Government Source Documents
Staying current with government regulations is always a challenge. That is why we do the hard work for you, collecting all of the information you need in one place. On this page, you’ll find the core government regulatory documents with which every long-term care nursing professional must be familiar. Click on the titles below to find a brief description of the regulation and the issues most relevant to you. AAPACN experts synthesize and break down updates on complex CMS regulations and requirements in the AAPACN Leader for the NAC and Navigator for the DNS bimonthly e-newsletters.
Rules and regulations: How a law becomes a rule that nursing homes must follow
The federal government has a profound impact on how nursing homes—nursing facilities (NFs) and skilled nursing facilities (SNFs)—operate. The U.S. Congress passes the bills that shape government programs, including Medicare and Medicaid. For example, the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) established the parameters for many of the Medicare/Medicaid conditions of participation that nursing homes now follow. More recent examples of Congress in action include the Protecting Access to Medicare Act of 2014 (PAMA), which established the legislative basis for a SNF Value-Based Purchasing (SNF VBP) program, and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, which established a SNF Quality Reporting Program (SNF QRP) for providers that meet Medicare requirements for Part A coverage.
After being signed by the president, bills passed by Congress become federal laws that, as required, amend Title 18 (Medicare) and Title 19 (Medicaid) of the Social Security Act. These laws generally contain basic requirements and definitions, but allow some room for interpretation by government agencies. Most laws that impact nursing homes are administered by the Centers for Medicare & Medicaid Services (CMS), with a few handled by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services and other entities.
To implement laws, CMS develops regulations based on those laws, releasing a draft or proposed rule for public comment via publication in the Federal Register. CMS gives providers and other interested parties 60 days to comment on most major proposed rules, but timeframes vary in the rule-making process. Once the public comment period has passed and CMS officials have reviewed all the comments and made any necessary revisions to the proposed rule, the agency issues a final rule with an effective date for implementation that providers must meet.
The basic requirements of a final rule are codified in the Code of Federal Regulations (CFR). For example, two key sections of the CFR for nursing homes are: Part 483, "Requirements for States and Long-Term Care Facilities," Subpart B, and Part 409, "Hospital Insurance Benefits," Subparts A – H, which are both in Chapter IV, "Centers for Medicare & Medicaid Services, Dept. of Health and Human Services,” of Volume 42, "Public Health.” Using the discussions and decisions in a final rule for guidance, CMS develops further rules for providers based on the core CFR requirements.
For nursing homes, further program guidance from CMS typically comes via two avenues:
1. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. The RAI User's Manual contains MDS (Minimum Data Set) coding and RAI (Resident Assessment Instrument) policy requirements, as well as policy requirements for the skilled nursing facility prospective payment system (SNF PPS).
2. The Internet-Only Manual (IOM) System. The IOM is the one-stop shop for CMS's program issuances, day-to-day operating instructions, policies, and procedures for the administration of the Medicare and Medicaid programs. For example, the IOM includes the Medicare Benefit Policy Manual, the Medicare Claims Processing Manual, and the State Operations Manual. These manuals are updated by transmittal.
Formerly Nursing Home Compare, the Care Compare database provides the public with each facility's overall Five Star Quality Rating System performance, as well as its performance on survey, staffing, and MDS-based and claims-based QMs that are sometimes referred to as the CASPER or NHQI QMs. In addition, some SNF QRP QMs also are now reported, as is Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program performance data.
The Centers for Disease Control and Prevention (CDC) provides evidence-based infection prevention and control resources, antibiotic stewardship resources, and infection-specific guidance (e.g., COVID-19, influenza, sepsis, etc.), as well as data statistics about nursing homes, services, and residents. The CDC also operates the National Health Safety Network (NHSN), which nursing homes can use to report COVID-19 infection and testing data, as well as other infection data (e.g., urinary tract infections).
This Code of Federal Regulations (CFR) is the codification of rules that are published in the Federal Register by the Centers for Medicare & Medicaid Services and other government agencies. It is the actual regulation from which CMS bases and issues Medicare and Medicaid program guidance, such as all of the manuals in the Internet-Only Manual System.
The eCFR is a searchable online version of the CFR.
Most information pertinent to SNFs and NFs is located in: Volume 42, "Public Health," Chapter IV, "Centers for Medicare and Medicaid Services, Dept. of Health and Human Services."
* Part 483, "Requirements for States and Long-Term Care Facilities," Subpart B. These sections cover the basic requirements of Medicare/Medicaid participation: from resident rights and resident assessment to the actual Conditions of Participation.
* Part 409, "Hospital Insurance Benefits," Subparts A - H. These sections cover such issues as the skilled level-of-care requirement, the "daily basis" criteria, and plan-of-care requirements.
Access the regularly updated eCFR here.
Via the Care Compare website, nursing homes are assigned an Overall Quality Rating of one to five stars based on how they perform on three domains, each of which has its own rating:
- Health Inspections: Measures based on outcomes from state health inspections.
- Staffing: Measures based on nursing home staffing levels: Staffing hours are reported using the Payroll-Based Journal (PBJ) electronic reporting system and census is reported using the MDS.
- Quality Measures: Measures based on MDS and claims-based QMs. These include nine long-stay measures and six short-stay measures posted on Care Compare.
The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them.
CMS implements updated MDS item sets every Oct. 1 to incorporate any changes for the corresponding Oct. 1 – Sept. 30 fiscal year. This link provides MDS forms for the current fiscal year for PPS, OBRA, and swing-bed assessments.
The MDS 3.0 QM User’s Manual contains detailed specifications for the MDS 3.0 long-stay and short-stay quality measures known as the Nursing Home Quality Initiative (NHQI) QMs, which are reported on Care Compare and some of which are used in the Five-Star Quality Rating System. The manual also includes the specifications for the surveyor QMs (e.g., the long stay QM, Prevalence of Behavior Symptoms Affecting Others), which are not publicly reported and only available via the CASPER reporting application. The manual features a Notable Changes section that summarizes the major changes from the previous version, as well as the Quality Measure Reporting Module Table that documents CMS QMs calculated using MDS 3.0 data and reported in a CMS reporting module. The most current manual is included in the Users-Manuals ZIP file available from this site.
The Medicare Benefit Policy Manual in the Internet-Only Manual System is a key source of guidance on technical coverage rules and skilled level-of-care criteria from the Centers for Medicare & Medicaid Services. The entire manual can be accessed online here.
Duration of Inpatient Services, Chapter 3, Medicare Benefit Policy Manual
Chapter 3, “Duration of Inpatient Services,” explains what a benefit period is, what counts as an inpatient day, and the impact of leaves of absence, as well as the impact of discharge or death on the first day of entitlement or participation.
Coverage of Extended Care (SNF Part A) Services, Chapter 8, Medicare Benefit Policy Manual
Chapter 8, “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” is the primary resource for information about Medicare Part A skilled coverage and level-of-care information. Topics include but are not limited to:
- Prior hospitalization and transfer requirements, including the medical appropriateness exception;
- Payment bans;
- The administrative level-of-care presumption;
- The components of a skilled level of care and the definition of skilled services;
- Principles for determining whether a service is skilled and related supporting documentation;
- Specific examples of some skilled nursing or skilled rehabilitation services, including management and evaluation of a patient care plan, observation and assessment of patient’s condition, and teaching and training activities;
- Direct skilled nursing services, including examples;
- Direct skilled therapy services, including examples;
- The definition of daily skilled services;
- What constitutes services provided on an inpatient basis as a “practical matter”;
- Detailed information on who can sign physician certifications and recertifications for Part A SNF services;
- Covered extended-care services; and
- Services furnished under arrangement with other providers.
Part B Therapy / Covered Medical and Other Health Services, Chapter 15, Medicare Benefit Policy Manual
Chapter 15, “Covered Medical and Other Health Services,” provides a wealth of information about coverage of Part B services, including Part B (aka outpatient) rehabilitation therapy services. This chapter reviews conditions of coverage and payment for Part B physical therapy, occupational therapy, and speech-language pathology services. Topics include but are not limited to:
- The plan of care, including establishment of the plan, plan contents, and therapy plan changes;
- Certification requirements;
- What constitutes reasonable and necessary services;
- Maintenance programs; and
- Documentation requirements.
General Exclusions From Coverage, Chapter 16, Medicare Benefit Policy Manual
Chapter 16, “General Exclusions from Coverage,” reviews the basic items and services that Medicare won’t pay for under certain conditions. For example, Medicare doesn’t cover personal comfort items, routine services and appliances, or custodial care.
The Medicare Claims Processing Manual in the Internet-Only Manual System contains information from the Centers for Medicare and Medicaid Services about accurate billing and the appeals process. The entire manual can be accessed online here.
General Billing Requirements, Chapter 1, Medicare Claims Processing Manual
Chapter 1, “General Billing Requirements,” explains an array of basic information, including but not limited to:
- The formats for submitting claims to Medicare;
- Jurisdictions for claims;
- Provider assignment to Medicare administrative contractors;
- Provider participation;
- Termination of provider agreements;
- The basic process for filing a request for payment, including the rules for billing frequency;
- Billing noncovered charges on institutional claims;
- Part A and Part B timely filing limits and exceptions;
- MAC claims processing timeliness;
- How to handle billing when a resident is a Medicare Advantage enrollee for a portion of the billing period;
- Duplicate claims;
- SNF Part A and Part B adjustment billing;
- SNF claims subject to expedited determinations; and
- Services paid on the Medicare Physician Fee Schedule for SNF Part B claims (22x and 23x bill types).
Administration and Registration Requirements, Chapter 2, Medicare Claims Processing Manual
Chapter 2, “Administration and Registration Requirements,” explains basic information, including but not limited to:
- General administration and registration rules, including Medicare beneficiary identifiers and SNF verification of prior hospital stay information for determining deductible and benefit period status;
- Information required to determine whether to bill Medicare or another payer; and
- Providers obtaining/verifying the Medicare beneficiary identifier and entitlement status, including the rules for accessing eligibility data from systems maintained by CMS and the Medicare administrative contractors.
Part B Outpatient Rehabilitation, Chapter 5, Medicare Claims Processing Manual
Chapter 5, “Part B Outpatient Rehabilitation and CORF/OPT Services,” includes information about the annual Part B financial limitations and the KX modifier thresholds, as well as instructions on HCPCS coding requirements, including reporting service units and using timed codes. In addition, the chapter has an appendix with relevant ICD-10 codes.
SNF Inpatient Part A Billing and Consolidated Billing, Chapter 6, Medicare Claims Processing Manual
Chapter 6, “SNF Inpatient Part A Billing and SNF Consolidated Billing,” provides nuts-and-bolts information on SNF PPS billing and consolidated billing. Topics covered include but are not limited to:
- Consolidated billing requirements, including the types of facilities and services that are subject to consolidated billing, and services subject to consolidated billing that are furnished under arrangement with outside entities;
- Services included in Part A PPS payments and not separately billable by the SNF, as well as services that are beyond the scope of the Part A benefit;
- Billing SNF PPS services, including an explanation of the Health Insurance Prospective Payment System (HIPPS) rate code, coding PPS bills for ancillary services, and adjustment requests;
- Special inpatient billing instructions, including the requirement to submit bills in sequence, as well as information about determining the Part A admission date, discharge date, and utilization days, which includes handling leaves of absence and same-day transfers;
- Instructions for ending a benefit period and billing in benefits-exhaust and no-payment situations;
- SNF payment bans, or denial of payment for new admissions (DPNA);
- Billing related to physician’s services; and
- Part A billing issues involving Medicare Advantage (MA) beneficiaries.
SNF Part B Billing, Chapter 7, Medicare Claims Processing Manual
Chapter 7, “SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule),” reviews the three situations where SNFs are allowed to submit claims for Part B services; billing for inpatient SNF services paid under Part B; billing for outpatient SNF services; determining how much to charge before billing is submitted; general payment rules and application of Part B deductible and coinsurance; HCPCS codes; billing formats and frequency; guidelines for submitting corrected bills; and billing requirements for an array of services, such as bone mass measurements, supplies (e.g., surgical dressings), and durable medical equipment.
Preventive and Screening Services, Chapter 18, Medicare Claims Processing Manual
Chapter 18, Preventive and Screening Services,” reviews the coverage and billing rules for multiple preventive services, including the pneumococcal pneumonia, influenza virus, and hepatitis B vaccines, as well as various screening services such as mammography screening.
Completing and Processing the CMS-1450 or UB-04, Chapter 25, Medicare Claims Processing Manual
Chapter 25, “Completing and Processing the Form CMS-1450 Data Set,” provides a field-by-field look at the coding requirements for creating an accurate institutional Part A/B bill to submit to Medicare administrative contractors.
Common Working File (CWF) Technical Basics, Chapter 27, Medicare Claims Processing Manual
Chapter 27, “Contractor Instructions for the CWF,” explains how the Common Working File operates from a technical perspective and explains the meaning of various codes, such as SNF consistency error codes.
Appeals of Claims Decisions, Chapter 29, Medicare Claims Processing Manual
Chapter 29, “Appeals of Claims Decisions,” walks through the administrative appeals process. Topics include but are not limited to:
- Who may appeal;
- Steps in the appeals process, as well as a detailed review of each level: redetermination, reconsideration, administrative law judge hearing, departmental appeals board/appeals council, and U.S. District Court review;
- Where to appeal;
- Time limits for filing appeals and good cause for extension of the time limit for filing appeals;
- Amount-in-controversy requirements;
- Appointment of representative and assignment of appeal rights;
- Fraud-and-abuse issues;
- Guidelines for writing appeals correspondence; and
- Disclosure of information.
Financial Liability Protections: ABN, SNF ABN, NOMNC, Chapter 30, Medicare Claims Processing Manual
Chapter 30, “Financial Liability Protections,” explains multiple aspects of financial liability protections for patients, including but not limited to:
- Limitation on liability when claims are disallowed;
- The rules for determining financial liability when claims are disallowed;
- Requirements, including content and delivery rules, for Form CMS-R-131, the Advance Beneficiary Notice of Noncoverage (ABN), which applies only to Part B services in SNFs;
- Requirements, including content, delivery, and signature rules, for Form CMS-10055, the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), which applies only to Part A services in SNFs;
- Indemnification procedures for claims falling within the limitation on liability provision; and
- Expedited determinations of provider service terminations , including the requirements for the Notice of Medicare Non-Coverage (NOMNC) and the Detailed Explanation of Non-Coverage for both fee-for-service Medicare and Medicare Advantage coverage. This section includes an example of an expedited determination scenario in a SNF.
Reopening and Revision of Claim Determinations and Decisions, Chapter 34, Medicare Claims Processing Manual
Chapter 34, “Reopening and Revision of Claim Determinations and Decisions,” explains the opportunities providers have to request a remedial action from Medicare contractors to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. Reopenings are separate and distinct from the appeals process. Topics include but are not limited to time frames to reopen claim determinations and what is good cause for reopening.
The Medicare General Information, Eligibility, and Entitlement Manual in the Internet-Only Manual System is a key source of eligibility and entitlement guidance from the Centers for Medicare and Medicaid Services. The entire manual can be accessed online here.
General Overview, Chapter 1, Medicare General Information, Eligibility, and Entitlement Manual
Chapter 1, “General Overview,” offers basic information about Medicare program benefits, including Part A and Part B; the administration of the Medicare Program; and the role of Medicare contractors, including Medicare Administrative Contractors.
Deductibles, Coinsurance, and Payment Limits – Plus Benefit Periods, Chapter 3, Medicare General Information, Eligibility, and Entitlement Manual
Chapter 3, “Deductibles, Coinsurance Amounts, and Payment Limitations,” explains annual deductibles and coinsurance amounts. However, this chapter also reviews how a benefit period starts and ends, the definition of a SNF for ending a benefit period, and the definition of inpatient for ending a benefit period.
Physician Certification and Recertification (Cert/Recert), Chapter 4, Medicare General Information, Eligibility, and Entitlement Manual
Chapter 4, “Physician Certification and Recertification of Services,” reviews who can sign the cert/recert for Medicare Part A SNF services, certification content and timing requirements, recertification content and timing requirements, the rules involving delayed certs/recerts; and the disposition of certs/recerts.
Definitions, Chapter 5, Medicare General Information, Eligibility, and Entitlement Manual
Chapter 5, “Definitions,” explains key definitions related to the Medicare program. These include but are not limited to the definition of:
- Provider agreements;
- A skilled nursing facility;
- A distinct part of an institution as a SNF;
- Transfer agreements; and
- Hospital providers of extended-care services.
Disclosure of Information, Chapter 6, Medicare General Information, Eligibility, and Entitlement Manual
Chapter 6, “Disclosure of Information,” reviews the rules related to privacy and the disclosure of information evolving from the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. For example, it provides guidelines for how Medicare contractors should handle requests for beneficiary-specific information from providers, physicians, and suppliers.
The Medicare Program Integrity Manual in the Internet-Only Manual System contains detailed information from the Centers for Medicare & Medicaid Services about benefit integrity and medical review activities, including how Medicare administrative contractors are supposed to conduct medical reviews to determine whether a claim should be paid. The entire manual can be accessed online here.
Medicare Improper Payments, Chapter 1, Medicare Program Integrity Manual
Chapter 1, “Medicare Improper Payments: Measuring, Correcting, and Preventing Overpayments and Underpayments,” provides an overview of program integrity and provider compliance activities using review contractors, i.e., Medicare administrative contractors (MACs), Comprehensive Error Rate Testing (CERT) contractors, recovery auditors, unified program integrity contractors (UPICs), and the supplemental medical review contractor (SMRC). Topics addressed include but are not limited to: the operation of the Medicare Improper Payment Prevention program, including program goals, the contractors that are involved, and the types of claims they handle; contractor medical director requirements; and contractor medical review manager requirements.
Medical Review Process Basics (ADRs, etc.), Chapter 3, Medicare Program Integrity Manual
Chapter 3, “Verifying Potential Errors and Taking Corrective Actions,” lays out the basic requirements that review contractors must use in conducting prepayment and postpayment reviews of provider claims. Topics addressed include but are not limited to:
- Additional documentation requests, including the types of information that can be requested and the time frames that providers must be allowed for responding;
- Policies and guidelines applied during review, including information on complex vs. noncomplex review and documentation signature requirements;
- Prepayment reviews, including random reviews and 100% prepayment reviews, diagnosis code requirements, and prepayment review edits;
- Postpayment reviews, including case selection;
- Determinations made during review, including how contractors verify errors, such as applying the reasonable-and-necessary criteria, as well as beneficiary and provider notifications;
- Corrective actions, including determining provider error rates and creating comparative billing reports; and
- How MACs should defend medical review decisions at administrative law judge hearings.
Benefit Integrity (UPICs), Chapter 4, Medicare Program Integrity Manual
Chapter 4, “Benefit Integrity,” offers an in-depth look at the Medicare Fraud Program, giving examples of fraud (e.g., billing noncovered or nonchargeable services as covered items) and providing details on operational requirements for UPICs.
SNF PPS Part A Medical Reviews, Chapter 6, Medicare Program Integrity Manual
Chapter 6, “Medicare Contractor Medical Review Guidelines for Specific Services,” provides a detailed review of how Medicare contractors should conduct medical review of SNF PPS claims. Topics include but are not limited to:
- Types of bill review, including focused medical review and demand bills;
- The bill review process, including how contractors obtain records, make coverage determinations, and decide how much if any of the claim to pay (including examples of medical review outcomes); and
- Medical review of physician certifications and recertifications for Part A services.
Comprehensive Error Rate Testing (CERT), Chapter 12, Medicare Program Integrity Manual
Chapter 12, “The Comprehensive Error Rate Testing (CERT) Program,” explains the basic operating structure of the CERT Program, which produces a national Medicare fee-for-service (FFS) improper payment rate by evaluating a random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.
Local Coverage Determinations (LCD), Chapter 13, Medicare Program Integrity Manual
Chapter 13, “Local Coverage Determinations,” explains the difference between a national coverage determination and a local coverage determination, which is a decision by a Medicare administrative contractor (MAC) whether to cover a particular item or service on a MAC-wide basis. The chapter then details the rules that MACs must follow in creating and using LCDs.
Exhibits (Sample Letters and Instructions), Medicare Program Integrity Manual
“Exhibits” provides an array of supporting documentation used in program integrity activities, ranging from consent settlement documents to postpayment additional documentation request sample letters.
The Nursing Home Compare Claims-Based Quality Measure Technical Specifications (Nursing Home Compare Claims-Based Measures Tech Specs.pdf), updated in April 2019, contains detailed technical specifications for all claims-based NHQI QMs, which are reported on Care Compare and some of which are used in the Five-Star Quality Rating System. The Nursing Home Compare Quality Measures Technical Specifications Appendices (APPENDIX - Claims-based measures Technical Specifications.pdf) contains tables and appendices related to these claims-based QMs. The Technical Specifications and an April 2019 version of the Appendices are available in the same Users-Manuals ZIP file that contains the MDS 3.0 QM User’s Manual. However, it’s important to note that a January 2020 version of the Appendices is available from the Five-Star Quality Rating System site.
The Office of Inspector General (OIG) has developed a series of voluntary compliance program guidance documents directed at various segments of the healthcare industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements.
Access the OIG Corporate Compliance Guidance 2000.
Access the OIG Corporate Compliance Guidance 2008.
For additional resources, visit the OIG Compliance Resource Portal.
Nursing Homes Reform of Requirements New Survey Process Resources
This CMS website provides two key sets of resources:
- The Long-Term Care Survey Process (LTCSP). Surveyors use a standardized set of tools and instructions, in addition to the interpretive guidance in Appendix PP of the State Operations Manual, to conduct LTCSP surveys. These include the Long Term Care Survey Process (LTCSP) Procedure Guide, an entrance conference worksheet, provider matrix., initial pool care area probe tools, Surveyor Pathways that target in-depth investigations of specific care areas (e.g., pain recognition and management), and facility task tools that address specific facility systems (e.g., dining observation).
- COVID-19 Focused Infection Control Surveys. Specialized tools used by surveyors in these surveys include an entrance conference worksheet and a survey protocol. The COVID-19 Focused Infection Control Survey Tool is embedded within the general Infection Prevention, Control & Immunizations surveyor pathway.
CMS Quality Safety & Oversight Policy and Memos
CMS Quality Safety & Oversight (QSO) memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices. This is where CMS posts critical updates related to surveys and survey guidance, the Nursing Home Quality Indicator (NHQI) Quality Measures (QMs), the Five-Star Quality Rating System, and the Care Compare (formerly Nursing Home Compare) website. Typically, memos that end in "NH" or "ALL" are most relevant to nursing homes.
CMS Quality Safety & Oversight Administrative Information Memos
CMS Quality Safety & Oversight memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices. This page generally offers overview information, such as annual survey priorities, changes to which CMS personnel handle specific survey-and-certification functions, and requirements for states to receive CARES Act funding.
In the National Partnership to Improve Dementia Care in Nursing Homes, CMS has partnered with federal and state agencies, nursing homes, other providers, advocacy groups, and caregivers. The partnership’s initial focus was reducing unnecessary antipsychotic medications. However, its overarching mission is to enhance the use of nonpharmacologic approaches and person-centered dementia care practices.
To continue to inform this work, as of FY 2021 (October 2020 – September 2021), CMS plans to conduct additional focused dementia care surveys in some states, as well as a limited number of focused schizophrenia surveys due to concerns about facilities using an inappropriate process to diagnose residents with schizophrenia.
Adverse Drug Event Trigger Tool
Based on findings of medication-related adverse events, CMS created the Adverse Drug Event Trigger Tool as a resource document containing necessary information for evaluating high-risk medications. This tool is a crosswalk that lists: common potentially preventable adverse drug events; risk factors related to those events; triggers—signs, symptoms, or clinical interventions that could indicate that the adverse drug event has occurred; and probes that would assist surveyors in evaluating systems around high-risk medications. Providers can use it as a risk management tool. The Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway used in the Long-Term Care Survey Process directs surveyors to this tool in the Record Review section.
Life Safety Code Resource Page – CMS
The Life Safety Code (LSC) is a set of fire protection requirements designed to provide a reasonable degree of safety from fire; CMS partners with State Agencies to assess compliance via LSC surveys. This page and attached resources detail LSC regulations and compliance information, as well as the certification process.
CMS Quality, Safety, and Education Portal (QSEP) e-Learning Website
CMS has developed training courses that help providers review survey requirements and processes, as well as access dementia care and infection control trainings and other resources.
- Non-therapy ancillary (NTA),
- Physical therapy (PT),
- Occupational therapy (OT),
- Speech-language pathology (SLP), and
The case-mix components derive from the resident’s 5-day PPS MDS (with an assessment reference date set on days 1 – 8 of the Part A stay), which determines the payment for the resident’s entire stay—unless the facility chooses to complete an unscheduled Interim Payment Assessment (IPA) to re-classify the resident into a new PDPM classification. That new payment rate would take effect on the ARD of the IPA (which must be set within 14 days of identifying the reclassifying change) and continues through discharge from Part A unless the facility chooses to complete another IPA.
Three of the case-mix components use a variable per-diem adjustment schedule. For the PT and OT components, the adjustment factor is 1.00 for days 1 to 20, payment declines 2 percent every seven days after day 20. For the NTA component, the adjustment factor is 3.00 for the first three days to reflect extremely high initial costs and 1.00 (two-thirds lower than the initial level) for days 4 – 100. A resident’s total PDPM per-diem payment rate is calculated as follows:
Total Case-Mix-Adjusted Per-Diem Payment =
(PT Component Per-Diem Rate * PT Variable Per-Diem Adjustment Factor) +
(OT Component Per-Diem Rate * OT Variable Per-Diem Adjustment Factor) +
SLP Component Per-Diem Rate +
(NTA Component Per-Diem Rate * NTA Variable Per-Diem Adjustment Factor) +
Nursing Component Per-Diem Rate +
Non-Case-Mix Component Per-Diem Rate
PDPM also uses an interrupted-stay policy to determine payments for residents who are discharged from Part A SNF care and subsequently readmitted to the same SNF for Part A care within three days of discharge.
Here is a list of government resources related to the PDPM:
The fiscal year (FY) 2019 Final Rule and its correction notice contain the regulations for the basic components of the PDPM system that was implemented on Oct. 1, 2019. CMS issues a new proposed SNF PPS rule each spring and a new final rule each summer for the upcoming fiscal year that begins on Oct. 1. These rules contain any proposed and finalized changes to the PDPM, including any related changes to the MDS. CMS maintains a list of each fiscal year’s proposed and final rules here.
CMS has developed this home page as the go-to resource for all things PDPM, including fact sheets, FAQs, training presentations, and educational tools. Annual updates and additional revisions to the SNF PDPM ICD-10 Mappings tool discussed below are posted to this page.
ICD-10 Diagnosis Code to PDPM Mappings tool
Each fiscal year, CMS issues an updated SNF PDPM ICD-10-CM Mappings tool that identifies allowed vs. disallowed ICD-10 codes for the purposes of PDPM case-mix classification. The tool includes:
- ICD-10 to Clinical Category Mapping: This maps the resident’s primary SNF diagnosis captured as an ICD-10 code in MDS item I0020B to the 10 PDPM primary diagnosis clinical categories, which are then collapsed to further classify the resident for payment purposes under the PT, OT, and SLP components of PDPM.
- SLP Comorbidity to ICD-10 Mapping: This maps SLP-related comorbidities (e.g., dysphagia and oral cancers) that are captured as ICD-10 codes in MDS item I8000 to the SLP payment component.
- NTA Comorbidity to ICD-10-CM Mapping: This maps NTA-related comorbidities (e.g., end-stage liver disease and cystic fibrosis) that are captured as ICD-10 codes in MDS item I8000 to the NTA payment component.
Section 6.6, PDPM Calculation Worksheet for SNFs, in chapter 6 of the RAI User’s Manual provides a narrative step-by-step walkthrough of how to manually determine a resident’s PDPM classification based on the data from an MDS assessment for each of the five PDPM case-mix components, including how and when to use the Mappings tool and how to apply the variable per-diem payment adjustments for the PT, OT, and NTA components.
PDPM Fact Sheets
- Administrative Level of Care Presumption under the PDPM
- PDPM Payments for SNF Patients with HIV/AIDS
- Concurrent and Group Therapy Limit (ZIP) (revision posted 8-30-19)
- PDPM Functional and Cognitive Scoring (ZIP) (revision posted 8-30-19)
- Interrupted Stay Policy (ZIP) (revision posted 8-30-19)
- MDS Changes (ZIP) (revision posted 8-30-19)
- NTA Comorbidity Score
- PDPM Patient Classification (ZIP) (revision posted 8-30-19)
- Variable Per Diem Adjustment
Payroll-Based Journal (PBJ) is a system developed by CMS for facilities to submit staffing information. The first mandatory reporting period began July 1, 2016, and PBJ staffing data is now used in the Five-Star Quality Rating System on Care Compare. More information about PBJ is available on the CMS and the QTSP websites. See links below.
To find the policy manual, frequently asked questions, and other resources, visit here.
To learn about using the PBJ submission system itself, visit
Tools and resources for Quality Assurance and Performance Improvement (QAPI) programs.
Beneficiary and Family Centered Care (BFCC)-QIOs are regional organizations that support beneficiaries. Their duties include reviewing resident appeals of expedited determination notices. This page includes look-up contact information for the BFCC-QIOs.
Quality Innovation Network (QIN)-QIOs are designed to improve healthcare services through education, outreach, sharing practices that have worked in other areas, using data to measure improvement, working with patients and families, and convening community partners for communication and collaboration. QIN-QIOs provide nursing homes with free resources and technical assistance in Quality Assurance and Performance Improvement (QAPI) activities for key resident care concerns. This page includes look-up contact information for the QIN-QIOs.
Find additional information on QIOs here.
The QIES Technical Support Office (QTSO) maintains the MDS submission system and the CASPER reporting application. These manuals provide guidance on how to successfully submit MDS files, how to find management reports to monitor your facility’s submissions and MDS process, and how to access CASPER QM reports for both the NHQI QMs and the SNF QRP QMs. Access the CASPER Reporting User's Guide for MDS Providers and MDS 3.0 Provider User's Guide here.
Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual
The SNF QRP Measure Calculations and Reporting User’s Manual explains in detail the measure calculations for the MDS-based SNF QRP quality measures. CMS also provides a Risk Adjustment Appendix File for SNF Measure Calculations and Reporting User's Manual at the same link.
More information about the SNF QRP is available via the SNF QRP portal.
The SNF VBP Program rewards high-performing skilled nursing facilities with incentive payments for the quality of care they give to people with Medicare. The SNF VBP Program started in fiscal year 2019.
More information about the SNF VBP, including the measure used, the scoring methodology and payment adjustment, confidential feedback reporting, public reporting, and exceptions and extensions, is available at the SNF VBP portal.
The State Operations Manual (SOM) in the Internet-Only Manual System contains the primary survey-and-certification rules and guidance for Medicare- and Medicaid-certified long-term care providers (i.e., NFs and SNFs) from CMS, including standard surveys, extended surveys, complaint procedures, Life Safety Code surveys, and Emergency Preparedness surveys.
State Health Departments
The federal government provides links to state health departments here.
Medicaid.gov provides access to federal policy guidance that impacts Medicaid programs, state-specific 1135 waivers, and other resources.
The National Council of State Boards of Nursing (NCSBN) provides a link to all State Nurse Practice Acts.