Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
CMS posted the SNF QRP APU Reporting Table – Assessment-Based Measures for FY2022 late in the day Thursday, January 30, 2020. This 18-page table shows the MDS data elements that are/will be used in determining the APU minimum submission threshold for the FY 2022 SNF QRP determination.
“The Centers for Medicare & Medicaid Services’ (CMS) Skilled Nursing Facility Quality Reporting Program (SNF QRP) requires SNFs to submit quality measure and standardized resident assessment data elements (SPADEs) to CMS. For a given data submission period, the Minimum Data Set (MDS) assessments submitted by a SNF must meet the APU minimum data completion threshold of no less than 80 percent of the MDS assessments having 100 percent completion of the required SNF QRP data elements. These are the standardized patient assessment data elements and the data elements needed to calculate the SNF QRP quality measures. Successful assessment completion means that the assessment does not contain noninformative responses, i.e., “dash” (–) for required data elements. Please note that while the coding of a “dash” is an optional response value for many of the data elements listed in this table, its use does not count toward meeting the APU minimum data completion threshold. Failure to meet the minimum threshold may result in a two (2) percentage point reduction in the SNF’s APU.
Below is a table indicating the MDS data elements that are used in determining the APU minimum data completion threshold for the FY 2022 SNF QRP determination. There are two columns spanning two versions of the MDS, and reflect the appropriate reporting periods:
(1) The MDS 3.0 Version 1.17.1 (effective October 1, 2019) is used for the CY Q1 – Q3 2020 (January – September 2020) data collection reporting period.
(2) The MDS 3.0 Version 1.18.0 (effective October 1, 2020) is used for the CY Q4 2020 (October – December 2020) data collection reporting period.
An “X” in the table below indicates the valid assessment type and data collection reporting periods. For detailed measure specifications, please refer to the documents listed under “References” below.
Note: This table is limited to the data elements that are used for determining SNF QRP compliance and are included in the APU data completion threshold. There are additional data elements used to risk adjust the quality measures used in the SNF QRP. Failure to submit all data elements used to calculate and risk adjust a quality measure can affect your SNF’s quality measure calculations that are displayed on the Compare website.”
Excerpts from 2 pages of this document illustrate the items from the current MDS 3.0 Item Set (v1.17.1) and the DRAFT MDS 3.0 Item Set (v1.18.0 – the final version will be implemented October 1, 2020. Check out the far right columns, beneath Data Collection Periods:
You’ll also note that the data collection for FY 2022 APU began January 1st and extends through December 31st of this year. Accurate coding of the entire MDS as well as these APU elements is always critical!