In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications. These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1. This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM ones and thereby inform their future payment models.
The changes to the technical data specifications that support these modifications are contained in the Errata v3.00.5 which can be accessed in the file: MDS 3.0 data specs errata (v3.00.5) Final 06-18-2020 in the Downloads section of the MDS 3.0 Technical Information page. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file: MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip, which are also posted in the Downloads section of the MDS 3.0 Technical Information page.
The Department of Social Services (DSS) is required to submit a Medicare Upper Payment Limit (UPL) Demonstration for nursing facilities to CMS at the end of each state fiscal year. Currently, the Missouri nursing facility UPL Demonstration is based on the Medicare Resource Utilization Groups (RUGs) reimbursement system and the associated MDS data. With Medicare’s change in reimbursement to PDPM, CMS has indicated that at some point RUGs calculations will no longer be supported. At that point, or perhaps sooner, the State anticipates transitioning the UPL Demonstration to be based on the PDPM payment methodology that Medicare now uses. DSS will need the additional data items to perform that calculation. This will allow DSS to continue to align the UPL calculation to most closely reflect the Medicare payment methodology. The DSS may also use the additional data for future acuity-based analysis that would require these data elements.
Since Missouri will require the calculation of the PDPM payment codes on the OBRA assessments when not combined with a 5-day SNF PPS assessment, SNFs and NFs in Missouri will need to complete additional items on OBRA assessments when not combined with a 5-day SNF PPS assessment. Additional items include:
- GG0130 Self-Care items;
- GG0170 Mobility items;
- I0020 and I0020B Primary Medical Condition items;
- J2100 Recent Surgery item. If J2100 is checked yes, J2300-J5000 are to be completed.
Coding instructions for these items on OBRA assessments when not combined with a 5-day SNF PPS assessment will be forthcoming so stay tuned.