MDS Alert

Access Information on PDPM Resources.

Did you miss the Medicare Learning Network Dec. 11 call on the Patient-Driven Payment Model (PDPM) hosted by Penny Gershman, John Kane, and Todd Smith? You can find a PDF of the presentation materials linked below. An audio recording and a written transcript of the presentation are also available at the same link.

Access the presentation materials here: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2018-12-11-PPS.html.

CMS Explains How PDPM Will Affect Medicaid Reimbursement

It’s no surprise that the PDPM will affect Medicaid reimbursement, and CMS has released more information on the specifics.

“Effective October 1, 2019, CMS will replace the existing Resource Utilization Group (RUG), Version 4 case-mix methodology that is used to classify Skilled Nursing Facility (SNF) patients in a covered Part A stay for payment purposes under the SNF Prospective Payment System with a new case-mix classification model, the Patient Driven Payment Model (PDPM),” says Mary Mayhew, deputy administrator and director center for Medicaid & CHIP services in Baltimore.

“On October 1, 2020 CMS will no longer support RUG-III and RUG-IV case-mix methodologies via the Minimum Data Set (MDS). PDPM utilizes a streamlined assessment schedule compared to RUG-III and RUG-IV by eliminating all current scheduled assessments, except the 5-day, and all unscheduled assessments (i.e., Other Medicare-Required Assessments),” she says.

Though the federal requirements are changing, CMS has created an optional assessment for states that rely on the assessments that will be eliminated with the arrival of PDPM on Oct. 1, 2019, Mayhew says.

“States will have some flexibility in crafting policies associated with this assessment. The optional assessment will be effective from October 1, 2019 through September 30, 2020,” she says.

The moves to cut red tape in long-term care and healthcare generally continue, with CMS moving to make the delivery of care more provider-friendly while still championing residents.

“In an effort to reduce provider burden, improve quality of care, and standardize data elements across provider settings, CMS will be removing several MDS data elements over the next few years. Many MDS data elements used in RUG-III and RUG-IV are no longer required for Federal purposes. With the removal of data elements, RUG-III and RUG-IV will no longer be functional. States that continue to use RUG-III or RUG-IV after October 1, 2020 will need to implement a new process to gather the needed data,” Mayhew says.

Check Out 2019 HCPCS Codes

“The SNF consolidated billing (CB) file reflects new codes that have been developed for 2019. In addition, the file reflects additions to categories of services excluded from consolidated billing. The annual update file below contains the complete list of HCPCS codes that are excluded from SNF CB for claims submitted to Part A MACs for payment. Minor Surgery and Part B therapy inclusions are also included with this file. This file is effective for claims with dates of service on or after 1/1/2019 unless otherwise noted below,” the Centers for Medicare and Medicaid Services (CMS) website says.

CMS provides the following summary of differing codes:

Major Category I. F. - Outpatient Surgery and Related Procedures—INCLUSION

REMOVE- 92977 (please include retro effective date of 1/1/17)

Major Category I. I. - Additional HCPCS EXCLUSIONS

ADD - 92977 (please include retro effective date of 1/1/17)

ADD - G0259 and G0260 (please include retro effective date of 1/1/17 for both codes)

Major Category III. A. -Chemotherapy

ADD - J9044, J9057, J9153, J9173, J9229, J9311, J9312, Q2041 and Q5107

REMOVE - J9310

Major Category III. D. - Customized Prosthetic Devices

ADD - L8701 and L8702

Major Category IV. J. - Initial Preventative Physical Exam

REMOVE - G0344 and G0367

Find out more here: www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2019-Part-A-MAC-Update.html including the General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing The SNF annual update file.

Check-in on Nursing Home Compare Claims

CMS has updated the technical specifications and accompanying appendices for Nursing Home Compare Claims.

The update includes “the specifications for the Number of Hospitalizations per 1,000 Long-Stay Resident Days measure, which is claims-based and risk-adjusted. This update also revises the MDS items included in the risk-adjustment models for the short-stay, claims-based quality measures, as well as the coefficients for the models,” says ABT Associates out of Cambridge, Massachusetts, which prepared the report for the Centers for Medicare and Medicaid Services.

You can read the report here: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/Nursing-Home-Compare-Claims-based-Measures-Technical-Specifications.pdf.

The accompanying appendices include the hard data for the technical specifications. You can find the data here: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/APPENDIX-New-Claims-based-measures-Technical-Specifications.pdf.

For more information on the Five-Star Quality Rating System and how Nursing Home Compare reflects and affects your facility — with a focus on inspections, staffing, and quality measures (QMs) — head here: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS.html.