES

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IMPACT Act

• Improving Medicare Post-Acute Care Transformation (IMPACT) Act– Bipartisan bill passed on September 18, 2014 & signed into

law on October 6, 2014– Required CMS to establish a SNF Quality Reporting

Program (QRP)– Required CMS to make resident assessments & QM data

standardized between post-acute care providers• Means of comparing, measuring outcomes• Systematic means of data collection of Medicare

beneficiaries

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IMPACT Act

• Affects four post-acute care settings– Skilled Nursing Facilities (SNFs)– Long-term Care Hospitals (LTCHs)– Inpatient Rehabilitation Facilities (IRFs)– Home Health Agencies (HHAs)

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IMPACT Act

• Mandated QM data be implemented across three domains– Falls with major injury– New or worsened pressure ulcers– Assessment & care planning for functional status

IMPACT Act

• SNF quality reporting– Reported separately with no overlap with Quality

Measures (QMs) & Value Based Purchasing (VBPs)– Public reporting will be separate from Nursing Home

Compare– For residents admitted on or after 10-1-16– Stay-driven ---- Not resident-driven

• Stay = consecutive time in facility • Starts with a 5-day & ends with a PPS Discharge

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IMPACT Act

• For FY 2019 payment determination– CMS started data collection on residents admitted to SNFs

on & after January 1, 2017 & discharged from the SNF up to & including December 31, 2017

• Data calculated on a quarterly basis– SNFs must report all of the data necessary to calculate the

quality measures on at least 80% of the MDS assessments they submit

– A measure cannot be calculated when there is use of a dash (-)

IMPACT Act

• Penalty

– Beginning FY 2018, SNFs will have their annual payment update reduced by 2% if 80% of their Medicare assessments do not have 100% of data elements needed to calculate all three of the new QRP QMs

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IMPACT Act

• SNF will receive a notification of noncompliance if CMS determines the SNF failed to submit data in accordance with reporting requirements– Reconsideration requests must be emailed to CMS

containing all requirements listed on the Reconsideration Request portion of the SNF QRP webpage

– 30-day deadline– Must use email: [email protected]

• Public reporting of SNF QRP quality data is scheduled to begin in fall 2018

FALLS WITH MAJOR INJURY

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IMPACT Act

• Residents experiencing one or more falls with major injury (long stay)– Will use standardized MDS items J1800 & J1900C– Outcome measure

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Falls With Major Injury

• Fall– Definition of fall in the MDS manual remains unchanged– Injuries associated with falls must be coded on the same

MDS that the fall is reported• Any documented injury that occurred as a result of, or

was recognized within a short period of time, e.g., hours to a few days, after the fall & attributed to the fall

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• Measure will look at a resident’s Part A stay between the start of the covered stay identified in A2400B & the end of the stay as identified in A2400C

• Identified by a 5-day PPS assessment & an associated Discharge assessment

• Assessments eligible for inclusion in the look-back scan include Scheduled PPS assessments, OBRA Discharge assessment, any OBRA assessment & SNF PPS Discharge assessment


• No risk adjustment• Look-back scan• Exclusion

– Excluded if none of the assessments included in the look-back scan have a usable response for items indicating the presence of a fall with major injury during the selected time window

– J1900C = (-)

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• Calculation of measure– Numerator – Number of Medicare residents with one or

more look-back scan assessments that indicate one or more major falls resulting in a major injury

– Denominator – Number of resident Medicare stays with one or more assessments that are eligible for a look-back scan except those with exclusions

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• Calculation of measure example

– A facility has a total of 250 SNF Part A stays during a 12-month-period (denominator)

– Of these stays, there were 10 documented falls with major injury reported in J1900C (numerator)

– 10/250 = .04 X 100 = 4%

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NEW OR WORSENED PRESSURE ULCERS

New/Worsened Pressure Ulcers

• Residents with pressure ulcers that are new or worsened– Will use the MDS item M0300 from PPS Discharge

assessment– Outcome measure

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• Percent of residents with Stage 2-4 pressure ulcers that are new or worsened since admission to the SNF

• Determined by the following conditions on the target assessment (PPS Discharge Assessment)– Stage 2 (M0300B1) – (M0300B2) > 0 OR– Stage 3 (M0300C1) – (M0300C2) > 0 OR– Stage 4 (M0300D1) – (M0300D2) > 0

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• Calculation of the measure– Denominator – Number of complete Part A stays (5-day

PPS assessment & a PPS Discharge assessment) ending during the selected time window, except those with exclusions

– Numerator – Number of complete Part A stays that end during the selected time window with one or more new or worsened Stage 2-4 pressure ulcers at the end of the stay

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• Exclusions– Data on new or worsened Stage 2, 3 or 4 pressure ulcers

are missing at discharge• Dashes at M0300B1, M0300B2, M0300C1, M0300C2,

M0300D1 or M0300D2– Resident expired during SNF stay


• Risk adjustment– Based on resident characteristics or covariates– Characteristics or conditions that place a resident at

increased risk for skin breakdown or impact their ability to heal on PPS 5-day assessment

• Require limited or more assist in bed mobility– Self performance = 2, 3, 4, 7 or 8

• At least occasional bowel incontinence– H0400 = 1, 2 or 3

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• Risk adjustment (cont.)• Diagnosis of diabetes or PVD

– I0900 or I2900 checked in Section I• Low body mass index (BMI) (height & weight)

– BMI >= 12.0 & <= 19.0

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• M0300 requires accuracy in coding of the following – “Present on Admission”

– “Worsened pressure ulcer”• Pressure ulcer must increase in numerical stage

indicating a deeper level of tissue damage

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New/Worsened Pressure Ulcers• “Present on Admission”

– On admission = as close to the actual time of admission as possible

– Means• The pressure ulcer was present at the time of

admission/entry or re-entry to this nursing home &

• The stage of the ulcer has not worsened at any time since admission

&• The pressure ulcer was not acquired while the resident

was in the care of the this nursing home during any stay


• FY 2018 proposed rule– Replacement of current pressure ulcer measure with an

updated version – Changes in Skin Integrity Post-Acute Care: Pressure

Ulcer/Injury• Include unstageable categories

– For FY 2020

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FUNCTIONAL ASSESSMENT

Functional Assessment

• Percent of Residents With Admission & Discharge Functional Assessment & a Care Plan that Addresses Function– Data collection started on October 1, 2016

– Measures the percent of residents with an Admission assessment, i.e., 5-day PPS, & a Discharge functional assessment & a treatment goal that addresses function

– Considered a process measure that looks at facility processes • No impact on SNF reimbursement (RUG level)

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• Separate data collection for SNFs– Traditional Medicare SNF Part A stay– Addition of Item A0310H to Section A– Addition of Section GG to the MDS

• Completion at start & end of Part A stay– Addition of End of Medicare Stay assessment (PPS

Discharge assessment)• New item set (Sections A, GG, J & M)

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• Section GG – Items in Section GG are used to calculate the SNF QRP function quality

measure– Assesses the need for assistance with & establishes goals for self-care

& mobility activities using a 6-point rating scale– Will be completed on a resident’s admission to & discharge from Part

A services– Three steps

• Admission assessment• Goal setting• Discharge assessment

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• Start of Stay Assessment– 5-day assessment – May be combined with an OBRA MDS– Data collection is for Days 1 thru 3 of the SNF PPS stay– Starts with date in A2400B (start of the most recent

Medicare stay or Day 1 of Part A stay)

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• Medicare Part A stay dates dictate when to code Section GG– A2400A is coded “yes” to a Medicare Part A stay– A2400B has a Medicare Part A start date

• A2400B is Day 1• Look-back ends on Day 3 of the Medicare stay

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• Section GG – Assessment of resident’s admission performance & discharge goal– GG0130 – Self-care (3)– GG0170 – Mobility (9)

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Section GG

Self-care Items (3)• Eating (does not include tube

feeding)• Oral hygiene• Toileting hygiene

Mobility Items (9)• Sit to lying• Lying to sitting on side of bed• Sit to stand• Chair/bed-to-chair transfer• Toilet transfer• Walk 50 feet with two turns• Walk 150 feet• Wheel 50 feet with two turns• Wheel 150 feet

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• Q & A Documents– June 2016 Provider Training– August 2016 Provider Training– September 2016 Questions & Answers – March 2017 HELP Desk


• Intent is to capture the resident’s true admission baseline status

• Code resident status based on their “usual” performance– Not the resident’s most independent status– Not the resident’s most dependent status

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• Key definition: Helper– Facility staff who are direct employees or facility

contracted employees (rehab & agency staff)

• Key definition: Helper Assistance– Required because the resident’s performance is unsafe or

of poor quality– Score according to amount of assistance (effort) provided –

not the amount of time spent with the resident


• 6-level rating scale– 01 = Dependent – also includes two-person assist

• Helper does all of effort

– 02 = Substantial/maximal assistance• Helper does more than half the effort

– 03 = Partial/moderate assistance• Helper does less than half effort

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• 6-level rating scale (cont.)– 04 = Supervision or touching assistance

• Helper provides verbal cues, touching/steadying assist as resident completes activity

– 05 = Set-up or clean-up assistance• Resident completes activity but helper sets up or cleans

up prior to or following the activity– 06 = Independent

• Resident completes activity by him/herself• No assistance from a helper

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• Special codes to report why an activity was not attempted– 07 = Resident refused to complete the activity

– 09 = Not applicable (resident did not perform the activity prior to the current illness, exacerbation or injury; consider prior level of functioning)

– 88 = Not attempted due to medical condition or safety concerns (consider endurance levels)

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• Assess the resident’s self-care status based on direct observation, the resident’s self-report, family reports & direct care reports documented in the resident’s medical record during the 3-day assessment period, which is Days 1 thru 3, starting with the date in A2400B, start of most recent Medicare stay


• 5-Day PPS assessment is the first Medicare-required assessment for a Part A stay– For the Admission assessment, code the resident’s

functional status based on an assessment of the resident’s performance that occurs soon after the resident’s admission. This assessment must be completed within three calendar days, starting with the date in A2400B & the following two days, ending at 11:59 pm on Day 3. The assessment should occur prior to the start of therapeutic intervention in order to capture the resident’s true admission baseline status. (Page GG-4)

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• Per RAI Version 1.15 --- Effective October 1, 2017– For the 5-day PPS assessment, code the resident’s

functional status based on an assessment of the resident’s performance that occurs soon after the resident’s admission….. The assessment should occur when possible, prior to the resident benefitting from treatment interventions in order to determine the residents true admission baseline status. Even if treatment started on day of admission, a baseline functional status can still be conducted. (GG-5)


• Lessons from the trenches– Documentation in the medical record should be used to

support assessment coding of Section GG• Every shift or daily documentation• Direct observation of staff• Interview/report of direct care staff, resident or family• Resident report of abilities• Family report of abilities

– Documentation processes should be user-friendly & not burdensome to staff

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• Lessons (cont.)– IDT approach

• Collaboration of MDS, therapy & nursing• Across all shifts

– Use of therapist only• Therapy perspective• Overstated performance• Lack of input across three shifts


• Lessons (cont.)– Use of nursing assistants

• “Report off” vs. direct documentation– Review processes quarterly– Revisit training ----- focus on accuracy– Update MDS policies & procedures

• “How” & “Who”– No transmission if completed for nontraditional Part A

residents

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Discharge Goals

• A minimum of one self-care or mobility function goal must be coded to meet measure– Goal can be to maintain, increase or decrease function

• Use of same 6-point scale• Options 07, 88 & 09 are not to be used when coding discharge

goals• If a goal is not required for a certain task enter a dash (-)

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Discharge Goals

• Expected to improve• Not expect to improve – maintain functional performance• Expected to decline

– Resident has progressive condition that is expected to cause rapid decline

– Services may slow the decline of function– Decline in function is anticipated & unavoidable

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Discharge Goals

• Licensed clinicians should establish discharge goals at the time of admission base on the 5-day PPS assessment, discussion with resident & family, professional judgement & profession standards of practice

• Goals should be established as part of the resident’s care plan• Training of nursing staff in writing of functional goals

PPS DISCHARGE ASSESSMENT

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PPS Discharge Assessment

• Contains data elements used to calculate current & future SNF QRP measures– Required when a resident’s Medicare Part A stay ends– Consists of demographic, administrative & clinical items– Part A PPS Discharge (NPE) item set– Requires accurate coding of End Date of Most Recent

Medicare Stay at A2400C


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• End of Medicare Date (A2400C) – Whichever occurs first– Date SNF benefit exhausts (100th day of benefit)– Date of last day covered as recorded on the effective date

from the Notice of Medicare Non-Coverage (NOMNC)– Last paid day of Medicare A when payer source changes to

another payer (regardless of whether the resident was moved to another bed or not)

– Date the resident was discharged from the facility


• Part A End of Stay Assessment– Required when a resident discharges from traditional

Medicare Part A– Data collection period is the last three days of the SNF PPS

stay– Ends with the date in A2400C (end date of most recent

Medicare stay)

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• Section GG is completed when all of the following occur– A0310G = 1 (Planned discharge)– A0310H = 1 (PPS Discharge assessment)– A2400C minus A2400B > 2– A2100 does not = 3 (Acute hospital)

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• Unplanned discharges– Acute care transfer of resident to a hospital or an

emergency department – Resident unexpectedly leaves AMA– Resident unexpectedly decides to go home or to

another setting

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• Required when a resident’s Medicare Part A stay ends, but the resident remains in the facility

• The ARD for a standalone PPS Discharge assessment is always equal to A2400C

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• Can also be combined with the OBRA Discharge assessment when a Part A resident has a Discharge Date (A2000) that occurs on the day of or one day after the End Date of the Most Recent Medicare Stay (A2400C)

• The ARD for a combined OBRA/PPS Discharge assessment must be equal to the Discharge Date at A2000

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• If the last day of the Medicare stay occurs on the same day that the resident dies, a Death in Facility Tracking Record is completed. A Part A Discharge assessment is not required.

• If the last day of the Medicare stay (A2400C) is earlier than the actual Discharge date (A2000) from the facility, the Part A Discharge assessment is required.


• May be combined with most OBRA & scheduled PPS assessments

• Scheduled PPS assessments– ARD (A2300) must be set for the last day of the

Part A stay– Last day of the Part A stay must fall within the

allowed window of the PPS scheduled assessment

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• May not be combined with standalone OMRA assessments– Change of therapy (COT)– End of therapy (EOT)– Start of therapy (SOT)– Start/End of therapy (SOT/EOT)

Functional Measure

• Purpose: To determine the percent of residents who have their functional status assessed upon admission & discharge & have a care plan addressing function– No risk adjustment– Process measure – Want high percent for measure– Implemented October 1, 2016 thru December 31, 2016 for

FY 2018 paymentResidents who meet criteria

(Complete or Incomplete Stay) X 100Total # of Part A stays

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Functional Measure

• Complete Stay– Valid score indicating

functional status or valid code why activity was not attempted on each functional item on admission & discharge to Part A

– At least one self-care &/or mobility goal

• Incomplete Stay– Valid score indicating

functional status or valid code why activity was not attempted on each functional item on admission to Part A

– At least one self-care &/or mobility goal

– Resident unplanned d/t to hospital, AMA discharge or expiration of resident

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Functional Measure

• Calculation of measure– Denominator – Number of Part A covered resident stays

during the reporting period– Numerator – Number of resident stays with functional

assessment data for each self-care & mobility activity & at least one self-care or mobility goal

– Facility would want a higher percentage of residents qualifying for the QM

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Functional Measure

• Calculation of measure example– A facility has a total of 225 SNF Part A resident stays that

meet the inclusion criteria during a 12-month-period (denominator)

– Of these stays, there were 175 with complete stays of which 165 had complete functional status data on admission & discharge

– There were 50 residents with incomplete stays of which 45 had complete admission functional status data

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Functional Measure

• Calculation of measure example

– Denominator = 225– Numerator = 165 + 45 = 210

– 210/225 = 0.933 X 100 = 93.3%

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ACHIEVING & MONITORING COMPLIANCE WITH QUALITY REPORTING

Quality Reporting

• Ensuring compliance– Ensure PPS Discharge assessments are completed

at the end of each Part A stay– Double-check system– Do not submit assessments intended for

nontraditional Part A residents --- Medicare Replacement, insurance, Medicare Advantage, etc.

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Quality Reporting

• Monitoring compliance– Submitter & Final Validation reports

• Warning #3863 thru 3877

– MDS 3.0 Error Number Summary by Facility by Vendor

– Error Detail by Facility – MDS 3.0 Assessment with Error Number XXXX– Submission Activity Reports– Review & Correct Reports

Quality Reporting

• Final Validation reports– Produced with each transmission– Error #3863 thru 3877

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Quality Reporting

• MDS 3.0 Error Number Summary by Facility by Vendor• MDS 3.0 Assessment with Error Number XXXX• Error Detail by Facility

Quality Reporting

• Review & correct reports– Available in SNF Quality Reporting Program report

category– Facility level measure data– Performance up to the last four full quarters– Update schedule

• Weekly – In early morning hours every Monday to incorporate any date submissions/corrections for an “open” quarter

• Quarterly – In early morning hours of the first day following a quarter

• End of Quarter – 4.5 months after completion of a quarter

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Quality Reporting

• Correct & review reports (cont.)– Information related to overall quality measure calculation– No risk adjusted– Issues

• Not being updated with corrected information• Miscalculation of Functional Assessment measure

– Correction• Early September 2017 – Enable modified records• Mid-September 2017 – View & once again modify Q1 2017 date• December 2017 – Reports updated• CY 2017 data submission deadline for all quarters May 15, 2018

Quality Reporting

• Correct & review reports (cont.)– SNF Quality Reporting Program

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Future Quality Reporting – What’s Next

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Functional Measure

• For FY 2020– Four outcome-based functional measures

• Change in Self-Care Score for Medical Rehab• Change in Mobility Score for Medical Rehab• Discharge Self-Care Score for Medical Rehab• Discharge Mobility Score for Medical Rehab

Quality Reporting Program

• Finalized for FY 2018 (Claims-based)– Medicare spending per beneficiary (MSPB)– Discharge to community– Potentially preventable 30-day post discharge

readmission (PPRM)

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• Medicare Spending per Beneficiary (MSPB)– To promote care coordination between providers– Compare a given SNF’s Medicare spending against other

SNF providers within a performance period– Medicare A & B claims– Admitted to facility within 30 days of hospital discharge– Admitting facility is provider for whom the measure will be

calculated


• Medicare Spending per Beneficiary (cont.)– Episode-based measure

• Treatment period starts upon admission to the SNF & ends with SNF discharge

• Associated service period starts after SNF discharge & continues for 30 days

– 20 minimum episodes

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• Medicare Spending per Beneficiary (cont.)– Excludes clinically unrelated services– Risk adjusted using claims from 60 days prior– Initial feedback for CY 2016 discharges– Public reporting for CY 2018


• Discharge to Community– Residents successfully discharged to community 31 days

following discharge• No unplanned hospital admit or death

– Community = Home or self-care with or without Home Health Services

– Will be taken from FFS claims• Patient Status Code of 01, 06, 81 or 86

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• Discharge to Community (cont.)– Will have risk adjustment based on age, sex, diagnosis,

ventilator status, ESRD, dialysis & other comorbidities– Will exclude residents sent to home-based hospice– Minimum of 25 eligible stays– Facility feedback for CY 2016– Public reporting for CY 2018


• Potentially Preventable 30-Day Discharge Readmission Measure (PPRM)– 30-day window starting two days after SNF discharge– Must have been admitted to the SNF within 30 days of

hospital discharge– Admitted to LTCH or acute care hospital with a diagnosis

considered to be unplanned & potentially preventable– Re-admission for which the probability of occurrence could

have been avoided with planned, explained &implemented post-discharge instruction

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• Potentially Preventable 30-Day Discharge Readmission Measure (cont.)– Inadequate management of

• Chronic conditions• Infections• Other planned events

– Risk adjustment for age, sex, hospital diagnosis, hospital LOS, ICU stay, renal status, hospital stays in prior year, etc.

– 25 minimum eligible stays


• Finalized for FY 2020 (MDS-based)– Drug Regimen review Conducted with Follow-Up for

Identified Issues– Initial data collection October 1, 2018 thru December 31,

2018– Subsequent collection will be on a calendar year

performance based on quarterly reporting periods– Will require modification of MDS for 10-1-18 for reporting

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• Drug Regimen Review Conducted with Follow-Up for Identified Issues– Review of all medications to identify any potentially

clinically significant medication issues– Evaluate whether SNFs were responsive to potential or

actual significant medication issues– Identify medication issues, communicate with physician &

have resolution within a rapid period of time (midnight of the next calendar day)

– Does not specify what clinical professional is required to perform review


• Drug Regimen Review Conducted with Follow-Up for Identified Issues (cont.)– Reported on admission & on discharge with look-back

through entire stay– Will require modification of MDS for 10-1-18 for reporting– No risk adjustment– Included in CASPER reporting in 2020– Confidential feedback in October 2019

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• Transfer of Health Information and Care Preferences (TOH)– Currently under pilot study– FY 2019– Two pieces

• Admission, Start or Resumption of Care from Other Providers/Settings

• Discharge or End of Care to Other Providers/Settings

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CONTINUING PROFESSIONAL EDUCATION (CPE) CREDIT

BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.nasbaregistry.org.

The information contained in these slides is presented by professionals for your information only and is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.

• CPE credit may be awarded upon verification of participant attendance

• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at [email protected]

CPE CREDIT

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QUESTIONS?

FOR MORE INFORMATION

THANK YOU!Deborah Lake | 260.460.4000 | [email protected]

Justin Thompson | 317.383.4000 | [email protected]

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