The Medicare Part A PPS Discharge assessment (i.e., the NPE item set) is now a crucial assessment with far-reaching impacts for skilled nursing facilities (SNFs) in the Skilled Nursing Facility Quality Reporting Program (SNF QRP), the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program, the Five-Star Quality Rating System, and potentially even the survey process. Note: For details, see the AAPACN article “PPS Discharge Assessment: Why Is It More Important Than Ever?”
The nurse assessment coordinator (NAC) can take the following steps to work with the interdisciplinary team to finetune PPS Discharge assessments so that they are timely and accurate no matter what purpose they fulfill:
Understand when the PPS Discharge assessment is completed
Essentially, the PPS Discharge assessment is completed whenever a resident’s fee-for-service Part A coverage ends for any reason except death, says Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, director of clinical reimbursement for LeaderStat in Powell, OH.
“Medicare Advantage organizations can add another layer of complexity because they follow their own rules about when the PPS Discharge assessment is needed,” says Heichel. “But from a traditional Medicare standpoint, you have to complete this assessment every single time the resident comes off of Part A unless they have died. That’s why I typically call it the end-of-Medicare-stay assessment.”
Therefore, the PPS Discharge assessment must be completed (when there is no interrupted stay) in the following common scenarios, according to Heichel:
- The Part A resident is discharged and goes to the hospital;
- The Part A resident is discharged and returns home; or
- The Part A resident is taken off of Part A skilled services, but remains in the building for long-term care.
The following chart, adapted from chapter 2 (page 2-47) of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual), sums up the core requirements:
Part A PPS Discharge Assessment:
| Assessment Reference Date (ARD) =
| This Assessment Is Completed:
|
Note: For more information about the PPS Discharge assessment requirements, see chapter 2 (pages 2-45 – 2-46) of the RAI User’s Manual. Also see pages 2-11 – 2-12, 2-17 – 2-19, and 2-51 – 2-54. The instructions for the PPS Discharge assessment do not change in the finalized v1.19.1 manual.
Completing the PPS Discharge assessment in these situations “puts a bow” at the end of that Part A stay, explains Heichel. “You have your beginning picture of the resident with the PPS 5-Day assessment, and then you have your ending picture of that resident with the PPS Discharge assessment.”
Track assessment documentation during the look-back period
The PPS Discharge assessment must be completed within 14 days following the date in A2400C (End Date of Most Recent Medicare Stay), says Heichel. “You don’t want to be in a position where you only discover that a clinical assessment is missing when you are trying to code the MDS during that 14-day completion time frame.”
It can be well over two weeks from the earliest point that assessment was possible (day 1 of the look-back period) to the final endpoint for MDS completion (14 days following the end of the Medicare stay), explains Heichel. “If, for example, you discover on day 13 following the end of the Medicare stay that there is a lack of assessment in the medical record to support a particular MDS item, you are extremely limited on what you can do at that point. Assessment that occurs after the ARD cannot be coded on the MDS. Your only option is to interview staff members, and it’s unlikely that staff will be able to recall with accuracy an assessment that occurred at least 15 days earlier.”
To avoid that type of scenario, the NAC or another nurse leader should monitor—on a very tight basis—whether interdisciplinary team members are completing required assessments (e.g., a wound measurement assessment), suggests Heichel. “For example, if interdisciplinary team members are tasked with doing some type of user-defined assessment in your electronic medical record to support MDS coding, most software systems will allow you to do daily monitoring of whether those assessments have been completed timely.”
Finding and addressing potential assessment shortfalls in real time during the look-back period will result in a more accurate, complete MDS assessment, says Heichel. “It can really save you down the road when you need to lean on that particular documentation to complete a section of the MDS.”
Double-check interview processes
While the NAC should monitor all assessment documentation, resident interviews are especially important because other documentation (e.g., a nursing note) can’t just be used as a substitute for the interviews, says Heichel. The PPS Discharge assessment now includes several key resident interviews:
- The Brief Interview for Mental Status (BIMS);
- The PHQ-2 to 9 Resident Mood Interview;
- The Pain Assessment Interview; and
- Other resident self-report items, including A1005 (Ethnicity), A1010 (Race), A1250 (Transportation (From NACHC)), and B1300 (Health Literacy).
Note: The Centers for Medicare & Medicaid Services (CMS) has finalized the removal of the transportation item from the PPS Discharge assessment effective Oct. 1, 2025, as part of a package of changes to the social determinant of health (SDOH) MDS items in the Fiscal Year (FY) 2025 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule.
Before Oct. 1, 2023, these interview components weren’t on the standalone PPS Discharge assessment, points out Heichel. “From an assessment completion standpoint, you generally were fine if you completed this MDS within the required 14-day assessment completion period using the assessment data gathered during the look-back period. The interdisciplinary team could have a ‘We’ll get to it when we get to it’ approach to completion. However, now the PPS Discharge assessment has interviews that need close attention during the look-back period just like the PPS 5-Day and OBRA assessments.”
All interviews are associated with a time burden, notes Heichel. “You cannot carry over interviews from one MDS to another. You have to start over with a new interview because the answers could change—it’s the resident’s voice.”
For example, the assessor can’t assume that the A1005 (Ethnicity) and A1010 (Race) answers that the resident gave in an interview for a combined PPS 5-Day/OBRA Admission assessment will be the same for the PPS Discharge assessment, explains Heichel. “HHYou want the resident to tell you their current opinion of their ethnicity and race for each assessment. So, all team members who conduct interviews need to have that time built into their schedule for the PPS Discharge assessment the same way that they do for other MDS assessments.”
To help staff coordinate their own schedules to complete interviews on time, the NAC should focus on the timely opening of those assessments and good communication with the interdisciplinary team, says Heichel. “You want to be sure that your team always understands, ‘Here are the MDSs that we need to work on; here are the sections that we still need to get done for each one; and here’s the completion date that you need to meet.’ You really have to ramp up the level of communication for those team members who are participating in the MDS process.”
Re-assess section GG documentation sources
Section GG of the MDS now has a prominent role in both the SNF QRP and the SNF VBP, so it’s critical to have documentation in the medical record that supports coding accuracy, says Heichel. “However, in audits that I’ve conducted, supporting documentation for section GG is often lacking.”
In particular, SNFs sometimes rely on one data source, points out Heichel. “The Steps for Assessment in the RAI User’s Manual for both GG0130 (page GG-15) and GG0170 (page GG-43) state that CMS expects the assessment process to be interdisciplinary. There are multiple ways to make it interdisciplinary. For example, you could include documentation from therapy, certified nursing assistants (CNAs), or floor nurses, or you could include documentation of NAC interviews and observations. CMS allows each interdisciplinary team to decide exactly what mix of sources are used to make the section GG assessment interdisciplinary.”
The key is not to use just one data source to try to populate section GG, stresses Heichel. “How can you stand behind your coding to say, ‘This is the usual performance over the three-day window,’ when you only have one individual giving a documented opinion on that? So, you need to broaden out your assessment data to be sure that each MDS could pass an audit.”
Document about section GG conflicts
Sometimes, the interdisciplinary team will disagree with some section GG documentation—and then ignore that documentation when making section GG coding decisions, points out Heichel. “The problem is that the documentation that you feel is inaccurate is part of the legal medical record, so an outside reviewer probably will take it into consideration whether or not you agree with it.”
Instead of ignoring that documentation, a better approach is to correct it, says Heichel. “For example, you could interview that caregiver and document the conversation to make adjustments to their assessment. Or, you could write an interdisciplinary team progress note that explains why you feel—based on review of all the documentation—that the caregiver’s assessment isn’t correct and why you are choosing to go this other route to code section GG. There needs to be something in the medical record that tells an auditor that you have identified and addressed any discrepancies between the documentation and the coding.”
Keep the prior assessment within reach when completing a PPS Discharge
When the NAC and other interdisciplinary team members are working on a PPS Discharge assessment, it’s important to have the prior MDS assessment (e.g., the PPS 5-Day) available to review and compare, says Nelia Sakai Adaci, RNC, BSN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, CDONA, IPCO, chief operating officer of The CHARTS Group in Lakewood, NJ.
“The goal is to have a successful discharge from Part A for your resident,” she notes. “Whether they are going home or remaining in your facility as a long-term care resident, you don’t want them to end up rehospitalized. So, you need to see that comparison.”
This end-of-stay review will allow the interdisciplinary team to assess the resident’s progress—and determine whether the discharge plan needs to be revised to ensure a successful discharge, says Sakai Adaci. “SNFs now have access to vital information that can be communicated within the interdisciplinary team and up and down the healthcare continuum to provide individualized care and ensure an effective, efficient transition of care that generates better clinical outcomes, as well as better long-term financial outcomes through the SNF QRP, the SNF VBP, and the Five-Star Quality Rating System.”
Consistently monitor the SNF QRP Review and Correct Report
The NAC should be pulling the SNF QRP Review and Correct Report from iQIES on a routine basis, says Heichel. “You should use this report to look for compliance issues with those assessments that you are sending in for the SNF QRP to ensure that you meet or exceed the 90 percent MDS reporting threshold.”
Note: Meeting the SNF QRP’s MDS reporting threshold also will help SNFs ensure that they have adequate data for the MDS-based Discharge Function Score for SNFs (DC Function) measure, which is included in both the pay-for-reporting SNF QRP and the pay-for-performance SNF VBP.
SNFs have 4.5 months after the end of each quarter to be sure that their MDS data is as complete and accurate as possible, says Heichel. “So, it’s not like CMS isn’t giving SNFs enough time. The key is to use the information that is available to you, like the SNF QRP Review and Correct Report, to investigate where you are in the process: Are you falling behind in MDS reporting threshold compliance? Does the report flag something that you are concerned about or confused about? If you routinely monitor this report, you have an opportunity to go in there and potentially fix inaccurate or missing data before CMS locks it in.”
Resources for reviewing the SNF QRP Review and Correct Report include the following:
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Investigate the root cause of dashes
The SNF QRP’s MDS reporting threshold is based on item completeness on the required submitted MDSs, says Heichel. “Dashing is a common cause of a reduced compliance rate. CMS does not consider dashing items to be an acceptable response from the standpoint of SNF QRP reporting.”
Just one required item that is dashed on the PPS Discharge assessment means that the MDS is not 100 percent complete, says Heichel. “For example, if A1250 (Transportation) is the only dashed item on the entire PPS Discharge assessment, that assessment will not count as 100 percent complete for the purposes of the MDS reporting threshold. The same holds true for required reporting items on the PPS 5-Day. And, any PPS 5-Day or PPS Discharge assessment that is not 100 percent complete will reduce your compliance rate.”
To guard against unnecessary dashing that eats into the SNF’s compliance rate, the NAC needs to monitor how frequently dashing occurs on an ongoing basis, suggests Heichel. “If dashing isn’t rare, you should share that administrative data with the director of nursing services (DNS) and then work together to understand why that dashing is happening—to figure out, ‘What is the root cause as to why we have to dash out an item?’”
For example, the assessor may have dashed a particular item because the medical record lacked documentation to support the coding of that item, says Heichel. “Did an interdisciplinary team member fail to do the clinical assessment needed to support that item during the look-back period? If no one on the team even assessed that item, that’s a concern. You are required to dash an item when it was not assessed.”
Review MDS backup systems
In many SNFs, the burden of doing the assessment for one specific section of the MDS—or even multiple sections—may fall on a single interdisciplinary team member, notes Heichel. “For example, one interdisciplinary team member may conduct all the resident interviews. When the SNF leans on an individual that way, who is the backup if they are not there (e.g., they go on vacation, are out sick, or take a leave of absence)? How does that system continue to move forward even in the absence of its normal ‘A team’ person? Which ‘B team’ person is trained to step in and make sure that that task, whatever it is, continues to move forward so that you still get that needed information for the MDS?”
Set up an internal MDS audit system
Historically, the likelihood of a government agency conducting an MDS audit in a SNF has been low, acknowledges Heichel. “It was easy to think, ‘We’re a small building. No one will ever pull my MDSs for an audit.’”
Then came the SNF 5-Claim Probe and Educate Review, and now CMS is putting a definite focus on MDS validation, says Heichel. “The FY 2024 SNF PPS final rule finalized an MDS validation process for the SNF VBP. This audit system will involve up to 1,500 SNFs annually—roughly 10 percent of all SNFs nationwide—submitting up to 10 medical charts each to validate the MDS coding underpinning the MDS-based QMs in the SNF VBP beginning with the FY 2027 SNF VBP program year. Additionally, CMS proposed that these same randomly selected SNFs undergo a similar 10-record MDS validation process for the SNF QRP effective with the FY 2027 program year in the FY 2025 SNF PPS proposed rule. In both programs, a financial penalty could be assessed for noncompliance.”
The bottom line is that the NAC and the interdisciplinary team need to look at all MDSs and the supporting documentation in the medical record through an auditor’s lens, suggests Heichel. “The question to ask is, ‘Could this MDS pass an audit, or do we not have the backup documentation that we need?’ You and your team should be concerned about MDS accuracy for reimbursement, but also for reporting compliance and accuracy in the SNF VBP and the SNF QRP.”
While SNFs should have internal audit processes, having an outside person do an audit is a valuable step, says Heichel. “That second set of eyes can be very helpful to identify concerns. When you look at your own MDSs over and over again, it’s easy to accidentally skip over potential problems. Hiring an auditor is always an option, but you could also trade audits with another team member or bring in someone from a sister facility to do audits on a routine basis. Whatever route you choose, you want to have systems and processes in place to address those MDS issues before the SNF VBP and SNF QRP audits begin.”
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