DAL NH 17-02 - Quality Reporting Requirements and MDS Changes

April 10, 2017

RE: DAL-NH-17-02

Dear Nursing Home Administrator:

The purpose of this is to inform Nursing Home Operators and Administrators of changes in the law related to reporting requirements and MDS 3.0 which occurred October 1, 2016 in accordance with the passage of the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) on September 18, 2014.

SNF Quality Reporting Program (QRP) effective October 1, 2016

There are a number of policies finalized in this SNF PPS FY2016 Final Rule that include but are limited to the following:

  • 1. Participation/timing of new SNFs
  • 2. Data collection timeliness and requirements for the FY2018 payment determination and subsequent years
  • 3. Data completion threshold
  • 4. Exception and Extension requirements
  • 5. Reconsideration and Appeals procedures
  • 6. Public display of quality data

For purposes of this DAL, items #2 and #3 only will be referenced.

Item #2 Data collection timeliness and requirements for the FY2018 payment determination and subsequent years:

  • FY2018 payment determination will be based on one quarter data from 10/1/16 to 12/31/16 with a data submission deadline of 5/17/17.
  • SNFs submit MDS 3.0 data to CMS through the Quality Improvement and Evaluation System (QIES) Assessment Submissions and Processing (ASAP). The October 1, 2016 implementation of the SNF QRP will not change this process of MDS 3.0 data submission. However, in order to collect the standardized data used to calculate SNF QRP measures, an additional MDS, the SNF Part A PPS Discharge Assessment is required. This discharge assessment includes discharge assessment data needed to inform current and future SNF QRP measures and their calculation.

The two major changes to the MDS related to a Medicare Part A stay were effective October 1, 2016.

  • Additional MDS submission, the Part A PPS Discharge Assessment and
  • Addition of Section GG
1. Additional MDS Submission, the Part A PPS Discharge Assessment

The Part A PPS Discharge Assessment is a discharge assessment developed to inform current and future SNF QRP measures and the calculation of these measures. It consists of demographic, administrative and clinical items. The Part A PPS Discharge Assessment is completed when a resident's Medicare Part A stay ends but the resident remains in the facility. If the Medicare Part A stay ends on the day of or one day before the date of physical discharge, the OBRA Discharge Assessment and PPS Part A Discharge Assessment are both required and may be combined.

2. Addition of Section GG: Functional Abilities and Goals:

This section is divided into two parts GG0130 Self Care and GG0170 Mobility. Section GG assesses the following 3 key concepts:

  • a. The resident's Admission Performance;
  • b. The resident's discharge goals (resident's goal along with therapy plan); and
  • c. The resident's performance at the time of discharge.
    • Item GG0130 codes the functional status with respect to self-care items, including eating, oral hygiene, and toileting hygiene.
    • Item GG0170 codes the resident's functional status with respect to mobility, including an assessment of how the resident moves from sitting to lying and from lying to sitting on the side of the bed. It also includes an assessment of how the resident moves from sitting to standing and in chair, bed, and toileting transfers as well as assessment of various walking skills.

Section GG only applies to residents admitted for a Medicare Part A PPS skilled stay with a planned discharge. It must be completed at the time of admission and at the time of discharge. Section GG is designed to assess the resident's current level of functioning at the time of admission and not the prior level of function. The assessment period to complete the Admission Performance and Discharge Goals is days 1 to 3 of the SNF PPS 5-Day Assessment. The assessment period to complete the actual Discharge Performance is the last 3 days of the SNF PPS stay. A new six-point Safety and Performance scale will be used to code Section GG.

CMS is benchmarking data from Section GG. Coding a dash (-) in these items indicates "No information." CMS expects dash use for SNF QRP items to be rare occurrence. (Use of these dashes may result in a 2% reduction in annual payment update). A four-part video series on Section GG is available as a playlist on the CMS YouTube Channel.The playlist is available from the following link: https://www.youtube.com/playlist?list=PLaV7m2-zFKpgYhG0FQv82l9dcqNl_9eO4

Per the statute;

  • SNFs that do not submit the required quality measures data may receive a two percentage point reduction to their Annual Payment Update (APU) for the applicable payment year.
  • In the FY 2016 SNF PPS final rule, three quality measures affecting FY2018 payment determination were finalized for adoption into the SNF QRP. These measures and their data sources are listed in Table 1, as well as a brief summary of any modifications to the MDS 3.0 implemented as a result of these measures into the SNF QRP.

Table 1. SNF QRP measures affecting FY2018 payment determination

Measure Data Source Resulting changes in MDS Data collection period for FY2018 payment determination Data submission deadline for FY 2018 payment determination
Application of percent of residents Experiencing one of more Falls with injury (Long Stay) (NQF #0674 MDS 3.0 None Items used to calculate the measure have been in place since 2010. Items for this measure are included in the SNF Part A PPS Discharge Assessment 10/1/16-12/31/16 5/15/17
Percent of Residents with Pressure Ulcers that are New or Worsened (NQF #0678 MDS 3.0 None Items used to calculate the measure have been in place since 2010 Items for this measure are included in the SNF Part A PPS Discharge Assessment 10/1/16-12/31/16 5/15/17
Application of percent of residents with an Admission and Discharge Functional Assessment and Care Plan that Addresses Function (NQF #2631 MDS 3.0 Addition of Section GG New Functional status items assessing self-care and mobility Activities are used to calculate this measure. Section GG is included in the SNF Part A PPS Discharge Assessment 10/1/16-12-31-16 5/15/17

Item #3 Data completion threshold

  • Beginning with the FY 2018 payment determination, SNFs must report all the data necessary to calculate the quality measures on at least 80% of the MDS assessments they submit
  • A SNF is compliant with the QRP if all the data necessary to calculate the measures has been submitted to fully calculate the quality measures.
  • A Measure cannot be calculated, for example, when the use of a dash (-), indicates that the SNF was unable to perform a pressure ulcer assessment.

Overview of Additional 2016 MDS 3.0 Updates and Clarification

Section C-Delirium

Psychomotor Retardation has been removed and a new item C1310A: Acute Onset Mental Status Change has been added.

Section C1300 which related to the identification of the signs and symptoms of delirium (from the Confusion Assessment Method-CAM) and Section C1600 (acute change in mental status) have been deleted and replaced by Section C1310.CAM provides a standardized method to enable non-psychiatrically trained clinicians to identify delirium quickly and accurately in clinical settings. The CAM assessment scoring methodology has been changed

Section C1310 contains the items previously coded in section C1300, with the exception of item D psychomotor retardation which is no longer identified for coding. Section C1310 also contains the information previously coded in item C1600.In addition, the Care Area Assessments for Delirium and Cognitive Status have also been updated as a result of this change.

Section M-Pressure Ulcer Present on Admission

Section M0300 used for coding the number of pressure ulcers present on admission/reentry will be added to the current Nursing Home Discharge and the new Medicare Part A End of Stay assessments. This is a Quality Measure item and facilities need to ensure they are coding this item correctly to avoid manipulating the QM data.

Section J-Modifying injuries related to Falls:

Section J1900 clarifies that a significant injury may not be present at the time of the MDS and should a serious injury present after the Assessment Reference Date (ARD), a modification must be done to indicate that serious injury. It is important to ensure the accuracy of the level of injury resulting from a fall. Since injuries can present themselves later than the time of the fall, the assessor may need to look beyond the ARD to obtain the accurate information for a completed picture of the fall that occurs in the look-back period of the MDS.

Section Q - Participation in Assessment and Goal Setting:

Section Q0100-Q0600 used to assure the individual's civil right to choose where to live and receive long term care services. It replaces staff opinion on "discharge potential' by enabling individuals to communicate with experts in LTC options, regardless of facility assessment of discharge potential. The assessor of section 0500B Return to Community should be cautious of anyone other than the resident, legal guardian or legal representative answering "No" as this could deprive the resident of a right. If the resident answers Yes, 1, to 0500B, the facility must refer the resident to its Local Contact Agency (LCA). The facility must know who their specific LCA(s) is and how to contact them. In all cases, documentation in the medical record will reflect the reasons why a referral was made or was not made.

Further clarification of the changes made to the MDS 3.0 including scoring methodology of the CAM assessment can be found in the updated version of the RAI Manual (MDS 3.0), dated October, 2016, and the Changing Tables found on the CMS website at https://www.cms.gov/

Sincerely,

Shelly Glock, Director
Division of Nursing Homes and ICF/IID Surveillance
Center for Health Care Provider Services and Oversight