SNF QRP Deadline

The submission deadline for the SNF Quality Reporting Programs (QRP) is approaching. MDS data for April 1 – June 30 (Q2) of calendar year (CY) 2018 are due with this submission deadline. All data must be submitted no later than 11:59 p.m. Pacific Standard Time on November 15, 2018.

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

www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines.html.

CORMAC sends informational messages to IRFs, LTCHs, and 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@cormac-corp.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

Payroll-Based Journal (PBJ) Deadline

The submission deadline for PBJ is approaching. PBJ data for 7/1/18 through 9/30/18 is due on 11-14-18. CMS uses PBJ data to determine each facility’s staffing measure on the Nursing Home Compare tool on Medicare.gov website, and calculate the staffing rating used in the Nursing Home Five Star Quality Rating System.

More information about PBJ can be found on the CMS webpage www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.

SNF Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 2.0

The SNF QRP Calculations and Reporting User’s Manual V2.0 has been added to the Downloads section of the SNF Quality Reporting Measures Information page found at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html. This version of the Manual is effective on October 1, 2018 and provides detailed information for each QRP QM.

SNF QRP Measure Calculations and Reporting User’s Manual Version 2.0 [PDF]

MDS Section K Updates for 10-1-18

The RAI Manual v.1.16, dated 10-1-18, in Chapter 3 in Section K states CMS does not require completion of Column 1 (While Not a Resident) for items K0510C (Mechanically altered diet), or K0510D (Therapeutic diet), K0710A (Proportion of total calories the resident received through parenteral or tube feeding) or K0710B (Average fluid intake per day by IV or tube feeding). Some states continue to require completion of these items. It is important to know your State’s requirements for completing these items. If the State does not require the completion of these items, use the standard “no information” code (a dash, “-”).

There are no Missouri State Regulation requirements for the MDS. Any MDS records for residents in Missouri SNFs and NFs with an ARD of 10-1-18 or later will no longer be required to answer Column 1 (While Not a Resident) for items K0510C, K0510D, K0710A or K0710B; dashing will be allowed for these items. Please note- Column 2 (While a Resident) will still be required to be completed for these items.

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Deadline

The submission deadline for the SNF QRP is approaching. MDS data for 1/1/18 through 3/31/18 is due on 8-15-18. Providers must submit all data necessary to calculate SNF QRP measures on at least 80% of the MDS assessments submitted to be in compliance with SNF QRP requirements.

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

The list of measures required for this deadline can be found on the CMS QRP SNF Quality Reporting Program Data Submission Deadlines webpage.

PBJ

May 15, 2018 is the deadline for submitting staffing data for the Q1 of CY 2018 (1/1/18 through 3/31/18). CMS uses PBJ data to determine each facility’s staffing measure on the Nursing Home Compare tool on Medicare.gov website, and calculate the staffing rating used in the Nursing Home Five Star Quality Rating System.

CMS encourages facilities to check provider preview reports in the CASPER system for information regarding submitted PBJ data and to run CASPER reports (1700D Employee Report, 1702D Individual Daily Staffing Report, and/or 1702S Staffing Summary Report) to ensure their PBJ data was submitted accurately.

Questions regarding PBJ policy information can be directed to NHStaffing@cms.hhs.gov.

Questions regarding PBJ Data Specifications can be directed to NursingHomePBJTechIssues@cms.hhs.gov.

SNF QRP Deadline

The submission deadline for the SNF QRP is approaching. MDS data for all four quarters (January-December) of CY2017 is due on 5-15-18. Providers must submit all data necessary to calculate SNF QRP measures on at least 80% of the MDS assessments submitted to be in compliance with FY 2019 SNF QRP requirements.

The list of measures required for this deadline can be found on the CMS QRP SNF Quality Reporting Program Data Submission Deadlines.

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

SNF Quality Reporting Program (QRP) Quality Measure (QM) Reports Available

As of 4/18/18, the SNF QRP report issues outlined in QTSO Memo numbers 2018-012 and 2018-046 were resolved. Data for SNF QRP Facility-Level QM Report, SNF QRP Resident-Level QM Report, and the SNF Review and Correct report has been recalculated to exclude the duplicated records, and the correct Admission Date displays on the SNF QRP Resident-Level Quality Measure report.

If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.

SNF QRP QM and Review and Correct Report Data Issues (2/1/18)

A calculation error has been identified for the three assessment-based quality measures reported on the SNF QRP Facility- and Resident-Level QM report and the SNF QRP Review and Correct reports. Duplicate stays and invalid admission dates can appear on these reports.

The issue is isolated to corrected stay-level records (A0050 = 2 [Modification] or A0050 = 3 [Inactivation]) accepted by the ASAP system since 12/18/2017. The issue does not affect new (A0050 = 1 [New]) stay-level records.

A fix to the QM calculation and Resident-Level report display is in progress. The data for the assessment-based measures will be recalculated once the fix is in place. The reports will continue to be available in CASPER until the fixes are implemented.

We will send follow-up announcements as each of these issues are resolved and further guidance can be given.

If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.

Newly Revised Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) (2/1/18)

CMS is releasing a newly revised SNFABN along with newly developed, concise and separate instructions for form completion. The revised SNFABN has the requirements from the denial letters and looks very similar to the ABN with three different options. They will be discontinuing the five SNF Denial Letters and the Notice of Exclusion from Medicare Benefits – Skilled Nursing Facility (NEMB-SNF). Since the NEMB-SNF was used as a voluntary notice for care that is never covered by Medicare, we will continue to encourage SNFs to issue the revised SNFABN in this voluntary capacity. Chapter 30, Section 70 of the Medicare Claims Processing Manual revisions will be forthcoming. The revised SNFABN will be mandatory for use on May 7, 2018. During the interim, SNFs may continue to use the old version of the SNFABN, the Denial Letters or the NEMB-SNF, however, it is recommended that the revised SNFABN be used as soon as possible. The revised SNFABN and the form instructions may be located at: http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html.

Enhanced MDS 3.0 Quality Measure Reports Available (1/31/18)

Facility Level QM Report, Monthly Comparison Report and Resident Level QM Report

These reports have been updated to include the following new measures:

• Percent of Residents Whose Ability to Move Independently Worsened (Long Stay)
  • Displayed as Move Indep Worse (L) on the reports
• Percent of Residents Who Used Antianxiety or Hypnotic Medication (Long Stay)
  • Displayed as Antianxiety/Hypnotic % (L) on the reports
• Percent of Residents Who Made Improvements in Function (Short Stay)
  • Displayed as Improvement in Function (S) on the reports

Data for the three new measures have been retroactively calculated to June 3, 2015. If a report date range includes dates prior to June 3, 2015, an “I” (Incomplete) will display indicating data are not available for all days selected.

Section 26 – MDS 3.0 Quality Measure (QM) Reports of the CASPER Reporting User’s Guide has been updated to include the new measure information.
The updated CASPER Reporting User’s Guide is available in the following locations:

• Training and Education page on the QIES to Success website
• MDS 3.0 User Guides & Training Information page on the QIES Technical Support Office (QTSO) website (https://www.qtso.com/mdstrain.html)

If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.

New SNF QRP Quality Measure Reports Available

Effective December 19, 2017, two new user-requested Quality Measure reports will be available in the SNF Quality Reporting Program report category in the CASPER Reporting application. The two new reports are as follows:

• SNF QRP Facility-Level Quality Measure Report

This report provides facility-level quality measure values for a select 12-month period. SNF quality measure values for this report are compiled from the following sources:

• SNF QRP Resident-Level Quality Measure Report

This report identifies each resident with a qualifying MDS 3.0 Medicare Part A Stay (SNF Stay) used to calculate the facility-level quality measure values for a select 12- month period.

Note: Only MDS 3.0 assessment-based measures are included in this report.

Data for the two new reports will be calculated on the first day of each month.

If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.

RAI User’s Manual Errata File

On 12-15-17, CMS posted a RAI User’s Manual Errata File that can be found on the CMS MDS 3.0 Manual webpage website at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html.

The Errata file, titled MDS 3.0 RAI User’s Manual (v1.15R) Errata (v1), is located in the Downloads section of the webpage and contains the RAI Manual Change Table and associated replacement pages.

Revisions include:

• New coding tips for I2300 Urinary Tract Infection
• A new coding tip in N0410 Medications Received
• In N0410 updated the resources and tools links and revised the accompanying explanation regarding their use
• New and revised coding tips in N0450 Antipsychotic Medication Review
• New bullet point added to P0200 Alarms, “Planning for Care
• New and revised coding tips in P0200 Alarms
• Updated manual pages are marked with the footer “October 2017 (R)”

Providers who use a print version the RAI User’s Manual should print the manual replacement pages and incorporate the replacement pages into the printed manual.

SNF Review and Correct Report Now Available

As of 12/19/17, the SNF Review and Correct Report is once again available in the SNF Quality Reporting Program report category in the CASPER Reporting application. All data for the Application of Percent of LTCH Patients with Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631) measure has been recalculated, and the updated results are available in the report. Providers are encouraged to request the report to view the updated measure results. The updated report should replace versions of the report previously requested by the provider.

If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.

SNF Review and Correct Report Unavailable

CMS notified SNF providers in August and September of an issue affecting the calculation of the Application of Percent of LTCH Patients with Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631) measure included in the SNF Review and Correct Report; and advised that the calculation would be corrected in early December.

The SNF Review and Correct Report in the CASPER Reporting application will be unavailable for the next few days while the correction to this measure calculation is made. SNF providers will be notified once the report is available again, which is anticipated to be early next week. During the time this report is unavailable, the data for this measure is being recalculated. The updated results will be on the Review and Correct Report when it is available again.

View previous updates on the SNF Quality Reporting Program Data Submission Deadlines webpage: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Data-Submission-Deadlines.html.

All facilities will receive an email blast notifying them of this. We will send a follow-up QTSO memo when the SNF Review and Correct Report is once again available.

If you have any questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1 (888) 477-7876.