MDS INFO

Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 7/1/24 through 9/30/24 is due November 14, 2024. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on November 18, 2024:

  • MDS data for 4/1/24 through 6/30/24;

  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 4/1/24 through 6/30/24;

 

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

Quality Reporting Program: Non-Compliance Letters for FY 2025 APU

CMS is providing notifications to facilities that were determined to be out of compliance with Quality Reporting Program (QRP) requirements for CY 2023, which will affect their FY 2025 Annual Payment Update (APU). Non-compliance notifications are being distributed by the Medicare Administrative Contractors (MACs) and were placed into facilities’ My Reports folders in the Internet Quality Improvement and Evaluation System (iQIES) for SNFs on July 03, 2024. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 14, 2024.

If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notice of non-compliance and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.

MDS Reminders

Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 1/1/24 through 3/31/24 is due May 15, 2024. Please submit PBJ data as soon as possible to avoid delays.

 

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on May 15, 2024:

  • MDS data for 10/1/23 through 12/31/23;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 10/1/23 through 12/31/23;
  • NHSN data for Influenza Vaccination Coverage Among Healthcare Personnel for 10/1/23 through 3/31/24.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

MDS Case Mix Review Training

The Missouri Department of Social Services has contracted with Myers and Stauffer to conduct provider training. This webinar will be divided into two sessions. You may choose to participate in one or both sessions.

The Morning Session (9:00 am – 10:00 am CST) will include:

    • Case Mix Review Process
    • Web Portal Access and Submissions

The Afternoon Session (1:00 pm – 2:30 pm CST) will include:

    • Supportive Documentation Requirements

Please plan to join us during one or both of the scheduled sessions. Registration is required.

March 19, 2024
Morning Session: 9:00 am – 10:00 am CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2421 836 0727
Event Password: MOTraining

Afternoon Session: 1:00 pm – 2:30 pm CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2428 242 0685
Event Password: MOTraining

March 26, 2024
Morning Session: 9:00 am – 10:00 am CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2438 288 2508
Event Password: MOTraining

Afternoon Session: 1:00 pm – 2:30 pm CST
To register for this webinar, click here!
To join by phone, dial: 1-844-740-1264
Access Code: 2437 705 7018
Event Password: MOTraining

Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 10/1/23 through 12/31/23 is due February 14, 2024.

Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.

Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.

 

More information about PBJ can be found on the following webpages:

CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ
PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals
PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on February 15, 2024:

  • MDS data for 7/1/23 through 9/30/23;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 7/1/23 through 9/30/23;

The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Internet Quality Improvement and Evaluation System (iQIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.

As a reminder, it is recommended that providers run applicable MDS reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

 

More information about SNF QRP can be found on the following webpages:

CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines
CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help
CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information
CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training

Medicare from Start to Finish

January 9, 2024: Live Virtual Workshop
March 12, 2024: In-Seat Workshop
May 14, 2024: In-Seat Workshop
September 17, 2024: In-Seat Workshop
November 12, 2024: Live Virtual Workshop

This workshop will review the SNF QRP reports from CASPER that provides information about the Medicare Part A stays in your SNF. It will also explore factors impacting SNF PPS assessment schedule, PDPM basics, and consolidating billing that can impact the financial facet of the facility. It also explains Medicare eligibility, coverage, and skilling criteria. The completion of the MDS is becoming more difficult and confusing, this workshop will help clear up the confusion surrounding this process. This workshop is geared towards those individuals working in long‐term care who have a leadership role such as ADM, DON, ADON, or MDS Coordinator.

RAI Process from Start to Finish

April 9-10, 2024: In-Seat Workshop
June 18-19, 2024: In-Seat Workshop
August 13-14, 2024: In-Seat Workshop
October 29-30, 2024: In-Seat Workshop
December 10-11, 2024: Live Virtual Workshop

This workshop will look at the RAI process from beginning to end and at each item of the MDS. The MDS is used for both a clinical and a financial assessment and will discuss the rules on scheduling these assessments and meeting the clinical & financial requirements. This includes a basic understanding of PDPM and how it correlates within the RAI process. This virtual workshop reviews how to gain access to and read the MDS reports from CASPER to self-audit your RAI process and look at your QMs. This workshop is designed for the MDS Coordinator and Care Plan Coordinator, or for the DON or ADM who needs a better understanding of the complexity of the RAI Process.

Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 7/1/23 through 9/30/23 is due November 14, 2023.

Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.

Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.

More information about PBJ can be found on the following webpages:

CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ

PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals

PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on November 15, 2023:

  • MDS data for 4/1/23 through 6/30/23;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 4/1/23 through 6/30/23;

The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Internet Quality Improvement and Evaluation System (iQIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.

As a reminder, it is recommended that providers run applicable MDS reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

More information about SNF QRP can be found on the following webpages:

CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines

CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help

CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information

CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training

MDS 3.0 RAI Manual version (v)1.18.11R Errata

The PDF file labeled “MDS3.0RAIManualv1.18.11R.Errata.v2.October.20.2023” is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The errata document contains revisions to the MDS 3.0 RAI Manual version (v)1.18.11R to provide clarity and additional guidance in Section D and Chapter 6 to support item D0100, Should Resident Mood Interview be Conducted? serving as a gateway item for the Resident Mood Interview (PHQ-2 to 9©) and D0500, Staff Assessment of Resident Mood (PHQ-9-OV©). Minor revisions also included are corrections to language in Section Q to provide proper guidance on Care Area Assessment (CAA) requirements, corrections to language in Chapter 2 to provide proper guidance on combining Omnibus Budget Reconciliation Act (OBRA) discharge assessments, an updated Internet Quality Improvement & Evaluation System (iQIES) warning error message in Chapter 5, updated screenshots in Section A and Section O, and an updated MDS Item Matrix. The errata document also includes all issues from previous MDS 3.0 RAI Manual v1.18.11R errata releases.

Changed manual pages are marked with the footer “October 2023 (R).”

The errata document begins with a table that lists all identified revisions and the pages to which they have been applied. Following the table are the actual corrected replacement pages for insertion into the printed manual.

UPDATED: Final MDS 3.0 Item Sets version 1.18.11 v6

The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. Changes in this version (listed below) align the item sets with the Errata V3.01.3 for MDS Data Specifications V3.01.1 (FINAL) posted September 21, 2023, on the Minimum Data Set (MDS) 3.0 Technical Information page. For a full list of changes to the final posted item sets since v1, see the Item Set Change Table Supplement that accompanies the posting. The MDS Item Sets v1.18.11 were effective beginning October 01, 2023.

M0300G1 on NPE

Replaced erroneous skip pattern <Skip to N2005, Medication Intervention> with the correct one: <Skip to N0415, High-Risk Drug Classes: Use and Indication>.

O0300A on NP and NQ

Corrected transposition of verbs in skip patterns (changed <Skip> to <Continue> in choice 0 and <Continue> to <Skip> in choice 1).

O0400 on NC and NQ

Removed completion language <Complete only when A0310B = 1 (complete O0400D2 when required by state)>.

O0400 on NP and SP

Removed completion language <Complete only when A0310B = 1>.

O0420 on NC, NP, and NQ

Removed completion language <Complete only when A0310B = 1>.

The SNF MDS 3.0 RAI v1.18.11 Guidance Training Program

Post-event materials are now available for the SNF MDS 3.0 RAI v1.18.11 Guidance Training Program.

Available Resources:

  • The recordings of the Part 1 pre-recorded training webinars and the Part 2 live, virtual coding workshop sessions are available on CMS YouTube.
  • See “2023_May_SNF Guidance Training Program_Part 1 (ZIP)” in the Downloads section of the SNF QRP Training page for Part 1 training materials.
  • See “2023_May_SNF Guidance Training Program_Part 2 (ZIP)” in the Downloads section SNF QRP Training page for Part 2 training materials.
  • See “2023_May_SNF Guidance Training Program_Supplemental Materials (ZIP)” in the Downloads section SNF QRP Training page for supplemental training materials.
  • See “2023_August_SNF Guidance Training Program_Q&A” in the Downloads section of the SNF QRP Training This document contains responses to questions asked throughout the training program.

If you have questions about accessing resources or feedback regarding the trainings, please email the PAC Training Mailbox. Content-related questions should be submitted to the SNF QRP Help Desk.

Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 4/1/23 through 6/30/23 is due August 14, 2023.

Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.

Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.

More information about PBJ can be found on the following webpages:
CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ
PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals
PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on August 15, 2023:

  • MDS data for 1/1/23 through 3/31/23;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 1/1/23 through 3/31/23;

The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Internet Quality Improvement and Evaluation System (iQIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.

As a reminder, it is recommended that providers run applicable MDS reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

More information about SNF QRP can be found on the following webpages:
CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines
CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help
CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information
CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training

NH Providers Login Credentials Maintenance

The purpose of this communication is to remind Nursing Home Providers to ensure you maintain accurate contact information and login credentials in the QIES system even though all Minimum Data Set (MDS) information is now being submitted via the Internet Quality Improvement and Evaluation System (iQIES) system. You will continue to receive important information regarding any findings of noncompliance with the requirement to report COVID-19 data to the Centers for Disease Control and Prevention (CDC) through the National Healthcare Safety Network (NHSN) in your CASPER Shared Folder. This means that facilities will need to continue to maintain two sets of login credentials, one set to access the CASPER Reporting application [CMS Network (CMSNet) and QIES Login credentials] and the HARP login credentials to continue submission of MDS records and accessing reports in iQIES.

Below is the link for the CASPER login. Please be sure that you are successfully logged into the CMS Network (CMSNet) prior to trying to access the CASPER link below.

https://web.qiesnet.org/qiesmds/mds_home.html

See below to find your CASPER Shared Folder:

Image 1. Welcome to CASPER

 

 

 

 

 

 

 

Image 2. CASPER folders.

 

 

 

 

 

 

 

 

 

iQIES Service Center

For questions regarding your CASPER Shared Folder, please contact the QIES/iQIES Service Center by phone at (800) 339-9313 or send an email.

SNF MDS 3.0 RAI v1.18.11 Guidance Training Program

REGISTRATION OPEN: The SNF MDS 3.0 RAI v1.18.11 Guidance Training Program

The Centers for Medicare & Medicaid Services (CMS is offering a virtual training program that provides instruction on the updated guidance for the Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) v1.18.11 Manual and Item Set. This training is part of a comprehensive strategy to ensure SNF providers have access to the educational materials necessary to understand and comply with the guidance changes. This guidance will affect reporting requirements associated with the SNF Quality Reporting Program (QRP) that will go into effect on October 1, 2023. A major focus of this training will be on the cross-setting implementation of the standardized patient assessment data elements to ensure more consistent reporting and evaluation across post-acute care settings.

The training program consists of two parts:

Part 1: LEARN Part 1 consists of pre-recorded training webinars that deliver foundational knowledge to assist in learning the new and/or revised items and associated guidance. A supplemental Capstone Case Study is also available to give providers additional practice in coding the new and/or revised items. These videos are intended to be viewed in advance of the Part 2 live event and are available now on CMS YouTube.

Part 2: PRACTICE Part 2 includes the live, virtual workshop sessions that provide practice coding scenarios on select data elements covered in the Part 1 training webinars. These live sessions will take place on June 21 between 12:30 p.m. and 5 p.m. ET. Registration is open and can be completed online through Zoom.

Additional training resources are located within a ZIP file in the Downloads section of the SNF Quality Reporting Program (QRP) Training page. These resources include an acronym list, Action Plan worksheet, Case Study documents, resource guide, and PDF versions of the training webinars.

If you have questions regarding access to the resources or feedback related to the training, please email the PAC Training Mailbox. Content-related questions should be submitted to the SNF QRP Help Desk.

Payroll-Based Journal (PBJ) Submission Deadline Reminder

Nursing homes are required to electronically submit direct care staffing information to the Payroll-Based Journal (PBJ) system. Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely. PBJ data for 1/1/23 through 3/31/23 is due May 15, 2023.

Please submit PBJ data as soon as possible to avoid delays. CMS recommends running staffing reports in CASPER prior to the submission deadline to ensure the accuracy and completeness of submissions. Please remember, the Final File Validation Report verifies that the submission was successful.

Please note: If you need assistance with the PBJ quarterly submission and the deadline falls on a weekend, you must contact the QIES/iQIES Service Center no later than the Friday before the submission deadline, as the Service Center will be unavailable to assist on the weekend.

More information about PBJ can be found on the following webpages:

CMS PBJ webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ
PBJ Reference Manuals – https://qtso.cms.gov/vendors/payroll-based-journal-pbj-vendors/reference-manuals
PBJ Training – https://qtso.cms.gov/training-materials/payroll-based-journal-pbj

SNF Quality Reporting Program (QRP) Submission Deadline Reminder

SNFs are required to report data to meet the SNF QRP requirements. The submission deadline for the SNF QRP is approaching. The following data must be submitted no later than 11:59 p.m. on May 15, 2023:

  • MDS data for 10/1/22 through 12/31/22;
  • NHSN data for COVID-19 Vaccination Coverage Among Healthcare Personnel for 10/1/22 through 12/31/22;
  • NHSN data for Influenza Vaccination Coverage Among Healthcare Personnel for 10/1/22 through 3/31/23.

The Minimum Data Set (MDS) 3.0 must be transmitted to the Centers for Medicare & Medicaid Services (CMS) through the Internet Quality Improvement and Evaluation System (iQIES). Data for the National Healthcare Safety Network (NHSN) measures must be submitted to the Centers for Disease Control and Prevention (CDC). No additional data submission is required for the claims-based measures.

As a reminder, it is recommended that providers run applicable MDS reports prior to each quarterly reporting deadline, in order to ensure that all required data has been submitted.

Swingtech sends informational messages to SNFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

More information about SNF QRP can be found on the following webpages:

CMS SNF QRP Data Submission Deadlines webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines
CMS SNF QRP Help webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-QRP-Help
CMS SNF QRP Measures and Technical Information webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information
CMS SNF QRP Training Webpage – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training

iQIES Minimum Data Set (MDS) Submission and Reports is Now Available

On April 17, 2023, the Centers for Medicare & Medicaid Services (CMS) transitioned to the Internet Quality Improvement and Evaluation System (iQIES) for Minimum Data Set (MDS) record submissions and reports.

All MDS submissions that were performed in the QIES Assessment Submission And Processing (ASAP) system prior to April 13 at 8:00 p.m. ET were processed in that system. As part of the migration, MDS data accepted into the ASAP system prior to the start of the migration were moved into iQIES. All new, modification, or inactivation records must be submitted in iQIES, even if the original record to be corrected was accepted into the QIES ASAP system.

As part of the migration, users are now able to access and run the user-requested reports in iQIES. User’s access to the reports is similar to the access in the Certification and Survey Provider Enhanced Reporting (CASPER) Reporting application, so long as their new HCQIS Access Roles and Profile (HARP) role allows access to generate and view reports. Users are only allowed to run reports for the providers to which they have access.

Register for an iQIES Account

For information and instructions to register for an iQIES account, please visit: https://qtso.cms.gov/news-and-updates/action-required-register-iqies-account.

User Manuals

Video Tutorials

Additionally, the iQIES Team has developed video tutorials to provide an overview of the MDS functionalities in iQIES. The video tutorials can be found on QTSO and are not mandatory: https://qtso.cms.gov/training-materials/iqies-training-videos

  • Upload an Assessment for MDS Users
  • How to Run Reports

iQIES Service Center

  • If you have questions or require assistance, please contact the QIES/iQIES Service Center by phone at (800) 339-9313 or send an email.

MDS Submissions Shut Off in QIES ASAP System in Preparation for April 17 Release

On April 17, 2023, the Centers for Medicare & Medicaid Services (CMS) will transition to the Internet Quality Improvement and Evaluation System (iQIES) for Minimum Data Set (MDS) record submissions and reports. As part of this transition, the QIES Assessment Submission And Processing (ASAP) system for MDS submissions will be turned off on Thursday, April 13 at 8:00 p.m. ET. Providers should submit completed MDS records prior to 8:00 p.m. ET on April 13 to the QIES ASAP system or wait until 8:00 a.m. ET on Monday, April 17 to submit data in iQIES. Once the transition is complete, all new, modification, or inactivation records must be submitted in iQIES, even if the original record to be corrected was accepted into the QIES ASAP system. Providers are expected to take into account all submission requirements when determining the date that they submit completed MDS records, including but not limited to, submission timeliness, claims processing, and care planning requirements.

MDS submission and records will be available in iQIES beginning Monday, April 17, 2023 at 8:00 a.m. ET. iQIES will be the only system in which MDS data submissions can occur.

What to Expect with the Minimum Data Set (MDS) Transition to iQIES

Please note there are some system-generated reports in the CASPER application that will not be migrated over to the iQIES folders. Users should download and save or print any of these system-generated reports that they wish to retain. For more information on MDS reports, please visit: https://qtso.cms.gov/news-and-updates/what-expect-minimum-data-set-mds-transition-iqies-april-17-2023.

Register for an iQIES Account

Please note that failure to obtain access to iQIES prior to April 17, 2023 will impact your ability to submit MDS records once the migration is complete. For information and instructions to register for an iQIES account, please visit: https://qtso.cms.gov/news-and-updates/action-required-register-iqies-account.

iQIES Service Center

If you have questions or require assistance, please contact the QIES/iQIES Service Center by phone at (800) 339-9313 or send an email. Please note that call volume may be higher than normal during this time.

What to Expect with the Minimum Data Set (MDS) Transition to iQIES on April 17, 2023

On April 17, 2023, the Centers for Medicare & Medicaid Services (CMS) will transition to the Internet Quality Improvement and Evaluation System (iQIES) for Minimum Data Set (MDS) record submissions and reports. As part of this transition, the QIES Assessment Submission And Processing (ASAP) system for MDS submissions will be turned off on Thursday, April 13 at 8:00 p.m. ET. Providers should submit completed MDS records prior to 8:00 p.m. ET on April 13 to the QIES ASAP system or wait until 8:00 a.m. ET on April 17 to submit data in iQIES. Once the transition is complete, all new, modification, or inactivation records must be submitted in iQIES, even if the original record to be corrected was accepted into the QIES ASAP system. Providers are expected to take into account all submission requirements when determining the date that they submit completed MDS records, including but not limited to, submission timeliness, claims processing, and care planning requirements.

Register for an iQIES Account

Please note that failure to obtain access to iQIES prior to April 17, 2023 will impact your ability to submit MDS records once the migration is complete. For information and instructions to register for an iQIES account, please visit: https://qtso.cms.gov/news-and-updates/action-required-register-iqies-account

Outlined below are a few highlights and expectations for the release of the iQIES MDS submission and reporting functionality.

Key Highlightsof iQIES

  • Users will be able to securely access iQIES at any time, from any location (provided there is an internet connection).
  • Users will log in once to iQIES. No longer will users be required to log into CMSNet and then into separate applications to upload MDS records or access reports.
  • Users will have access to tips and information to guide them throughout the MDS submission process and accessing reports.
  • Users will be allowed to upload MDS assessments in a similar manner as was done in the QIES.
  • MDS reports will be similar to those in the Certification and Survey Provider Enhanced Reporting (CASPER) application, with some new functionality built in.
    • Users can initially view the report information on the screen and if desired, can then download the report to a Portable Document Format (PDF) or Comma-Separated Values (CSV) file.
    • Users can schedule reports to run at their desired interval and frequency.

What to Expect for Providers and Vendors

  • QIES Assessment Submission And Processing (ASAP) system for MDS submissions will be turned off as of Thursday, April 13 at 8:00 p.m. ET.
  • Beginning April 17, 2023 MDS records will be available in iQIES. iQIES will be the only system in which MDS data submissions can occur. 

Report Information – QIES/CASPER

  • The reports in the following report categories in CASPER will become permanently unavailable on Thursday, April 13, 2023 at 8:00 p.m. ET:
    • MDS 3.0 NH Final Validation Report
    • MDS 3.0 SB Final Validation Report
    • MDS 3.0 Submitter Validation Report
    • MDS 3.0 NH Provider
      • Exception for this report category: the MDS 0003D/0004D Package Reports in this category will remain available
    • MDS 3.0 SB Provider
    • MDS 3.0 QM Reports
    • SNF Quality Reporting Program
  • The ASAP system-generated Nursing Home (NH) and Swing Bed (SB) final validation reports in the facility-specific Validation Report (VR) folders will reflect processing information for MDS records submitted to the ASAP system prior to the migration. These reports will not be migrated to the iQIES folder; however, users will be able to generate a new user-requested report in iQIES.
    • Note: since the QIES system-generated final validation reports will not be moved into iQIES, users should download and save or print any system-generated reports that they wish to retain.
  • Users will continue to access reports or files in their provider’s shared non-validation report folder in CASPER until summer 2023 when delivery of the SNF VBP files and provider preview reports will be migrated into iQIES.
    • The shared non-validation report folders are named in this manner:
      • [State Code] LTC [Facility ID] for nursing home providers
      • [State Code] SB [Swing Bed ID] for swing bed providers
    • The reports/files in these folders could include those listed below.
      • SNF QRP Provider Preview Reports
        • April 2023 reports will be in CASPER
      • MDS 3.0 Provider-Level Quality Measure and MDS 3.0 Resident-Level Quality Measure Provider Preview reports
        • April 2023 reports will be in CASPER
      • SNF VBP files
      • Non-compliance Notification Letters, if applicable
  • Note: since the files listed above will not be moved into iQIES, users should download and save or print any of the reports or files that they wish to retain.

Report Information – iQIES

Following completion of the migration, users will be allowed to access and run the user-requested reports in iQIES. User’s access to the reports below will be similar to the access in the CASPER Reporting application, so long as your new HARP role allows access to generate and view reports. Users will only be allowed to run reports for the providers to which they have access.

Below are the report categories/types and each MDS report that is associated to the category/type combination.

  • Provider Report Category / Validation Report Type
    • MDS 3.0 NH Final Validation Report
    • MDS 3.0 SB Final Validation
    • MDS 3.0 Submitter Final Validation
  • Provider Report Category / Submission Report Type
    • MDS 3.0 Activity
    • MDS 3.0 Missing OBRA Assessment
  • Provider Report Category / Error Report Type
    • MDS 3.0 NH Error Detail
    • MDS 3.0 SB Error Detail
  • Provider Report Category / Admission/Discharge Report Type
    • MDS 3.0 Admissions/Reentry – Discharges Report
  • Provider Report Category / Roster Report Type
    • MDS 3.0 Roster
  • Quality Measure Report Category / Facility-Level Quality Measure
    • MDS 3.0 Facility Characteristics Report
    • MDS 3.0 Facility-Level QM Report
    • SNF Quality Reporting Program (QRP) Facility-Level QM Report
  • Quality Measure Report Category / Resident/Patient-Level Quality Measure
    • MDS 3.0 Resident-Level QM Report
    • SNF QRP Resident-Level QM Report
  • Quality Measure Report Category / Review and Correct
    • SNF QRP Review & Correct Report
  • Quality Measure Report Category / Provider Threshold Report
    • SNF QRP Provider Threshold Report
  • MDS 3.0 QM Package Reports / Package Reports
    • MDS 3.0 QM Package Reports
  • System-generated MDS 3.0 NH and SB Final Validation Reports for MDS records submitted to iQIES will be accessed in the MDS 3.0 Final Validation Reports permanent folder in iQIES.

 

Data Availability for iQIES User-Requested Reports

  • Data for the Provider reports above will be available for Calendar Year (CY) 2013 (01/01/2013-12/31/2013) forward.
  • Data for the Quality Measure reports above will be available for Fiscal Year (FY) 2022 (10/01/2021-09/30/2022) forward.
    • Users wishing to retain Quality Measure reports for older time periods should obtain those reports from CASPER prior to the migration.

Resident Internal IDs on MDS and SNF QRP Reports

  • As part of the MDS submission and reporting transition, MDS 3.0 records that had previously been processed and accepted into the QIES ASAP system will be migrated into iQIES. As part of this migration, a new unique state-level patient identifier has been created and will replace the previous QIES ASAP system-assigned Resident Internal ID on all MDS assessment records.
  • This new state-level patient ID will display on any MDS or SNF QRP report(s) that currently display the Resident Internal ID value.
  • For example, a resident whose Resident Internal ID was initially 58608036 as assigned from QIES ASAP, will now be 298899278 as assigned by iQIES for all reporting and processing purposes.

SNF QRP Quality Measure Report Information

  • The SNF QRP quality measures in iQIES will be calculated using the quality measure specifications and supportive documentation that were in effect 10/01/2022, including the following:
    • SNF-Quality-Measure-Calculations-and-Reporting-User’s-Manual-V4.0
    • Risk-Adjustment-Appendix-File-for-SNF-Effective-10-1-2022
    • SNF-Mobility-Model-ICD10-HCC-Crosswalk-Effective-10-01-2022
    • SNF-Self-Care-Model-ICD10-HCC-Crosswalk-Effective-10-01-2022

The above files can be downloaded from the SNF QRP Measures and Technical Information page on the CMS website: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/skilled-nursing-facility-quality-reporting-program/snf-quality-reporting-program-measures-and-technical-information.

  • The SNF QRP Facility-Level QM report will contain updated Medicare Fee-For-Service claims measure results when a Quarter End Date of 03/31/2022 or later is selected when requesting the report.
  • The new SNF Healthcare Personnel (HCP) Influenza vaccination measure will display on the iQIES SNF Provider Threshold Report following the migration; however, submission success results for this measure will not display on the report until the data submission deadline date for Q4, 2022 (12/31/2022) has passed.
    • The data submission deadline date for Q4, 2022 is May 15, 2023.

iQIES Service Center

If you have questions or require assistance, please contact the QIES/iQIES Service Center by phone at (800) 339-9313 or send an email. Please note that call volume may be higher than normal during this time.

NOW AVAILABLE: Draft MDS 3.0 RAI User’s Manual version 1.18.11

The draft Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version (v)1.18.11 is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The MDS 3.0 RAI User’s Manual v1.18.11 will be effective beginning October 01, 2023.

This version of the MDS 3.0 RAI Manual contains substantial revisions related to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), which requires that standardized assessment items be collected across post-acute care (PAC) settings. Standardized data will enable cross-setting data collection, outcome comparison, exchangeability of data, and comparison of quality within and across PAC settings. Additionally, the language of the manual has been updated throughout to be gender neutral. Guidance and examples in numerous chapters and appendices have been revised for clarification and to reflect current regulations and best practices. Due to the scope of the revisions, CMS will not issue Replacement Pages for v1.18.11; those wishing to continue using a physical copy of the manual are encouraged to print the new version.