QRP Deadline Approaching Soon - Does your facility meet the minimum threshold for the APU?
- Vanessa Tyscka, RN, BSN, MBA, RAC-CT
- Oct 21, 2021
- 6 min read
In 2016 CMS finalized the SNF QRP (Quality Reporting Program) compliance requirements. By doing so, any SNF who does not comply with the minimum reporting requirements are subject to a 2% reduction in the APU (Annual Payment Update) for Medicare.
The SNF QRP has 10 MDS-based measures and (2 of them are on hold until we are 1 full year outside the current pandemic), 3 claims-based measures and 1 is collected via the NHSN (National Healthcare Safety Network) portal.
The next deadline for corrections and updates is on November 15, 2021 and it affects Medicare beneficiaries who were in your facility at any time between April 1, 2021 - June 30, 2021. You will want to ensure that all assessments affecting these dates of service are accurate and not dashed. The quarterly data submission deadlines apply to Medicare patients with an admission and/or discharge date that occurs within that quarter. For example, if a patient was admitted on June 29 (Quarter 2: April 1 - June 30) and discharged on July 5 (Quarter 3: July 1–September 30), there would be two submission deadlines to meet. The second quarter data submission deadline (November 15) would apply for the patient’s MDS five-day PPS assessment and the third quarter data submission deadline (February 15) would apply for the patient’s MDS PPS discharge record.
If your software or MDS scrubber has a report that can tell you which assessments have dashes that is a great place to start. If not, you can download a Preview Report directly from the QIES website. Instructions for downloading the report can be found by clicking here. Any area that is showing less than 80% compliance puts you at risk of losing 2% of your annual payment! Correct these areas if at all possible. You will need to dig through the chart and see if anything was missed and submit a modification for the MDS in question prior to the deadline (at the time of this article before 11/15/21). Here is a link for deadlines for the rest of FY2023. As a best practice, always shoot for 95% compliance just to have a nice cushion!
MDS Assessment-based Measures
Below is a list of MDS-based QRPs and a short description of what they are measuring. For more details click the link for access to the CMS SNF QRP Measures Calculations and Reporting User's Manual Version 3.0.
Changes in Skin Integrity Post- Acute Care: Pressure Ulcer/Injury
This measure reports the percentage of Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays) for residents with Stage 2-4 pressure ulcers that are new or worsened since admission.
Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long-Stay) (NQF #0674)
This quality measure reports the percentage of Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays) where one or more falls with major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) were reported during the SNF stay.
Skilled Nursing Facility (SNF) Functional Outcome Measure: Change in Self-Care Score for Skilled Nursing Facility Residents (NQF #2633)
This measure estimates the risk-adjusted mean change in self-care score between admission and discharge for Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays).
Skilled Nursing Facility (SNF) Functional Outcome Measure: Change in Mobility Score for Skilled Nursing Facility Residents (NQF #2634)
This measure estimates the risk-adjusted mean change in mobility score between admission and discharge for Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays).
Skilled Nursing Facility (SNF) Functional Outcome Measure: Discharge Self-Care Score for Skilled Nursing Facility Residents (NQF #2635)
This measure estimates the percentage of Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays) that meet or exceed an expected discharge self-care score.
Skilled Nursing Facility (SNF) Functional Outcome Measure: Discharge Mobility Score for Skilled Nursing Facility Residents (NQF #2636)
This measure estimates the percentage of Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays) that meet or exceed an expected discharge mobility score.
Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
This quality measure reports the percentage of Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays) with an admission and discharge functional assessment and a care plan that addresses function.
Drug Regimen Review Conducted with Follow-Up for Identified Issues- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
This measure reports the percentage of Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays) in which a drug regimen review was conducted at the time of admission and timely follow-up with a physician occurred each time potential clinically significant medication issues were identified throughout the stay.
Claims-based Measures
Potentially Preventable 30-Day Post-Discharge Readmission Measure for Skilled Nursing Facility Quality Reporting Program
This measure estimates the risk-standardized rate of unplanned, potentially preventable readmissions for residents (Medicare fee-for-service [FFS] beneficiaries) who receive services in skilled nursing facilities.
Discharge to Community - Post Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program (NQF #3481)
This measure reports a SNF’s risk-standardized rate of Medicare FFS residents who are discharged to the community following a SNF stay, and do not have an unplanned readmission to an acute care hospital or LTCH in the 31 days following discharge to community, and who remain alive during the 31 days following discharge to community. Community, for this measure, is defined as home or self-care, with or without home health services.
Medicare Spending Per Beneficiary (MSPB) - Post-Acute Care (PAC) Skilled Nursing Facility Quality Reporting Program
This measure evaluates SNF providers’ efficiency relative to the efficiency of the national median SNF provider. Specifically, the measure assesses the cost to Medicare for services performed by the SNF provider during an MSPB-PAC SNF episode. The measure is calculated as the ratio of the price-standardized, risk- adjusted MSPB-PAC amount for each SNF divided by the episode-weighted median MSPB-PAC amount across all SNF providers.
NHSN-based Measure
COVID-19 Vaccination Coverage among Healthcare Personnel (HCP)
This measure is effective for dates of 10/1/21 - 12/31/21 and has a deadline of 5/16/22.
To meet SNF QRP compliance, SNFs are required to submit COVID-19 vaccination data for eligible healthcare personnel (HCP) one week out of every month, but SNFs have the option of which week to report. The COVID-19 vaccination among HCP measure is stewarded by the CDC’s NHSN. The CDC makes reports accessible to SNFs that allow for real-time review of data submission. These reports reflect the data that will be sent by the CDC to CMS on behalf of each SNF. The CDC publishes reference guides for SNFs that explain how to run and interpret reports. These can be found on the NHSN website.
For further QRP training CMS has posted a few options. Click here for a PAC Training called introduction to SNF QRP. There are also several YouTube videos that can be accessed by searching on YouTube for "SNF QRP". The most recent video at the time of this article is Skilled Nursing Facility Quality Reporting Program: Achieving a Full Annual Payment Update .
If you are out of compliance, you will receive a letter in the CASPER system and in the mail from your MAC. There is a process for requesting a reconsideration, exception or extension if you met certain criteria. There are instructions in the letter to do this. There is also more information on the CMS webpage located here.
Resources
MDS Solutions HQ
Do you want to take your facility to the next level? Let MDS Solutions HQ show you where your opportunities are. Whether it’s improved quality of care, better survey outcomes or if revenue is your focus it all begins with the MDS. I specialize in training MDS nurses in the RAI process, training floor nurses to document skilled need, educating revenue capture through the PDPM process, analyzing and creating action plans for QM and 5 star success.
Contact me at:
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Vanessa Tyscka founded MDS Solutions HQ after 25+ years of service focused on serving Skilled Nursing Facilities and their residents. During her career she has worked as a Senior Reimbursement Specialist, Regional MDS Director, MDS Coordinator, DON, ADON, Unit Manager, RN, LPN, and CNA. She has worked for large and medium sized corporations and also has consulting experience in standalone and small organizations. She brings a passion of caring and expert knowledge to every facility she visits. To learn more about Vanessa’s experience and services check out her website or visit her LinkedIn page: www.linkedin.com/in/vanessatysckarn
When Vanessa isn’t working she enjoys cooking things she’s never tried before and spending time in the mountains or on a beach.
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