MDS Alert

Follow 5 easy steps to check this report in the CASPER system.

You have only until May 15 to correct and submit your Quality Reporting Program (QRP) data for the fiscal year (FY) 2018 reporting period. And if you don’t submit your data — or if you have too much missing data — you could face a 2-percent cut to your reimbursement.

The Centers for Medicare & Medicaid Services (CMS) will determine your FY 2018 QRP compliance based on one quarter of quality data, from Oct. 1, 2016 through Dec. 31, 2016. This means that CMS will evaluate data submitted for admissions to your SNF on and after Oct. 1, 2016, and then discharged from the SNF up to and including Dec. 31, 2016.

The three MDS 3.0 quality measures (QMs) for which you must submit your data are as follows:

• NQF #0678 – Percent of Residents or Patients with Pressure Ulcers That are New or Worsened (Short-Stay)
• NQF #0674 – Application of Percent of Residents Experiencing One or More Falls with Major Injury (Short-Stay)
• NQF #2631 – Percent of Long-Term Care Hospital Patients with an Admission or Discharge Functional Assessment and a Care Plan That Addresses Function

Hunt for Missing MDS Data

You must submit your SNF QRP data through the MDS 3.0 via the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. But before you submit your data, you should really double-check your data to make sure it’s accurate and that you don’t have any missing data.

Problem: CMS will look for providers to submit all data necessary to calculate the QRP measures on at least 80 percent of the MDS assessments submitted. If you fall short of this 80-percent minimum, or otherwise don’t comply with the quality data submission requirements, CMS will reduce your market basket update (or Annual Payment Update) by 2 percentage points.

Solution: So how can you ensure that you’ll meet the data minimum? An important step in verifying your data is to obtain a Final Validation Report.

5 Steps to Obtain the Final Validation Report

Follow these steps to view the system-generated MDS 3.0 NH (or SB) Final Validation report in the CASPER reporting system (for additional instructions, see www.qtso.com/download/mds/MDS_3.0_Helpful_Hints.pdf):

1. Log in to CASPER with your individual user ID and password. This is the same user ID/password (MDSxxxxxxx or SWBxxxxxxx) with which you access the MDS 3.0 Submission system.
2. Select the Folders button located on the tool bar across the top of the page. The folders available to you are along the left-hand side of the CASPER Folders page.
3. Find and select the facility folder with the naming structure of:

“[State Code] LTC [Facility ID] VR” (for nursing homes)

                                    Or

“[State Code] SB [Facility ID] VR” (for swing bed providers)

4. With the VR folder selected, look at the main body of the page for a list of the Final Validation reports that were system-generated and are available for you to view. The report names are formatted as “[Submission Date & Time].[Submission ID.”

5. Select the report that corresponds to the submission file you want to verify. Below is a mock sample MDS 3.0 NH Final Validation Report:

Resources: For more information on the SNF QRP, visit the CMS web page at www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-IMPACT-Act-2014.html. Also, check out the new SNF QRP Quick Reference Guide at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-Quick-Reference-Quide-April-2017.pdf.