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December Advisor Newsletter

What’s New with CMS?
Four Big CMS Changes and “Bottom-Line” Solutions from HealthPRO®/Heritage 

CHANGE #1: Comprehensive Care for Joint Replacement Model Policy Changes and Cancellation of Episode Payment Models and Cardiac Rehabilitation Incentive Payment Model

Details related to this change include:

  • Thirty-three of the 67 MSAs in CJR have an option to voluntarily participate in CJR for years 3, 4 and 5. These rural-area hospitals with low volume will be given a one-time opportunity to continue their participation.
  • From January 1 through January 31, 2018, CMS will hold a one-time participation election period for hospitals with a CCN primary address located in the voluntary-participation-MSAs, and for specified low-volume hospitals and rural hospitals in the mandatory participation MSAs. CMS must receive the hospital’s voluntary participation election letter no later than January 31, 2018 in order for a hospital to voluntarily continue to participate in the CJR Model.
  • For reference, the CJR webpage lists:
    • all CJR participating hospitals and respective MSAs
    • mandatory or voluntary MSA status
    • whether the hospital is rural or low volume
  • In the future, CMS anticipates:
    • more opportunities for providers to participate in voluntary initiatives
    • possible changes to current CJR pricing methodology

CMS provided notice on November 30, 2017. Effective January 1, 2018.

Although mandatory expansion has been cancelled, providers must understand that bundled payment is here to stay! Focus must remain on fundamental performance metrics (such as 5-Star Ratings and Quality Measures) that ensure safe transitions to the next level for the residents in our care. After all, upstream providers continue to seek out partnerships and “preferred provider” relationships with skilled nursing facilities able to consistently capture, track and demonstrate positive outcomes.

CHANGE #2: CMS Delays Phase 2 Nursing Home Enforcement Penalties & Unveils New Survey Process

AHCA has been working with CMS to assist LTC providers in relieving some of the burden associated with the overwhelming Rules of Participation. CMS has released two memos regarding this process.

  1. Temporary Enforcement Delays for Certain Phase 2 F-Tags and Changes to Nursing Home Compare is available online here.
  2. Preparation for Launch of New Long-Term Care Survey Process (LTCSP) is available online here.

AHCA’s summary of the first memo:

  • Temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements: CMS will provide an 18-month moratorium on use of certain enforcement remedies (CMP, DPNA and discretionary termination) for specific Phase 2 requirements (see below). However, CMS may use directed plans of correction or directed in-services for these specific Phase 2 requirements. This 18-month period will be used to educate facilities about specific new Phase 2 standards.
  • Freeze health inspection star ratings: Following implementation of the new survey process on November 28, 2017, CMS to hold constant the current health inspection Star Ratings on the Nursing Home Compare website for any surveys occurring between November 28, 2017 and November 27, 2018. There is no change to the staffing or Quality Measure component and the overall rating can still change based on these factors.
  • Availability of survey findings: As facilities are surveyed under the new survey process, results will be published on Nursing Home Compare (CMS to add indicators that capture new findings). These results will not be incorporated into calculations for the 5-Star Quality Rating System for 12 months.
  • Methodological changes and changes in Nursing Home Compare: In early 2018, Nursing Home Compare health inspection star ratings will be based on the two most recent cycles of findings for standard health inspection surveys and the two most recent years of complaint inspection.

CMS has provided the following list of F-Tags included in the 18-month moratorium on use of CMPs:

  • F655 (Baseline Care Plan); §483.21(a)(1)-(a)(3)
  • F740 (Behavioral Health Services); §483.40F741 (Sufficient/Competent Direct Care/Access Staff-Behavioral Health); §483.40(a)(1)-(a)(2)
  • F758 (Psychotropic Medications) related to PRN Limitations §483.45(e)(3)-(e)(5)
  • F838 (Facility Assessment); §483.70(e)
  • F881 (Antibiotic Stewardship Program); §483.80(a)(3)
  • F865 (QAPI Program and Plan) related to the development of the QAPI Plan;
  • §483.75(a)(2) and,
  • F926 (Smoking Policies). §483.90(i)(5)

Frozen 5-Star Ratings
5-Star Ratings will be frozen for any surveys or IDRs that are initiated after November 28, 2017. Any survey or IDR initiated before November 28, 2017 will continue to impact facility 5-Star Ratings. Survey results, including number, type and severity of deficiencies, will continue to be posted on Nursing Home Compare. Also, in early 2018 CMS intends to recalculate all 5-Star Ratings, excluding the third oldest survey from every rating. After that time, only the past two surveys will be included in the rating system. CMS recommends that providers impacted by this freeze that are involved with ACOs or managed care provide a copy of the explanatory memo to the ACO or hospital. (CMS Policy And Memos To States And Regions)

New Survey Process
The second memo, Preparation for Launch of New Long-Term Care Survey Process, confirms that CMS began the new survey process on November 28, 2017. Guidance to state surveyors as they implement the new survey was provided.

CHANGE #3: Reprieve for Home Health Agencies Facing Reimbursement Changes in 2019

The 2018 Proposed Rule for Home Health agencies was released in July and included one of the most significant regulatory proposals to hit the home health care industry in decades: Home Health Groupings Model (HHGM). HHGM proposes the following:

  • Changing from the current 60-day episodic reimbursement to a 30-day payment
  • Decreasing reimbursement to home health providers by $950 million in 2019
  • This amounts to an estimated 15-17% rate cut to home health providers

Fortunately, CMS announced on November 1 that implementation of HHGM will not be included in this final rule, but the HHGM model is not completely off the table.

Currently, CMS is reviewing and considering the many public comments received before determining further action.

CHANGE #4: MDS 3.0 Version 1.16

A drafted version of the new Minimum Data Set has been posted, and it promises to keep PAC providers on their toes in 2018!

Multiple sections have been modified in this newest version and several items have been added to support calculations of functional and mobility changes related to Quality Measures. The implementation of these updates coincides with the proposed initiation of the Medicare Part A PPS RCS-1 reimbursement system (scheduled to go into effect October 1, 2018), which promises to reduce the requirement for multiple MDS assessments under Medicare A. Although this news is being well-received, newly proposed coding items in the draft MDS 3.0 version 1.16 will be included on 5 Day PPS and discharge assessments.

It is imperative every post-acute care facility understands and prepares for MDS changes, because the expansion of coding items on the 5 Day assessment promises to keep providers on their toes for coding precision so as to accurately calculate the Quality Measures. Specifically, the following sections are subject to change:

  • C
  • GG
  • I
  • J
  • M
  • N
  • O

Proposed changes to Section GG:

  • Details RE: prior level of function will be captured. New coding items to include: Indoor mobility, stairs and functional cognition.
  • Prior devices and aids utilized including manual wheelchair, motorized wheelchair and/or scooter, mechanical lift, walker and/or orthotics/prosthetics.
  • Scoring to be expanded to allow for versatility in why an item was not assessed. This will read as: 10. Not attempted due to environmental limitations” (e.g., lack of equipment, weather constraints) in addition to the current not assessed coding items.
  • The term “Contact Guard” to be added to the definition when scoring level 04 in the 6 point scale:  04. Supervision or touching assistance: Helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completes activity.
  • Elimination of section that reads: Does the resident walk and replacing it with Walking 10 feet on even and uneven surfaces, rolling, car transfers and curb management. Step climbing and descending will be scored by assessing 4 and 12 steps as well as picking an item up off the floor.

Proposed changes to Section I:
Providers will be required to report on the medical condition which best describes the primary reason for admission. The clinical team will need to verify that the facility communication system for new admissions and discharge status is seamless for collecting and reporting.

Proposed changes to Section J:
Providers will be expected to capture whether the resident has had major surgery during the 100 days prior to admission (requiring there to be a system in place to collect this data).

Proposed changes to Section M:
Current terminology to be included consistent with the NPUAP for labeling tissue injuries.

Small steps towards big changes: Prepare today!

As providers prepare for sweeping industry changes in 2018 and beyond – as with the proposed RCS-1 system – PAC providers must recognize the value in taking critical, but simple, more accessible steps TODAY.

HealthPRO®/Heritage recommends refining current protocols to prepare for next level of care reform. Consider care redesign initiatives inclusive of systematic changes to primary care practices to improve the quality, efficiency, and effectiveness of patient care. Caregiver teams must be supported by ongoing education and communication systems and be held accountable to a system that embraces effective collection of data and accurate/compliant coding practices.

For more information on how HealthPRO®/Heritage can support your successful transition to a new world of MDS/health care reform, please email: MDS@healthpro-rehab.com.

RCS-1 Readiness
As part of HealthPRO®/Heritage’s ongoing commitment to ensuring a smooth transition during impending payment reform, our subject-matter experts offer perspective on the 3rd of 5 myths related to RCS-1.

MYTH #3: “SNFs are already familiar with coding, and RCS-1 will not require new processes.”

This commonly held myth addresses misconceptions related to the role of ICD-10 coding in reimbursement under the new system. In reality, the need for proper coding practices will be among the most significant changes under RCS-1.

Consider current coding process:
Diagnostic coding has no role in SNF reimbursement. Often times, multiple members of the nursing staff – who are untrained in the nuances of accurate coding – handle processes related to coding. Moreover, coding is typically completed later in the resident’s stay or even upon discharge.

Under RCS-1:
Diagnostic coding significantly impacts the initial reimbursement rate (which is less likely to change throughout the stay, as compared to the current system, excluding a significant change in condition) so precise and accurate coding is critical! Specifically, ICD-10 coding must reflect the main reason for the SNF stay with reimbursement weighted to both the primary code selected and the sequence of supporting codes. Moreover, ICD-10 coding must be aligned among multiple disciplines for proper billing. Perhaps equally important: coding must be accurately completed very early in the resident’s stay; this requisite represents a drastic change in current workflow for most skilled nursing providers.

Strategic solutions:
HealthPRO®/Heritage recommends that providers proactively establish processes to ensure MDS, Nursing and Rehab address the need for these systemic changes. Among the many possible tactics, consider the following:

  • MDS and RD to discuss clinical and cognitive and coding versus minutes
  • Evaluate coding options during baseline care plan
  • Initiate efforts re: proper coding during preadmission process

HealthPRO®/Heritage has invested heavily in research and development efforts with our own consultants to develop an understanding of, and an effective response to, impending payment reform.

Our efforts have yielded:

  • Consulting services with subject-matter experts to evaluate current systems and processes; to offer guidance/solutions; to implement initiatives to drive success
  • An MDS-based reimbursement “Crosswalk Model” to highlight areas of risk and opportunities. This cloud-based patient pre-admission system will serve to predict episodic payments based on key patient characteristics and a framework for patient care plan, needs assessment and to effectively allocate resources.

HealthPRO®/Heritage has developed a one-of-a-kind “Crosswalk Model” that mirrors the CMS impact file, but this analysis takes 6+ months of recent MDS data that demonstrates a facility’s opportunities for optimal reimbursement.

Based on the “Crosswalk Model,” HealthPRO®/Heritage is able to recommend clinical and operational functions for coding, cognitive status and functional status are important strategies to (1) prepare for payment reform, and also (2) help with today’s reimbursement, quality measures and IMPACT measures as well.

For more information, please email Clinical Strategies.