FY2020 Proposed SNF PPS Rule – Preview Copy Posted

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

CMS posted the inspection copy of the FY2020 Proposed SNF PPS Rule (232 pages) last week with the official Federal Register posting scheduled for this week – Thursday, April 25, 2019.

As found in the CMS summary, this proposed rule would:

  • Update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2020 (the Federal fiscal year starts October 1st).
  • Revise the regulation text to reflect the revised assessment schedule under Patient Driven Payment Model (PDPM).
  • Revise the definition of group therapy under the SNF PPS and to
  • Implement a sub-regulatory process for updating the code lists (International Classification of Diseases, Tenth Version (ICD-10) codes) used under PDPM.

(CMS) is also soliciting comments on stakeholder concerns regarding the appropriateness of the wage index used to adjust SNF payments. In addition, the proposed rule includes proposals for the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program that will affect Medicare payment to SNFs.

The deadline for submitting comments is no later than 5 p.m. on June 18, 2019.

The corresponding Fact Sheet provides details on these major provisions (I’ve taken the liberty of bolding and italicizing key information within each proposed provision):

Strengthening Medicare

CMS projects aggregate payments to SNFs will increase by $887 million, or 2.5 percent, for FY 2020 compared to FY 2019. This estimated increase is attributable to a 3.0 percent market basket increase factor with a 0.5 percentage point reduction for multifactor productivity adjustment.

As amended by section 4432 of the Balanced Budget Act of 1997 (BBA 1997) (Pub. L. 105-33, enacted on August 5, 1997), section 1888(e) of the Act provides for the implementation of a PPS for SNFs.  This methodology uses prospective, case-mix adjusted per diem payment rates applicable to all covered SNF services defined in section 1888(e)(2)(A) of the Act.  The SNF PPS is effective for cost reporting periods beginning on or after July 1, 1998 and covers all costs of furnishing covered SNF services (routine, ancillary, and capital related costs) other than costs associated with approved educational activities and bad debts.

Sub-Regulatory Process for International Classification of Diseases, Tenth Version (ICD-10) Codes Revisions:

CMS’ Patient Driven Payment Model (PDPM), an innovative and historic change in how we pay for care that is more focused on value rather than volume, will be effective October 1, 2019 under the SNF Prospective Payment System (PPS) for classifying patients in a covered Medicare Part A SNF stay. PDPM utilizes ICD-10 codes to classify SNF patients into certain payment groups. Each year, the ICD-10 codes and guidelines are revised in a variety of non-substantive ways, such as a single code being split into two more specific codes.  To help ensure SNFs have the most up-to-date ICD-10 code information as soon as possible, in the clearest and most useful format, CMS proposes a sub-regulatory process for making non-substantive changes to the list of ICD-10 codes used to classify patients into clinical categories under the PDPM.  This sub-regulatory process aligns with similar policies in the SNF PPS and the Inpatient Rehabilitation Facility (IRF) PPS.  The SNF PPS already uses a sub-regulatory process to make non-substantive updates to the list of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to consolidated billing.  In addition, the IRF PPS uses a similar sub-regulatory updating process for the IRF tier comorbidities list and for updating the ICD-10 code lists used for the IRF presumptive compliance methodology.

Align SNF PPS Group Therapy Definitions with Other PAC Settings:

Various PAC settings permit therapists to furnish therapy to their patients in three different modes: individual, concurrent, and group. Under the current SNF PPS, group therapy is defined as consisting of exactly four patients. Other payment systems, such as the IRF PPS, define group therapy as including as few as two patients. For more fair and consistent therapy definitions across care settings, we are proposing to adopt the definition of group therapy that is used in the IRF PPS: group therapy consists of two to six patients doing the same or similar activities. CMS believes aligning the group therapy definition serves to improve the agency’s consistency in payment policies across PAC settings, and to create opportunities for site neutral payments.

SNF Value-Based Purchasing Program (VBP)

The SNF VBP Program began rewarding SNFs with incentive payments based on their quality measure performance on October 1, 2018.  The program currently scores SNFs on an all-cause measure of hospital readmissions, and in the future, will transition to a measure of potentially preventable hospital readmissions.  As required by statute, the program reduces SNFs’ Medicare payments by two percentage points, then redistributes 60% of those funds as incentive payments.

In the FY 2020 SNF PPS proposed rule, the SNF VBP Program is changing the name of the program’s measure to the “Skilled Nursing Facility Potentially Preventable Readmissions after Hospital Discharge” measure. The measure will retain the same abbreviation (SNFPPR). The proposed rule also includes an update to the public reporting requirements to ensure that CMS publishes accurate performance information for low-volume SNFs.

Scoring & Operational Updates:  The SNF VBP Program’s scoring and operational policies for FY 2020 include:

  • An update for the Skilled Nursing Facility Potentially Preventable Readmissions (SNFPPR) Measure’s name.
  • Updated public reporting requirements for SNFs with less than 25 eligible stays during the baseline period or performance period for a Program year, and SNFs with zero eligible cases during the performance period for a Program year.
  • A 30-day deadline for Phase One Review and Corrections requests.

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

The SNF QRP is authorized by section 1888(e)(6) of the Social Security Act and applies to freestanding SNFs, any SNF affiliated with acute care facilities, and all non-critical access hospital (CAH) swing-bed rural hospitals. Under the SNF QRP, SNFs that fail to submit the required quality data to CMS will be subject to a 2-percentage point reduction from the applicable fiscal year’s annual market basket percentage update.

As part of CMS’ MyHealthEData initiative and commitment to improve interoperability of health information and our ongoing efforts to increase quality and safety in SNF operations, CMS proposes to adopt two new quality measures in FY 2020 to assess how health information is shared.  The two proposed measures are: 1) Transfer of Health Information from the SNF to another Provider, and 2) Transfer of Health Information from the SNF to the Patient.

In addition, CMS proposes to adopt a number of standardized patient assessment data elements that assess either cognitive function and mental status, special services, treatments and interventions, medical conditions and comorbidities, impairments, or social determinants of health (race and ethnicity, preferred language and interpreter services, health literacy, transportation, or social isolation). Finally, CMS proposes updates to specifications for the Discharge to Community PAC SNF QRP measure to exclude baseline nursing home residents.

In response to public input, we are proposing to collect standardized patient assessment data and other data required to calculate quality measures using the MDS on all patients, regardless of payer source.

I encourage you to read this proposed rule and submit comments to CMS within the allowed deadline. Page 2 of the inspection copy provides the addresses for submission of public comments. Page 3 provides the names and phone numbers to contact CMS officials for further information. Each individual has a designated area of expertise so pay close attention to those if you need to speak to CMS about a specific topic within the proposed rule.