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AAPACN Advocates for Skilled Nursing Facilities: Response to Comment Request for FY 2024 SNF PPS Proposed Rule

The American Association of Post-Acute Care Nursing (AAPACN) team collaborated with its members and post-acute care experts to advocate for skilled nursing facility (SNF) professionals by making comments on the fiscal year (FY) 2024 SNF Prospective Payment System (PPS) Proposed Rule. The Centers for Medicare & Medicaid Services (CMS) issued the proposed rule in early April and allowed a 60-day window to submit comments.

The AAPACN response to CMS focused on key topics, such as Medicare rates, ICD-10-CM mapping, changes to the SNF Quality Reporting Program (QRP), and changes to the Value-Based Purchasing (VBP) Program. The proposed rule did not include the minimum staffing mandate as expected; however, CMS indicates it will be addressed in a separate rule-making process to be announced soon. The following is a brief overview of some of the key topics addressed in AAPACN’s response to CMS.

Proposed Increase to the SNF PPS Rate

CMS proposed an aggregate increase in Medicare rates of 6.1%. AAPACN commented that we support and appreciate the proposed increase.

Proposed Changes to the ICD-10 Mappings

CMS proposed several changes to align primary ICD-10-CM codes more appropriately with clinical categories under the Patient-Driven Payment Model (PDPM). Although AAPACN agreed with some of the proposed changes, we did not support all of them.

AAPACN did support the remapping of these diagnoses to the Medical Management PDPM clinical category:

AAPACN commented that we do not support the remapping of F43.81, “Prolonged grief disorder,” and F43.89, “Other reactions to severe stress,” to “Return to Provider.” CMS pointed out that most SNFs would likely not be the most useful setting for these beneficiaries, but we asked CMS to consider that a subset of SNFs specialize in behavioral and mental health treatment and may require these diagnoses as the primary diagnosis codes to meet beneficiary needs.

AAPACN also supported CMS‘s proposal to remap the Substance Use Disorders (SUDs) codes toReturn to Provider.”However, we disagreed with the guidance to replace these codes with either F10.10 or F10.20 because this change does not align with the ICD-10-CM Official Guidelines for Coding and Reporting that must be followed when assigning codes. The SNF provider would be unable to assign a code such as F10.10 or F10.20 without physician documentation to support that alcohol abuse or dependence was present.

AAPACN also supports the proposed changes to fracture codes and the Medicare Code Editor (MCE) Unacceptable Principal Diagnosis List to better align appropriate diagnosis mapping.

CMS also asked for input regarding substantive and nonsubstantive changes to ICD-10-CM mapping that commenters believe are necessary. AAPACN asked CMS to reconsider mapping of M62.81, “Muscle weakness (generalized),” from “Return to Provider” to “Non-surgical orthopedic, musculoskeletal.” AAPACN supported this request by citingtheNational Institutes of Health study, The Relationship Between Muscular Strength and Depression in Older Adults with Chronic Disease Comorbidity.

The study states, “Other studies reported that there was a significant relationship between depression and functional disability in elderly populations, and persistent elevation in depression was observed following the worsening of functional capacity.” It also says, “In the elderly populations, clinical condition and functional capacity appear to be associated with handgrip strength (HGS), a general indicator of muscular strength. Numerous studies observed that lower muscular strength was independently related to development of depression” (Lee & Ryan, 2020).

AAPACN also pointed out that a beneficiary may require skilled therapy due to the late effects from conditions, resolved physical condition, effects of prolonged untreated mental health conditions, or an extended acute or psychiatric inpatient stay that resulted in muscle weakness but has not yet resulted in a more severe complication, such as muscle wasting or atrophy.

AAPACN also asked CMS to consider additional dysphagia ICD-10-CM codes to map to the dysphagia Speech Language Pathology (SLP) comorbidity in PDPM. This change would support beneficiaries who have dysphagia caused by other conditions that do not have dysphagia-specific sequela ICD-10-CM codes, such as Parkinson’s disease, multiple sclerosis, muscular dystrophy, dementia, pharyngoesophageal diverticulum, metastatic oral or laryngeal cancers, spinal cord injury, or esophageal stricture. Currently, only dysphagia diagnoses caused by cerebrovascular disease are included in the dysphagia SLP comorbidity.

Specifically, AAPACN recommends that CMS consider mapping of these dysphagia codes to the dysphagia SLP comorbidity under PDPM:

Proposed Changes to the Skilled Nursing Facility Quality Reporting Program

AAPACN provided an overarching comment that supports CMS’s efforts to adjust and provide reliable data to consumers but encouraged CMS to provide more transparency on the overall effectiveness of the SNF QRP program. We commented that it would help providers and stakeholders to have access to the data showing how the SNF QRP program has contributed to Medicare savings, the percentage of facilities that have maintained compliance during the fiscal year, and the percentage of facilities that have been penalized. Additionally, it would be useful at an organizational and association level to have access to the most common reasons that facilities nationwide are out of compliance, whether due to National Healthcare Safety Network (NHSN) reporting or dashing K0200B, Weight, to allow for focused analysis.

Proposal to Adopt the Discharge Function Score for SNF QRP Program FY 2025

AAPACN commented that we agree Medicare beneficiaries and providers would benefit from the proposed adoption of the Discharge Function Score and the retirement of these three redundant SNF QRP measures:

  1. The Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function measure
  2. The Application of Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients measure
  3. The Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients measure

AAPACN also encouraged CMS to provide more transparency on the expected Discharge Function Score used in the Discharge Function Score measure. We asked CMS to include both the observed Discharge Function Score and the expected Discharge Function Score on the SNF QRP Review and Correct Report, so providers can monitor their performance and work toward performance improvement.

Proposal to Adopt the CoreQ: Short-Stay Discharge Measure for SNF QRP Program FY 2026

AAPACN responded that Medicare beneficiaries and providers would benefit from adopting the CoreQ Short-Stay Measure and overall supports this proposed change. However, we also voiced concerns regarding the process and deadline for the low-volume exemption, the lack of use of a minimum sample size or response rate, and the potential negative impact of including results from health maintenance organization (HMO) stays.

Proposal to Adopt the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date Measure for SNF QRP Program FY 2026

AAPACN supported this proposed change and encouraged CMS to include a follow-up question to learn why the vaccine is not up to date, allowing for further analysis by providers and CMS. We suggest CMS use a follow-up question, like Minimum Data Set (MDS) item O0300B for the pneumococcal vaccine, with three response options: “Not eligible – medical contraindication,” “Offered and declined,” and “Not offered.”

Proposal to Increase the SNF QRP Data Completion Thresholds for MDS Data Items from 80% to 90% Beginning with FY 2026 SNF QRP

AAPACN noted that this change would better align SNF QRP with IRF QRP and LTCH QRP requirements, but not with the home health agency current thresholds. We requested that CMS consider delaying this requirement to allow SNFs to adjust to the vast increase in required data elements that SNFs will begin to collect as of October 1, 2023. We also noted that in addition to the MDS reporting thresholds, SNFs are also required to report 100% of the data required for the NHSN measures, and starting with FY 2026, if finalized, additional reporting requirements to the approved vendor for the CoreQ Short-Stay Discharge surveys.

Proposed Changes to the Skilled Nursing Facility Value-Based Purchasing Program

Proposal to Refine the SNF Potentially Preventable Readmission Measure Specifications and Update the Name

AAPACN commented that we support the proposed changes to the measure specifications and updated name that more appropriately aligns with changes and improvements within the facility’s control.

Proposal to Adopt the Percent of Residents Experiencing One or More Falls with Major Injury (Long-Stay) Measure for FY 2027

AAPACN responded with lack of support for this proposed change and commented that the use of this long-stay measure is not appropriate for the SNF VBP program. AAPACN maintained that the resident population and characteristics of long-stay residents are very different than short-stay Medicare residents, citing a 2016 study that showed long-stay residents tend to have “low-income subsidy recipients, have multiple comorbidities, and have higher mortality but have fewer hospitalizations and SNF services” (Wei et al., 2016).

AAPACN also noted that in 2022, approximately 62% of residents in nursing homes had a payer source of Medicaid, whereas only 13% used Medicare, and the remaining 25% were other payer types or private payers (Kaiser Family Foundation, 2022). We advocated that this measure uses data of a larger, unrelated population, potentially penalizing the reimbursement of a smaller, characteristically different, population. Furthermore, AAPACN encouraged CMS to employ the Application of the Falls with Major Injury SNF QRP measure, which is currently used in the SNF QRP program, publicly reported, and narrows the scope to Medicare Part A stays. This measure better aligns with the outcomes related to the Medicare Part A reimbursement that is impacted by the SNF VBP program.

Proposal to Adopt the Discharge Function Score Measure Beginning in FY 2027

AAPACN reiterated the request for CMS to include both the observed Discharge Function Score and the expected Discharge Function Score on the SNF QRP Review and Correct Report, so providers can monitor their performance and work toward improving it. Because this measure has the potential to impact Medicare payment through both the QRP and VBP programs, it is essential to provide SNFs with enough information to make meaningful changes toward process improvement.

Proposal to Adopt the Number of Hospitalizations per 1,000 Long-Stay Resident Days Measure Beginning with FY 2027

AAPACN commented that we do not support the use of long-stay measures for the VBP program, due to the unrelated long-stay population, and we emphasized that the program already utilizes the SNF 30-Day All-Cause Readmission Measure (SNFRM) and, if finalized, will transition to the Skilled Nursing Facility Within-Stay Potentially Preventable Readmission (SNF WS PPR) measure to appropriately capture hospital readmissions of the Medicare Part A short-stay population.

Proposal to Incorporate Health Equity into the SNF VBP Program Scoring Methodology Beginning with the FY 2027 Program Year

AAPACN applauded CMS’s efforts to address health inequity but believes it is premature to incorporate in a payment-related program. We asked CMS to work with the Partnership for Quality Measurement (PQM) to develop meaningful health equity-related measures that are reliable and valid in the SNF setting. We also encouraged the release of education, resources, and projects that enable SNFs to learn how health equity items impact their resident population and how to use this information to make meaningful changes to reduce health inequities.

AAPACN also noted that the two proposed long-stay VBP measures do not represent the outcomes of the dual eligibility status (DES) proportion of short-stay residents. We further commented that the combination of the proportion residents with DES and measures unrelated to health equity does not provide meaningful data to address any health inequities. Further, we do not agree that SNFs will be able to make meaningful changes based on the proportion of residents with DES and the outcome of the VBP measures.

Proposal for Validation Methods for VBP Measures

AAPACN commented that we do not support the proposal to select facilities randomly for validation audits for the SNF VBP program. We maintained that the MDS source documentation for these measures is already audited during the annual survey process and other payment-related audits and do not agree that an additional audit solely for this purpose is warranted or cost-effective. AAPACN does not support using the withheld money to fund validation audits and increase the burden of the SNFs to respond to additional documentation requests required for these audits. We believe that MDS validation achieved through the other programs and penalties the SNFs receive through those programs is adequate.


Kaiser Family Foundation. (2022, August 23). Distribution of certified nursing facility residents by primary payer source. https://www.kff.org/other/state-indicator/distribution-of-certified-nursing-facilities-by-primary-payer-source/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D

Lee, J.-M., & Ryan, E. J. (2020). The relationship between muscular strength and depression in older adults with chronic disease comorbidity. International Journal of Environmental Research and Public Health, 17(18), 6830. https://doi.org/10.3390/ijerph17186830

Wei, Y.-J., Simoni-Wastila, L., Zuckerman, I. H., Brandt, N., & Lucas, J. A. (2016). Algorithm for identifying nursing home days using Medicare claims and Minimum Data Set assessment data. Medical Care, 54(11), e73 – e77. https://doi.org/10.1097/mlr.0000000000000109

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