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FY 2024 SNF PPS Final Rule Initial Timeline for NACs: How/When the MDS Takes Center-Stage

Breathing room will be in short supply for nurse assessment coordinators (NACs) and other interdisciplinary team members who need to implement and monitor the multitude of changes to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP) that are in the Fiscal Year (FY) 2024 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule. AAPACN has developed the following timeline to show NACs the new MDS-focused requirements that the Centers for Medicare & Medicaid Services (CMS) expects SNFs to meet from Oct. 1, 2023 – Jan. 1, 2024:

Key DatesNew Actions Mandated by the FY 2024 SNF PPS Final Rule
Oct. 1, 2023SNF PPS  

Fee-for-service payment rates will update. CMS estimates that the aggregate impact of the FY 2024 (Oct. 1, 2023 – Sept. 30, 2024) payment policies will be a net increase of 4 percent ($1.4 billion) in fee-for-service (FFS) Medicare Part A payments to SNFs. Each facility’s specific increase can vary widely depending on where they are located. Note: The case-mix-adjusted Patient-Driven Payment Model (PDPM) payment rates for FY 2024 are listed separately for urban and rural SNFs in table 5, “PDPM Case-Mix-Adjusted Federal Rates and Associated Indexes—Urban (Including the Parity Adjustment Recalibration),” and table 6, “PDPM Case-Mix Adjusted Federal Rates and Associated Indexes—Rural (Including the Parity Adjustment Recalibration),” of the FY 2024 SNF PPS final rule. These tables don’t reflect adjustments that may be made to the SNF PPS rates, such as adjustments related to the SNF VBP or the variable per-diem payment policy.
Oct. 1, 2023SNF QRP  

New Quality Measure (QM) changes go into effect beginning with the FY 2025 SNF QRP. The data collection period for the FY 2025 (Oct. 1, 2024 – Sept. 30, 2025) SNF QRP annual payment update (APU) determination is calendar year (CY) 2023 (Jan. 1, 2023 – Dec. 31, 2023). Therefore, these changes will all take effect on Oct. 1, 2023.  

While CMS will modify the National Healthcare Safety Network (NHSN) measure COVID-19 Vaccination Coverage Among Healthcare Personnel, the majority of these changes are MDS-based. Specifically, CMS will do the following:  

Adopt the MDS-based measure Discharge Function Score. SNFs will be required to report the MDS assessment data using the v1.18.11 item sets for the Discharge Function Score measure beginning with residents admitted and discharged on Oct. 1, 2023, for purposes of the FY 2025 SNF QRP. Then starting Jan. 1, 2024, SNFs will need to submit data for the entire calendar year to support subsequent program years, beginning with the FY 2026 SNF QRP.  

This cross-setting, risk-adjusted, assessment-based measure “evaluates functional status by calculating the percentage of Medicare Part A SNF residents who meet or exceed an expected discharge function score,” says CMS. The Discharge Function measure reflects the progress of a resident across both the mobility and self-care domains, says CMS. “[It’s] meant to supplement, rather than replace, the Discharge Self-Care Score and Discharge Mobility Score measures, which implement the remaining self-care and mobility function items not captured in the DC Function measure.”  

The Discharge Function measure is calculated similarly to the existing functional outcome measures, but there are some modifications. “Specifically, the measure (1) considers two dimensions of function (self-care and mobility activities) and (2) accounts for missing data by using statistical imputation to improve the validity of measure performance,” explains the agency. “The statistical imputation approach recodes missing functional status data to the most likely value had the status been assessed, whereas the current imputation approach implemented in existing functional outcome measures recodes missing data to the lowest functional status.”  
Note: CMS will consider testing the statistical imputation methodology in other existing and future measures as well. For example, the agency could re-specify the Discharge Self-Care Score and Discharge Mobility Score measures to use statistical imputation so that they more closely align with the Discharge Function measure.  

Remove three measures:  

* The MDS-based measure Application of Percent of Long-Term Care Hospital Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function. Related to the discontinuation of this measure, SNFs will no longer be required to report a Self-Care discharge goal (i.e., GG0130, Column 2) or a Mobility discharge goal (that is, GG0170, Column 2) beginning with residents admitted on or after Oct. 1, 2023. CMS will remove these items with the next release of the MDS, and they will stop being part of the SNF QRP data reporting threshold requirements effective Oct. 1. 

The revised SNF QRP Overview of Data Elements Used for Reporting Assessment-Based QMs and Standardized Patient Assessment Data Elements Affection FY 2025 APU Determination adds that “SNFs will continue to receive an APU warning if an MDS is submitted to iQIES without at least one self-care or one mobility discharge goal. SNFs can ignore this warning and proceed with submitting their assessment.”  

* The MDS-based measure Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients measure.  

* The MDS-based measure Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients.
Oct. 1, 2023  ICD-10-CM Code Mappings for PDPM  

CMS finalized (with no revisions) the proposed changes to the PDPM ICD-10 code mappings, which map ICD-10 codes to PDPM clinical categories, speech-language pathology (SLP) comorbidities, and non-therapy ancillary (NTA) comorbidities.  
The updates in the FY 2024 PDPM ICD-10 Mappings file, which was released in conjunction with the final rule and then updated on Aug. 7, all involve clinical category mapping changes. First, the file includes revised mappings for five ICD-10 codes that just became effective in FY 2023. D75.84 (Other platelet-Activating Anti-Platelet Factor 4 (PF4) Disorders), G90.A (Postural Orthostatic Tachycardia Syndrome (POTS)), and K76.82 (Hepatic Encephalopathy) will map to the Medical Management category. However, F43.81 (Prolonged Grief Disorder) and F43.89 (Other Reactions to Severe Stress) will map Return to Provider (RTP) effective Oct. 1.  

In addition, there are clinical category changes in the following three areas:  

– Unspecified substance use disorder codes: There are 168 category changes.

– Fracture codes in the S42.2 and M84.5 subcategories: There are 91 category changes.

– Unacceptable principal diagnosis codes: Ninety-five diagnosis codes will newly map to RTP to better align the clinical category mappings with the Unacceptable Principal Diagnosis edit code list in the Medicare Code Editor (MCE) used by Medicare administrative contractors (MACs) on inpatient claims. CMS points out that “future updates to align the PDPM ICD-10 code mappings with the MCE Unacceptable Principal Diagnosis edit code list [will be made] on a subregulatory basis going forward.”  

Note: It’s worth reviewing the Proposed FY 2024 PDPM ICD-10 Mappings file, which includes three tables that itemize each set of these clinical category code changes: Proposed Clinical Category Changes for Unspecified Substance Use Disorder Codes, Proposed Clinical Category Changes for S42.2 and M84.5 Fracture Codes, and Proposed Clinical Category Changes for Unacceptable Principal Diagnosis Codes. CMS updated the proposed changes file in conjunction with the Aug. 7 update to the final file. Also see the zip file, FY 2024 PDPM ICD Codes (I0200B Acceptable Codes).
Oct. 1, 2023SNF VBP  

CMS has adopted the Total Nursing Staff Turnover (Nursing Staff Turnover) measure for the SNF VBP beginning with the FY 2026 (Oct. 1, 2025 – Sept. 30, 2026) program year. The associated performance period will be FY 2024 (Oct. 1, 2023 – Sept. 30, 2024). This measure calculates annual turnover rates for nursing staff, including registered nurses (RNs), licensed practical nurses (LPNs), and nurse aides. Like the Total Nursing Hours per Resident Day Staffing (Total Nurse Staffing) measure that CMS adopted for the FY 2026 program year in the FY 2023 SNF PPS final rule, the Nursing Staff Turnover measure is a Nursing Home Quality Initiative (NHQI) QM that is used in the Five-Star Quality Rating System—and primarily is based on Payroll-Based Journal (PBJ) data.  

However, both of these staffing measures use daily resident census data derived from MDS assessments, and they are case-mix-adjusted based on how the facility’s MDS assessments distribute into a case-mix model. Note: For details, review the Five-Star Quality Rating System: Technical Users’ Guide.
Jan. 1, 2024SNF QRP  

CMS will change the MDS data submission threshold: The agency finalized the requirement for SNFs to report 100 percent of the required QM data and standardized patient assessment data collected using the MDS on at least 90 percent of all required assessments submitted (i.e., the PPS 5-Day MDS and/or the Part A PPS Discharge assessment) beginning with data collection period (Jan. 1, 2024 – Dec. 31, 2024) for the FY 2026 (Oct. 1, 2025 – Sept. 30, 2026) program year. The current threshold is to report 100 percent of the required data on at least 80 percent of all required MDS assessments, so CMS is substantially reducing the margin for error.  

“Complete data are needed to help ensure the validity and reliability of SNF QRP data items, including risk-adjustment models,” says CMS. “The … threshold of 90 percent is based on the need for substantially complete records, which allows appropriate analysis of SNF QRP measure data for the purposes of updating quality measure [QM] specifications as they undergo yearly and triennial measure maintenance reviews with the CBE.” Note: With certain exceptions, CMS is required to obtain the endorsement of the cross-setting SNF QRP QMs it proposes and implements from a consensus-based entity (CBE).  

In addition, more complete SNF QRP measure data, when publicly reported, will help Medicare beneficiaries better understand SNF performance and make informed healthcare choices, says CMS. Last but not least, data completion thresholds across post-acute care (PAC) settings will be further aligned.  

Any SNF that fails to meet the annual 90 percent MDS data completion threshold will be subject to the 2 percent APU reduction in the applicable fiscal year. However, most SNFs are “already in compliance with, or exceeding” the 90 percent threshold, according to CMS data. While many new items are being added to the MDS effective Oct. 1, 2023, with v1.18.11 of the MDS item sets, CMS has built in some options that should help NACs and other interdisciplinary team members avoid unwarranted dashing.  

For example, three of the new items that will be required for the SNF QRP effective Oct. 1, 2023—K0520 (Nutritional Approaches), N0415 (High-Risk Drug Classes: Use and Indication), and O0110 (Special Treatments, Procedures, and Programs)—offer the response option, “None of the Above.” NACs and other assessors can choose the “None of the Above” response for residents who are not receiving special nutritional approaches, high-risk drug classes, and/or special treatments, procedures, and programs during the look-back period.  

“When ‘None of the Above’ is selected, 46 of the items are eliminated, and SNFs do not have to complete them,” points out CMS.
Jan. 1, 2024Consolidated Billing  

New therapy/counseling exclusions go into effect. Effective with services furnished on or after Jan. 1, 2024, the services of marriage and family therapists and mental health counselors will be excluded from consolidated billing under SNF PPS thanks to the Consolidated Appropriations Act of 2023. Those services will no longer be included in the SNF per-diem payment, and performing clinicians will be able to bill Medicare separately. In the final rule, CMS finalized conforming revisions to the existing SNF consolidated billing regulations to implement these exclusions.  

The new exclusions should be incorporated into the 2024 SNF Consolidated Billing HCPCS Code Update, which will be posted under the heading 2024 Part A MAC Update on the CMS consolidated billing webpage. Historically, this annual file is posted by the first week of December for the following year, but last year it wasn’t posted until early January.

CMS has provided some additional resources that may help NACs navigate these changes:

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