Jessie McGill, RN, RAC-MT, RAC-MTA and Alexis Roam, MSN, RN-BC, DNS-CT, QCP
The annual rulemaking process enables stakeholders to comment on proposals that will affect skilled nursing facilities (SNFs) throughout the next year. In early April, the Centers for Medicare & Medicaid Services (CMS) issued its fiscal year (FY) 2023 SNF Prospective Payment System (PPS) Proposed Rule and invited comments. The American Association of Post-Acute Care Nursing (AAPACN) team collaborated with various long-term care professionals and gathered member feedback to develop our response letter. The response to CMS emphasized key topics such as ICD-10-CM mapping, the PDPM parity adjustment, and changes to the SNF Quality Reporting Program (QRP) and Value-Based Purchasing (VBP) program. However, in the FY 2023 Proposed Rule, CMS also requested information on a minimum staffing mandate. To address this, AAPACN created a subcommittee to develop a response letter focused solely on this request for information. The following summarizes some of the key topics AAPACN’s response to CMS addressed.
Part 1: ICD-10 Mapping, Infection Isolation, PDPM Parity Adjustment, SNF QRP, and SNF VBP
Technical Updates to PDPM ICD-10 Mappings
CMS proposed remapping specific diagnosis codes and invited comments on additional substantive and non-substantive changes. We noted in our comments that we did not agree with some mapping changes because CMS’s suggested alternative coding for nonspecific codes does not align with ICD-10-CM official coding guidelines. For example, we explained why F32.A, “Depression, unspecified” may be appropriate to use as a primary diagnosis and why it should not remap to Return to Provider.
We also repeated our request from the FY 2022 Proposed Rule comments letter that CMS consider remapping M62.81 “Muscle weakness (generalized)” and R62.7 “Adult failure to thrive” from Return to Provider to an appropriate clinical category. With our suggestion, AAPACN provided evidence to support our rationale.
Additionally, we addressed a list of humeral fracture codes that have select encounter codes, but which are not eligible for one of the two orthopedic categories, even though other encounter codes for the same diagnosis are. We requested that CMS remap so that all encounter codes are mappable to one of the two orthopedic categories if the resident had a major surgery during the prior inpatient stay.
Moreover, we addressed a recent update to the Definitions of Medicare Code Edits ICD-10 Version, v39.1, released April 2022. It lists several diagnoses that currently map to a clinical category in the PDPM ICD-10 Mappings tool as an “unacceptable principal diagnosis” for use on the Medicare claim. If a diagnosis on the unacceptable principal diagnosis list is used at MDS item I0020B and listed as the principal diagnosis on the Medicare claim, the claim will be denied. After reviewing the list, we agreed that the diagnoses on the unacceptable principal diagnosis list should not be the primary diagnosis to support a skilled Medicare stay. However, we requested that CMS map the unacceptable principal diagnoses in the Medicare Code Edit document as Return to Provider in the PDPM ICD-10 Mappings tool to prevent a denial when the claim reaches the Medicare Administrative Contractor (MAC).
Consider, for example, a resident receiving skilled care for treatment of Methicillin resistant Staphylococcus aureus (MRSA) infection in a knee prosthesis. The ICD-10-CM code B96.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, is on the unacceptable principal diagnosis list. In this situation, the resident is being treated for the infection, not the specific type of organism causing the infection. The primary diagnosis would be the infected knee prosthesis (T84.54XD), and the MRSA (B96.62) would be a secondary diagnosis.
Request for Information: Infection Isolation
CMS invited comments on whether the increased resource utilization for each of the patients within a cohorted room, all with an active infection, is the same or comparable to the utilization of those in single room isolation. We responded that residents in isolation use a significant amount of resources, whether they are cohorted or not and provided examples and rationale to explain why. We also respectfully requested that CMS consider adding cohorted residents with the same or similar infection to the definition of infection isolation, or that it add a sub-coding of isolation to indicate if the isolation was single room or cohorted, so that reimbursement can be adjusted accordingly to account for the resources used in these situations.
Recalibrating the PDPM Parity Adjustment
CMS proposed a 4.6% reduction in aggregate spending to account for overpayments resulting from the transition to PDPM and invited comments on the methodology and findings. In our comments, AAPACN noted concerns with the overarching effect the COVID-19 public health emergency (PHE) had on beneficiaries, the data used for analysis, and the negative effects a full implementation without a phase-in would have.
We provided evidence that COVID-19 affected all beneficiaries during the PHE, regardless of whether they contracted COVID-19. We also addressed the impact that post-COVID symptoms, also known as long-haul COVID, may have had on beneficiaries. The post-COVID diagnosis was not available until October 1, 2021, though the underlying condition may have resulted in additional resource use and longer lengths of stay. We further noted that the post-COVID diagnosis of U09.9 was available during the time frame used for data analysis. Additionally, we asked CMS to remove data from August and September 2021 from its analysis period due to a surge in the Delta variant, which may have skewed the results in those months.
In addition, AAPACN advocated for a three-year phase-in period for any parity adjustment applied. We noted that implementing the full 4.6% reduction during one fiscal year could place SNFs in a negative profit margin, in which facilities operate at a loss. Because this would force some facilities to close, it would have a direct negative impact on the Medicare beneficiaries and other residents those SNFs serve. We noted that a three-year phase-in would minimize the impact on SNFs. AAPACN’s comments also emphasized that facilities continuing to use additional resources to battle the COVID-19 PHE and to maintain staff during a national staffing crisis are already constrained and poorly positioned to absorb a 4.6% reduction in payments.
Skilled Nursing Facility Quality Reporting Program (SNF QRP)
CMS proposed several changes to the SNF QRP program, including the addition of a new measure and a new start date for the Transfer of Health (TOH) information measures and Standardized Patient Assessment Data Elements (SPADEs). It also requested information on future measures.
AAPACN noted that the new measure, Influenza Vaccination Coverage among Healthcare Personnel (HCP), does not fully align with the purpose of SNF QRP, which requires reporting of standardized patient assessment data. The proposed measure focuses on HCP data, regardless of their possible contact with the Medicare beneficiary. AAPACN also noted that reporting vaccination coverage from the previous influenza season may be misleading during a current influenza season, since the metric does not reflect current staff compliance.
AAPACN agreed with CMS’s proposal to start the two TOH information measures with discharge assessments effective October 1, 2023. Since that process is already in place in SNFs, drawing from it for an information measure would have a low impact on resources. However, we expressed concern with the proposal to implement SPADEs with MDS 3.0 v1.18.11, which was noted to include up to 59.5 changes to the MDS. We commented that the scope of changes could be overwhelming to facilities, especially with the ongoing PHE and national staffing crisis.
CMS also requested information on contemplated future measures on equity and healthcare disparities across the QRP program. Regarding the PAC-COVID-19 Vaccination Coverage among Patients measure, we requested more information on how data would be collected and reported as part of the SNF QRP program. Since QRP measures only include data from Medicare Part A beneficiaries’ MDS assessments, we expressed concern that applying the same methods to COVID vaccination coverage would not accurately represent the entire facility.
Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)
CMS proposed to suppress the FY 2023 program year, to add new measures, and to change how the scores are calculated. We supported the suppression of the Skilled Nursing Facility Readmission Measure (SNFRM) for the FY 2023 program year due to the possible impacts of the COVID-19 PHE on readmissions. We further advocated for CMS to award 70% of the withholdings back to SNFs, rather than the 60% finalized in previous rulemaking.
CMS proposed to adopt the SNF Healthcare-Associated Infections (SNF HAI) Requiring Hospitalization measure into the SNF VBP for the FY 2026 program year. While we support this measure, we advocated for additional reporting to be made available in CASPER so that SNFs can work toward process improvement.
CMS also proposed to add a new measure, Total Staffing, for the FY 2026 SNF VBP program year. AAPACN commented that we do not support the timing of this measure, since the national staffing crisis is beyond facilities’ control, and we encouraged CMS to work toward rebuilding the healthcare workforce before penalizing facilities.
Additionally, we requested that CMS complete an updated staffing time study. We explained that we do not support using the outdated STRIVE (Staff Time and Resource Intensity Verification) data, which was introduced in 1998 and then updated using data collected in 2006 and 2007. We emphasized that in the 15 years since the STRIVE data was last collected, resources and SNF care patterns have changed substantially, and the transition to the Patient-Driven Payment Model (PDPM) in 2019 reoriented payments away from the RUG-IV model STRIVE used. We respectfully encouraged CMS to complete an updated staff time study to reflect the changes in resources and care patterns before proposing a measure that would potentially reduce Medicare payments to SNFs.
Part 2: Request for Information: Mandatory Minimum Staffing Level
CMS also requested information on a proposal to revise the current requirements and establish a mandatory minimum staffing level rule.
AAPACN Position and Request for Alternative Actions
AAPACN recognizes the need for Medicare beneficiaries to receive individualized, person-centered care in an environment that is safe, compliant with regulations, and meets the expectations of both CMS and the public. We share the goal of ensuring Medicare beneficiaries have quality outcomes. In addition, AAPACN recognizes that nurses should work in an environment that enables them to practice safely and supports their own health and wellness. With these reasons in mind, the initial idea that a mandated staffing level will achieve quality of care and support a healthy work environment in nursing homes seems reasonable. Patient advocates and policymakers have for years attempted to identify ideal staffing ratios and discussed possible staffing mandates. This includes the Staffing Study Phase II report, which recommended 4.1 total nursing hours per patient day. However, to achieve and sustain compliance with a mandated minimum staffing level of 4.1 total nursing hours per patient day, there must be an available workforce to meet the mandated levels.
AAPACN strongly believes that the nursing shortage and loss of 400,000 healthcare workers since the start of the pandemic renders any staffing mandate unworkable and ill-advised, at this time or in the near future. Additionally, increasing staffing levels would significantly increase labor costs at a time when staff costs are rising and CMS has proposed to cut reimbursement rather than provide additional funding. These proposals will exacerbate financial solvency issues for skilled nursing facilities, which will disproportionally impact nursing homes providing care in underserved and rural counties. It is fiscally impossible for many nursing homes, especially those caring for higher percentages of Medicaid recipients, to continue operating with the additional cost that meeting an unfunded mandated staffing level would impose.
AAPACN asked that prior to implementing a minimum staffing standard, CMS and other federal agencies work collaboratively and transparently with nursing homes and other stakeholders to address the shortage of healthcare workers. The shortage of nurses and other healthcare workers is a crisis that will not be solved with a mandate for nursing homes to hire people who simply are not available. Similarly, punitive measures will not result in the availability of more staff.
AAPACN also asked that CMS and other federal agencies accept the National Academies of Science, Engineering, and Medicine (NASEM) recommendation that “high-quality research is needed to advance the quality of care in nursing homes.”Specifically, current research is needed to understand the causal relationships and factors between staffing and quality of care and quality of life outcomes for different populations, acuity levels, and other resident-driven factors.
Finally, AAPACN asked CMS to examine the cost of additional staffing versus the benefits of additional staffing and include negative outcomes in the analysis. For example, pursuing mandated staffing levels may inadvertently harm other priorities, such as access to care and health equity. Once a cost-benefit analysis is complete, it will be imperative for CMS and other stakeholders to find a reasonable balance of responsibility to cover the cost of the additional staff needed to meet the mandate.
Now we wait. By mid-August, CMS will release the final rule, which will include responses to the comments received and final decisions. Then, we will know which of our comments have been acted upon and can begin to prepare for implementation.
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