Payment Impacts

CMS finalized a number of items that will impact SNF rates beginning October 1, 2021, including:

• SNF Prospective Payment System:, SNFs will see their FY2022 Prospective Payment System rates increase by a mere 1.2%, which is lower than the originally proposed 1.3% update but is based off of more recent data. Specifically, this rate increase is the result of a 2.7% market basket less a 0.7% productivity adjustment and 0.8% forecast error adjustment. This differs slightly from the proposed rule, which estimated the market basket at 2.3%. The market basket was updated after release of the proposed rule based on the IGI second quarter 2021 forecast and the productivity adjustment was updated accordingly. Additionally, CMS finalized the proposal to update the market basket to base year 2018.  In comments on the proposed rule, LeadingAge noted that the proposed increase was less than in years past and comes at a time when providers are even more stretched due to the increased costs of care, operations, and supplies as a result of the COVID-19 public health emergency. CMS acknowledged these comments in the final rule, but noted that the updated forecasts provided by IHS Global Inc. included experiences during the COVID-19 public health emergency and were therefore considered to be accurate and appropriate.
• Patient Driven Payment Model Updates: On a positive note, the rule staves off the proposed 5% parity adjustment to the patient-driven payment model (PDPM) but CMS promises to re-evaluate for FY 2023. In comments on the proposed rule, LeadingAge opposed the proposed recalibration methodology, stating that the full impact of the COVID-19 public health emergency (PHE) was not accurately accounted for in the proposed methodology. The PHE caused significant disruption and pervasive changes to the healthcare system that could not adequately be controlled for by eliminating residents from calculations who had COVID-19 diagnoses or who had utilized the qualifying hospital stay waiver. Examples of these disruptions include changes in operations, such as visitor restrictions, that may have led to resident declines or cohorting of residents due to limited physical capacity to meet surges; changes in the acuity of admitting residents due to illness, aftereffects, and hospital capacity strategies of halting elective surgeries; and lack of appropriate identification, diagnosis, and coding early in the pandemic and when testing supplies were scarce. Given the strong opposition and reasoning shared by LeadingAge and many other commenters, CMS has delayed the PDPM parity adjustment and will consider these comments for the FY 2023 SNF PPS proposed rule. On a related note, CMS finalized revisions to ICD-10 code mappings as proposed. The most updated code mappings and lists are available on the PDPM website.
• SNF Value-Based Payment Adjustments: SNF rates will be further impacted by an 0.8% rate reduction resulting from CMS’s approach to FY2022 SNF VBP adjustments.
• Consolidated Billing Exclusions: CMS finalized the proposal to exclude codes related to blood clotting factors from SNF consolidated billing. The Healthcare Common Procedure Coding System (HCPCS) codes associated with these factors are as follows: J7170, J7175, J7177–J7183, J7185–J7190, J7192–J7195, J7198–J7203, J7205, and J7207– J7211. Additionally, based on public comments, CMS added J7204 and J7212 to the list of excluded codes related to blood clotting factors. CMS requested feedback in the proposed rule for additional HCPCS codes to be added to the other 4 existing exclusion categories: chemotherapy items, chemotherapy administration and services, radioisotope services, and customized prosthetic services. Based on public comments, CMS added Q5123 for chemotherapy drug RIABNI under chemotherapy items. The latest list of all excluded codes can be found at the SNF Consolidated Billing website.

SNF Quality Reporting Program

CMS finalized 2 new quality measures for the SNF QRP program: Healthcare-Associated Infections (HAI) Requiring Hospitalization and the COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP). Both measures are finalized for FY 2023 of the SNF QRP.

The HAI measure was approved for implementation in FY2023 even without National Quality Forum (NQF) endorsement though CMS notes it will pursue such endorsement. LeadingAge encouraged CMS to obtain NQF endorsement prior to implementation. CMS responded, “Despite the current absence of NQF endorsement, we still believe it is critical to adopt the SNF HAI measure into the FY 2023 SNF QRP as one in four adverse events among SNF residents are due to HAIs, and approximately more than half of all HAIs are potentially preventable. Identifying several types of severe HAIs attributable to the SNF setting in one composite score provides actionable information to providers that may hold them accountable, encourage them to improve the quality of care they deliver, and improve transparency. ” SNF performance on the HAI measure performance will be publicly reported beginning with the April 2022 refresh.

In response to a request for support for providers around the HAI measure, CMS identified several existing training and other resources that providers might benefit from, including several resources available such as free online training modules in partnership with the CDC and Quality Improvement Organizations (QIOs) and the following webpages provided by the CDC:

· https://www.cdc.gov/longtermcare/prevention/index.html

· https://www.cdc.gov/longtermcare/training.html .

·The CMS Office of Minority Health (OMH) offers a Disparity Impact Statement tool as an intervention to address HAI-related disparities. This tool may be used to provide health equity technical assistance and reduce HAIs among vulnerable populations. 

Regarding the COVID-19 vaccination coverage of HCP measure, LeadingAge expressed concern in comments on the proposed rule that this measure was not a true reflection of quality but rather a measure of individual staff medical decisions, whether to accept the vaccine. CMS acknowledged the challenges of vaccine hesitancy but stated that COVID-19 vaccination coverage among healthcare personnel would allow for the assessment of risk of transmission within nursing homes, making it an appropriate measure of nursing home quality.

LeadingAge also commented on the risk of a double penalty associated with non-reporting or incomplete reporting on this measure. Providers who fail to report staff vaccination data could be penalized under CMS-3414-IFC, published after the release of the SNF PPS proposed rule, in addition to being penalized for non-reporting through the SNF QRP program requirements. CMS dismissed this concern because penalties would derive from separate requirements. CMS clarified, however, that “… a SNF that submits four weeks of data to meet the requirements of participation at § 483.80(g) [May 2021 IFC requiring staff and resident vaccine reporting] would also meet the data submission requirement for the COVID-19 Vaccination Coverage among HCP for the SNF QRP.”

CMS has indicated that the HCP Vaccination information submitted by the provider will not be contained in SNFs’ Quality Measure Reports, which contain facility and patient level data to help with quality improvement, until Fall 2022, due to the haste with which CMS seeks to implement the measure. CMS notes it has never included CDC NHSN data in its Review and Correct reports but that the CDC makes similar reports available to SNFs called CMS Reports that allow for real time review of data submissions for all CDC NHSN measures adopted for use in the SNF and other PAC QRPs. These reports can be found within the Analysis Reports page in the NHSN Application and mimic the provider’s data that will be sent to CMS.

Three months prior to public reporting of the HCP measure on Care Compare, providers will receive a preview of their SNF’s performance on the COVID-19 Vaccination Coverage among HCP measure, available in the SNF Provider Preview Report. Just like with all Provider Preview Reports, the provider will have 30 days to review the data and request a formal review of the data if there are any discrepancies. CMS aims to first publicly report this Vaccination of HCP data with the October 2022 Care Compare refresh or as soon as feasibly possible regarding Q4 2021 data. CMS will begin by publicly reporting the most recent quarter of data until four full quarters are available, from that point forward the published information will be based on four full, rolling quarters of data.

The final rule updates the current SNF QRP Transfer of Health Information to the Patient – Post-AcuteCare (PAC) measure denominator to exclude residents discharged home under the care of an organized home health service or hospice. This change will be effective FY2023, by which time CMS believes the MDS will be updated to collect the necessary discharge information to calculate this measure.

SNF Value Based Payment Program (SNF VBP)

CMS will suppress the SNF 30-day All-Cause Readmission Measure (SNFRM) for FY 2022 under the SNF VBP and has finalized the policy for future measure suppressions in the rule. This means CMS will not use SNFRM performance to determine a value-based incentive payment adjustment during this timeframe nor will they rank providers.  As noted earlier, the outcome of the suppression policy is that CMS will assess all SNFs a 0.8% rate reduction on SNF Medicare PPS rates for FY2022, as they are required by law to make a rate adjustment.  The data is being suppressed because it is believed that the data may not be reflective of quality of care being delivered due to the COVID-19 pandemic. CMS will still calculate each SNF’s readmission rate (using data from April 1 – December 31, 2019 and July 1 – Sept 30, 2020) and publicly report it at: https://data.cms.gov/provider-data/ . This is the successor site to Nursing Home Compare.

CMS will use the measure suppression policy adopted in these rules to evaluate whether the SNFRM should be suppressed in subsequent years. If CMS opts to invoke the measure suppression policy for future years, it will outline its approach via rulemaking in order to allow for stakeholder feedback. CMS also finalized that it will use a 90-day lookback period for risk-adjustment in the FY 2023 performance period (FY 2021) citing that analysis shows a similar result for a 365-day look-back. In addition, any future adjustments to the FY2023 performance period will be addressed in future rulemaking and will consider the effects of the public health emergency and changes in utilization patterns.

While CMS received considerable feedback on future measures to be added to the program, they did not make any decisions about additional measures to be included in SNF VBP in the final rule. We can anticipate future rulemaking to address the inclusion of up to 9 new measures for the program.

Beginning October 1, 2021, CMS will be changing the timing of when a provider can review and correct the underlying data used to calculate the SNFRM. SNFs will only be able to correct underlying administrative data (e.g. discharge destination) up to the point that CMS pulls the claims data, which follows a 3-month run out period after the last index SNF admission during the applicable baseline or performance period. Once a SNF receives its Review and Correct report it can only challenge errors in CMS calculations and not update the underlying claims data.

For example, for performance or baseline periods that end September 30, 2021, CMS will extract the MedPAR claims data on December 31, 2021. This means providers can only make corrections to the underlying administrative data for those performance periods through December 30, 2021. After that, CMS will calculate SNFRM rates and providers can only request corrections for CMS calculation errors.