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FY 2020 SNF PPS Rule Provides Opportunity for Comments

Payment Matters
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Comments are due on June 18 for the FY2020 skilled nursing facility prospective payment system (SNF PPS) proposed rule. The rule, which was published on April 25, includes discussion of the standard annual payment updates. In addition, it proposes changes to the SNF quality reporting program (QRP), including discussion of standardized patient assessment data elements (SPADEs) and related updates to the SNF value-based purchasing program. It also addresses implementation of the Patient-Driven Payment Model (PDPM), including changes to the definition of group therapy for patients receiving skilled therapy in SNFs.

Payment Changes

In the aggregate, under the proposed rule, CMS proposes a two and one-half percent increase in total payments to SNFs. This reflects a three percent market basket increase less a half percent productivity adjustment. The proposed rule details how the implementation of PDPM affects the methods used to calculate these adjustments on a going-forward basis.

Consolidated Billing

CMS discusses the types of services that are specifically excluded from SNF consolidated billing, such as physician services and other specifically identified "high-cost, low probability services." CMS invites commenters to identify specific services (by HCPCS code) that represent recent medical advances potentially eligible for exclusion from consolidated billing. Such services must fall into one of the categories of service eligible for exclusion (chemotherapy items, chemotherapy administration services, radioisotope services, and customized prosthetic devices).

PDPM-Related Updates

Several issues raised in the proposed rule are relevant to the PDPM implementation process.

Group Therapy Definition

Under existing rules, SNF residents may receive up to 25 percent of the total therapy services in a particular discipline in a group setting. A group setting is defined as four patients who are performing the same activity. Under the proposed change, CMS would broaden the definition of group therapy to include as few as two patients and as many as six patients who are performing the same or similar activities. CMS reiterated its belief that individual therapy is the preferred mechanism and stressed that clear documentation for the rationale, medical necessity, and goals for group therapy is still essential.

Regulatory Language Changes

Under PDPM a single patient assessment generates the necessary payment data, and additional assessments are required only when clinical changes occur that may affect payment. CMS proposes adjustments to regulatory language to reflect a single initial patient assessment (rather than several assessments) and interim payment assessments as necessary.

ICD-10 Code Mapping

CMS also proposed a subregulatory process for updating ICD-10 code mappings due to changes in the coding system (rather than changes in services).

SNF Quality Reporting

SNFs continue to be subject to payment reductions if they fail to report the quality data that CMS requires. CMS proposes to adopt two new process measures for FY 2022, both of which relate to the transfer of information to other post-acute care providers and to patients. CMS notes that effective coordination of information transfer during transitions in care is a key aspect of quality care. CMS proposes to measure provider-to-provider information transfer by measuring the proportion of patients discharged to a subsequent provider where the MDS discharge assessment indicates a current reconciled medication list was provided to the subsequent provider. For provider-to-patient information transfer, CMS proposes to measure the proportion of patients discharged to home, an assisted living facility, or with home health or hospice in place where the MDS discharge assessment indicates a current reconciled medication list was provided to the resident or a family member. CMS also proposes that, beginning in FY 2022, it will collect quality data for all residents, not just Medicare beneficiaries.

The proposed rule also includes discussion of Standardized Patient Assessment Data Elements, or "SPADEs." CMS indicated it will use this acronym in the future to refer to its collection of required patient assessment data. CMS will collect SPADEs through existing assessment instruments (i.e., the MDS) beginning in FY 2022, but seeks input on the measures it will use. These are described in more detail below. Most interestingly, CMS proposes to collect data on social determinants of health such as race and ethnicity, preferred language, health literacy, transportation, and social isolation and solicits comments on these measures and proposals for data collection methodologies.

CMS solicits comments on data to be collected in several categories. For cognition and mental status, the rule proposes using the Brief Interview for Mental Status (BIMS) and the Confusion Assessment Method (CAM) for reporting data on cognition and mental status, and the Patient Health Questionnaire (PHQ-2 to 9) for data on depression. CMS also proposes measures to obtain more detailed data on special services, including chemotherapy (oral, intravenous, or other), oxygen therapy (intermittent, continuous, or high concentration), respiratory therapy (suctioning, tracheostomy care, and ventilator use), transfusions, dialysis, IV access, nutritional approaches (parenteral nutrition, feeding tubes, and altered diets), and high-risk drug classes. To collect data on medical conditions and comorbidities, CMS will focus on pain status; for data on impairments, CMS will collect information on hearing and vision status.

Value-Based Purchasing

CMS proposes a clarifying change to terminology used in the VBP program. The VBP program uses data related to potentially preventable readmissions within 30 days of hospital discharge, while the QRP follows readmissions after SNF discharge. CMS proposes clarifying the title of the VBP measure to include a reference to hospital discharge.

Opportunity for Providers to Comment

This proposed rule contains multiple opportunities to provide input on the changing landscape of SNF reimbursement and quality reporting. Providers should pay close attention to the proposed quality data collection, both in terms of substance and collection methods, particularly where a proposed approach would create burdensome requirements for facility staff. Comments are due by June 18.

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