October 1, 2019 will mark the launch of what could be a sustained period of considerable change for the Skilled Nursing Facility Prospective Payment System (SNF PPS), the Skilled Nursing Facility Quality Reporting Program (SNF QRP), the MDS itself—and the role of the nurse assessment coordinator (NAC), suggests Jessie McGill, RN, RAC-MT, RAC-MTA, curriculum development specialist at AANAC.
The changes start this October 1 with the implementation of the Patient-Driven Payment Model (PDPM) for the fee-for-service Medicare Part A SNF PPS. “This is a distinctly different payment model than RUG-IV, and it will drive a complete shift in the NAC’s focus. Instead of concentrating on therapy minutes and the activities of daily living (ADLs), the NAC will have to pay attention to a whole array of clinical services that need to be captured by the 5-day MDS’s assessment reference date (ARD),” says McGill. “This will mean spending a lot of time looking for documentation, not only from the nursing staff but also from the physicians to support ICD-10-CM codes.”
The second wave could implement on October 1, 2020, if the Centers for Medicare & Medicaid Services (CMS) adopts several key proposals in the Fiscal Year (FY) 2020 SNF PPS Proposed Rule (CMS-1718-P). The Standardized Patient Assessment Data Elements (SPADEs)—a mix of brand-new MDS items, revised existing MDS items, and current OBRA MDS items added to PPS assessments—would be used to satisfy the IMPACT Act requirements for post-acute care data standardization, as well as to implement two new MDS-based quality measures (QMs) in the IMPACT Act’s Transfer of Health Information domain for the SNF QRP. All told, “we propose to add 60.5 items across the PPS 5-day and PPS discharge assessments,” says CMS in the proposed rule.
In addition to counting MDS data reported for 10 MDS-based SNF QRP QMs toward the data submission threshold requirement for the annual payment update, CMS seeks to count all SPADEs toward the threshold requirement. The agency also proposes to expand the SNF QRP to cover all SNF payer types.
“AANAC is projecting significant growth to the PPS assessments due to the SPADEs,” says McGill. “And while CMS hasn’t provided enough information for providers to grasp how the SNF QRP expansion would be implemented, the NAC also could spend even more time completing either the additional PPS assessments or the additional MDS items (if the SNF QRP items were added to OBRA assessments) needed to include all SNF residents, regardless of payer type, in the SNF QRP.”
With so much still unknown about how PDPM theory will work in practice this October 1 and how the proposed SPADEs and SNF QRP changes will implement next October 1 (if adopted), “it’s premature to say exactly what the NAC role will look like in the next few years,” says McGill. Nevertheless, NACs can take steps to position themselves to successfully navigate these upcoming changes. Mission-critical steps include the following:
Focus on PDPM now, proposed changes later
“Take it one step at a time. Don’t start worrying now about what will happen in 2020,” advises McGill. “First, prepare for PDPM. As you move toward October 1, there is a lot you can do to get ready. Use this time to prepare and put systems and processes in place.”
NACs then should continue to finetune the facility’s PDPM processes through the first six months of 2020, she advises. “In the third quarter of 2020, you should begin preparing for the Oct. 1, 2020 changes, including those new MDS items that will be added for the SPADEs and the new SNF QRP measures.”
Audit supporting documentation
Except for the new items I0020B (ICD-10 code) and J2100 – J5000 (major surgical procedure), the current MDS essentially has all of the MDS items that feed into the PDPM case-mix methodology, says McGill. “So now is the perfect time to audit your supporting documentation for each MDS item that will impact PDPM. Then you can begin doing targeted education with interdisciplinary team members, including the nursing staff, the dietary staff, and the physicians, to make sure that the documentation supports everything from the clinical items to the ICD-10 codes that you will need under PDPM.”
Prep for the RUG-IV/PDPM transition
After NACs make sure that the documentation in the medical record can support PDPM, the next step is to focus on the actual transition, suggests McGill. “For a resident who is already on fee-for-service Medicare Part A prior to October 1, you will need to have an MDS with an ARD set by September 30 to pay for any September days that you will bill Medicare under RUG-IV. If that resident remains on Medicare effective October 1, you will need to have a transitional Interim Payment Assessment (IPA) with an ARD set from October 1 to October 7 to establish the HIPPS payment code for billing Medicare under PDPM October 1 forward.”
This transition policy set by CMS means that NACs should put a transition process in place prior to October, says McGill. “Especially in facilities with heavy fee-for-service Medicare caseloads, you may need to work with your management team to ensure you have the resources to do these transition assessments timely.”
Strengthen/align processes and policies
After the transition period, NACs should assess the facility’s performance under PDPM, says McGill. “You want to look at how well the interdisciplinary team is capturing the required clinical data and further strengthen your processes for establishing that primary diagnosis as part of the preadmission process.”
NACs should also double-check that complementary facility processes and policies are in line with PDPM, says McGill. “For example, the triple check that you complete under PDPM will not be the same triple check that you complete under RUG-IV because the information that drives billing will have changed. So you have to ensure that those types of processes that are impacted by PDPM are also updated as implementation occurs.”
Seek joint trainings if you haven’t had them yet
The ideal training scenario for NACs is to have some joint trainings with the director of nursing services (DNS), the administrator, and the billing staff, says McGill. “The entire facility will be very heavily involved in the PDPM reimbursement model. One of my favorite phrases right now is, PDPM is putting the ‘clinical’ back in clinical reimbursement. So it’s important that everyone be involved in PDPM training, especially the DNS.”
Talk to the DNS
NACs who haven’t yet initiated conversations with the DNS should get that ball rolling now, says McGill. “You should center the first conversation around what clinical items need to be captured on the MDS to support reimbursement. How can the DNS support getting that documentation in place and holding nurses accountable to complete that documentation, which must be very timely to be able to capture it on the 5-day MDS?”
Another conversation with the DNS should address ICD-10 coding, she recommends. “Who will be responsible for ICD-10 coding and what training do they need?”
Talk to the administrator
NACs may want to focus conversations with the administrator on the bigger picture, says McGill. “CMS has emphasized reduced provider burden due to the shortened PPS assessment schedule. So you need to make sure the administrator knows how your responsibilities will shift. NAC time won’t disappear with the reduction of assessments. Additional tasks you will need to focus on include conducting clinical audits to ensure documentation is in place and following up with physicians to obtain ICD-10 codes.”
NACs also should talk to the administrator about the 2 percent financial penalty that comes with failing to meet the SNF QRP data submission threshold for the applicable program year, says McGill. “Make sure the administrator knows that CMS continues to expand the SNF QRP. So not only do you have to make the transition to PDPM this year, but October 2020 could bring more MDS-based SNF QRP QMs, additional SPADEs that would also impact the data submission threshold, and the expansion of the program to all SNF payer types.”
Don’t obsess over case-mix classification
Under PDPM, residents will be classified into five case-mix groups, one each for physical therapy, occupational therapy, speech-language pathology services, nursing, and non-therapy ancillaries. NACs who try to analyze how each resident falls into each case-mix group to look for every single opportunity for improvement “may end up doing too much data analysis,” says McGill.
“With so many variables impacting payment under PDPM, don’t spend too much time on the nitty-gritty details,” she explains. “You don’t want to try to maximize the reimbursement. Instead, you want to try to capture all of the clinical characteristics that the resident has during the assessment window. If you accurately capture all of those services and conditions, that is where your reimbursement lies—in the accuracy of your documentation.”
For example, the ICD-10 codes identifying the resident’s primary clinical category must be based on the supporting physician documentation, points out McGill. “You can’t take an ICD-10 code and fit it into a certain clinical category. You must first identify the code based on the documentation you have and then figure out where it lands using the mapping files provided by CMS. In other words, don’t take time trying to fit a square peg into a round hole. Instead, focus on having the processes to ensure you have accurate documentation. Then the reimbursement will fall into place.”
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