In the fiscal year (FY) 2016 Skilled Nursing Facility (SNF) Prospective Payment System proposed rule posted April 20, the Centers for Medicare & Medicaid Services (CMS) details plans to expand the Minimum Data Set 3.0 (MDS). Targeting Oct. 1, 2016, (FY 2017) for implementation of new or refined MDS coding items, the rule highlights significant steps CMS is taking to move toward a value-based Medicare payment system.
CMS details its process to add or refine coding questions on the MDS item set to comply with the Improving Medicare Post-Acute Care Transformation Act of 2014 (Public Law 113-185; IMPACT Act), which “requires the alignment of standardized assessments across the care continuum.” The IMPACT Act mandates that CMS develop a quality reporting program to capture outcomes of care for payment.
Specifically, for payment determinations beginning in FY 2018 (Oct. 1, 2017), CMS is in the process of developing quality measures (QMs) related to three quality domains specified in section 1899B(c)(1) of the act: functional status, skin integrity and incidence of major falls. The proposed rule summarizes the planned QMs that will be used for cross-setting measurement in the developing value-based payment system:
The proposed quality measure addressing skin integrity and changes in skin integrity is the NQF [National Quality Forum]-endorsed measure, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678).
The proposed quality measure addressing the incidence of major falls is an application of the NQF-endorsed Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674).
…The proposed quality measure addressing functional status, cognitive function, and changes in function and cognitive function is an application of the Percent of Long-Term Care Hospital Patients With an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631; under NQF review).
In the rule, CMS indicates that in FY 2017 (Oct. 1, 2016), to adopt a new cross-setting QM for functional status, they plan to add additional coding items to MDS section G. Because of the “reliability and validity” of the functional status items developed as part of Post-Acute Care Payment Reform Demonstration (CARE), CMS proposes to base the new section G items on the CARE item set’s functional status items.
These items would capture residents’ functional status on the six-level scale at admission, to indicate the goal for the plan of care, and at discharge from the facility. The functional score at discharge would be compared to the admission score and the care-plan goal score to determine outcomes of the care episode. The final rule explains the new functional QM as follows:
For this quality measure, there must be documentation at the time of admission that at least one activity performance (function) goal is recorded for at least one of the standardized self-care or mobility function items using the 6-level rating scale. This indicates that an activity goal(s) has been established. Following this initial assessment, the clinical best practice would be to ensure that the resident’s care plan reflected and included a plan to achieve such an activity goal(s). At the time of discharge, goal setting and establishment of a care plan to achieve the goal, is reassessed using the same 6-level rating scale, enabling the ability to evaluate success in achieving the resident’s activity performance goals.
For unplanned discharges, only the admission score and functional goal score will be reported. The discharge functional status will not be required.
Related to the upcoming fiscal year’s MDS changes, the rule states that when the ICD-10 diagnoses coding system is implemented on Oct. 1, 2015, the AIDS add-on billing code will be B20, sunsetting the ICD-9-CM code 042. For information on the ICD-10 compliance date, facility staff are instructed to access the ICD-10 regulations posted in the Federal Register on Aug. 4, 2014 (79 CFR 45128–45134).
Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, is vice president of curriculum development for the American Association of Nurse Assessment Coordination.