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Last week, the Centers for Medicare & Medicaid Services (CMS) released the long-awaited version 1.17.1 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. One change from the draft version 1.17 manual highlights some ongoing confusion about how to code ICD-10-CM diagnosis codes in MDS items I0020B (ICD Code/Resident’s Primary Medical Condition) and I8000 (Additional Active Diagnoses) to ensure accurate case-mix classification in the Patient-Driven Payment Model (PDPM).
The ICD-10 code entered in I0020B determines a Part A resident’s default primary diagnosis clinical category for the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) payment components under PDPM. In addition, ICD-10 codes entered in I8000 determine whether the resident qualifies for certain comorbidities under the SLP component (identified in Table 14, “SLP-Related Comorbidities,” in the PDPM Calculation Worksheet for SNFs section of chapter 6 in the RAI User’s Manual) or the nontherapy ancillaries (NTA) component (identified in Table 16, “NTA Comorbidity Score Calculation”).
SNFs are in the final stage of preparation for Patient-Driven Payment Model (PDPM) implementation, but alongside the payment model’s introduction, new policies are being introduced that add layers of complexity that nurse assessment coordinators (NACs) must master this fall. For example, the new Interrupted Stay Policy adds a whole new critical thinking process to what has been a simplified PPS schedule. However, the Interrupted Stay Policy does not need to cause anxiety—it just needs to be better understood. Here are seven tips to uncomplicate the Interrupted Stay Policy:
1. Understand the two criteria of the Interrupted Stay Policy.
The Interrupted Stay Policy essentially combines multiple SNF PPS stays that are separated by less than three days into one stay when the resident meets both of the following criteria:
1. Resident returns to the same skilled nursing facility (SNF), and
2. Returns by 11:59 pm of the third calendar day
The Interruption Stay Policy also introduces the concept of the “interruption window,” which begins with the calendar day of discharge and includes the two calendar days immediately following. If the resident’s Medicare stay ends, and the resident remains in the facility with benefit days remaining, then the interruption window begins on the first non-covered day and includes the next two calendar days.
The Patient-Driven Payment Model (PDPM) is designed to reallocate Medicare Part A payments made in the Skilled Nursing Facility Prospective Payment System (SNF PPS) to currently underserved beneficiaries, i.e., residents who have more clinically complex needs and high nontherapy ancillary (NTA) costs. To navigate PDPM, nurse assessment coordinators (NACs) will need to be able to code the appropriate active diagnoses, conditions, and treatments for these complex medical residents on the MDS.
Researching and using accurate ICD-10-CM diagnosis codes is critical to achieving appropriate PDPM case-mix groups for these residents. The ICD-10 code for the resident’s primary diagnosis for the SNF stay, reported in new item I0020B (ICD Code/Primary Medical Condition), will determine their default primary clinical category for classification under the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) payment components. ICD-10 codes entered in I8000 (Additional Active Diagnoses) also can factor into comorbidities that would further impact the SLP component, as well as the NTA component.
Under the Patient-Driven Payment Model (PDPM), resident outcomes will be key to avoiding medical review, said officials with the Centers for Medicare & Medicaid Services (CMS) during the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training session, Patient-Driven Payment Model: What Is Changing (and What Is Not). Note: Find the session slides here.
The goal of PDPM is for SNFs to provide value-driven care, said officials. “Fundamentally, it comes down to a balance. A high-value and efficient provider is one that is able to achieve high-quality outcomes at low cost.”
CMS measures SNF quality of care in three main ways:
The SNF QRP;
The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program; and
The Five-Star Quality Reporting System on Nursing Home Compare.
It can start out as little things. Something doesn’t feel quite right. The environment around you feels hushed or hostile. And then you become the target.
That was the experience for a nurse who was bullied for eight years by another staff member in her facility. She was about to walk away quietly and quit her job, like so many had before her, feeling like she could not do anything about her situation other than remove herself from it. But just in time, she found the strength she needed to keep going and to share her voice.
Although she would like to remain anonymous (we’ll refer to her as Nancy), she wanted to share her story so that, if you are experiencing workplace bullying, you can learn how to overcome it, to move forward, and to start healing.
The Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 3.0 has been posted. The Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 3.0 contains detailed specifications for the assessment- and claims-based quality measures reported under the SNF QRP. The manual can be found below and the Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 2.0 has been moved to the Quality Measures Archive page.
Under the Patient-Driven Payment Model (PDPM), the Centers for Medicare & Medicaid Services (CMS) will implement an interrupted-stay policy for the first time in the Skilled Nursing Facility Prospective Payment System (SNF PPS). The agency is already ironing out some potential bumps in the implementation process. Following the release of the draft v1.17 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, CMS has clarified the new policy to account for the difference in how the day of discharge is treated for Part A residents who physically discharge from the SNF vs. those who discharge from Part A and remain in the building (e.g., as a Medicaid resident).
CMS officials reviewed key aspects of the interrupted-stay policy, including this new clarification that impacts the count of noncovered days, during two sessions at the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training event: Section A, I, J, and O Updates and Patient-Driven Payment Model: What Is Changing (and What Is Not).
CMS has released the PDPM ICD-10 Mappings File for FY 2020 as well as the I0020B Code Lookup File.
This section includes fact sheets on a variety of PDPM related topics.
PDPM Frequently Asked Questions
This section contains frequently asked questions (FAQs) related to PDPM policy and implementation.
Launch of the CMS Beneficiary Notices Initiative (BNI) Mailbox Portal for Beneficiary Notices and Related Policy Questions
This message is to announce the launch of the new CMS Beneficiary Notices Initiative (BNI) mailbox portal for beneficiary notices and related policy questions. Please note this mailbox portal replaces the BNI mailbox, BNImailbox@cms.hhs.gov. The purpose of this new BNI mailbox portal is to provide a more efficient method for responding to provider, industry, and stakeholder questions.
The new BNI mailbox portal provides links to a variety of resources and links to other CMS mailboxes and e-mail addresses. CMS encourages you to review the available resources before submitting a question to ensure that we have not already provided information on the specific topic in question. Please also refer to the list of other CMS mailboxes and e-mail addresses to ensure that you direct your question to the most appropriate area of expertise.
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