In preparation for the unified Prospective Payment System (PPS) for post-acute care (PAC) settings, the Centers for Medicare & Medicaid Services (CMS) released a draft version of the 2020 Minimum Data Set (MDS) item sets. It is important for facilities to begin reviewing and preparing for the implementation of these changes.
The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires that standardized patient assessment data elements (SPADEs) be collected across post-acute care (PAC) settings. PAC settings include Home Health (HHAs), Long-Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs). The standardized data goal is to enable the following:
- cross-setting data collection
- outcome comparison
- exchangeability of data
- comparison of quality across PAC settings
The IMPACT ACT requires the Medicare Payment Advisory Commission to investigate a unified payment system for PAC providers. The reports concluded that a unified PPS would establish accurate payments for most of the more than 40 patient groups reviewed and would increase the equity of Medicare’s payments across providers.
The IMPACT ACT requires the Medical Secretary to collect uniform patient assessment information and develop like quality measures across the PAC settings. Presently, regulatory requirements vary across PAC settings. HHAs and SNFs must meet setting-specific requirements while IRFs and LTCHs must meet hospital requirements in addition to setting-specific rules. CMS is looking for a unified PAC PPS to establish a common payment system that would be mostly aligned so that PAC providers face the same set of requirements and associated costs. Of course, there would continue to be some distinctions due to differences between institutional and noninstitutional care.
The Medicare Payment Advisory Commission is suggesting a 2-tier unified payment system. The first tier would establish the core clinical services for patients who do not require specialized care. This tier’s requirements would define the levels of physician supervision, nursing services and rehabilitation services required by the most common conditions treated in PACs, such as patients with pneumonia, urinary or kidney infections or patients recovering from hip and knee surgeries. The second tier of requirements would apply to patients with specialized care needs. Categories of patients with conditions or treatments that require higher levels of staffing, clinical expertise, or ancillary services (e.g. ventilators and high stage wounds).
MDS Item Set Changes
On December 20, 2019, CMS released the draft version of the 2020 MDS item sets that will be effective October 1, 2020. The changes are major. The comprehensive MDS is currently 51 pages and is slated to be 61 pages as of October 1, 2020. Some of the areas changed include:
- A1000 Race/Ethnicity will be deleted and replaced with A1005 Ethnicity and A1010 Race, which has more choices. This change aligns with the Home Health race and ethnicity data.
- A1100 Language will be replaced by A1110 Language. With this change, the questions are separated.
- New item A1250 Transportation will be added. This item is consistent with SPADEs priority to address resident social determinants of health.
- A1800 Entered From will be replaced by A1805 Entered From with more response choices. This aligns with the other PAC assessments tools.
- A2100 Discharge Status will be replaced by A2105 Discharge Status with more response choices. This aligns with the other PAC assessments tools.
- New Item A2121 Provision of Current Reconciled Medication List to Subsequent Provider at Discharge and A2123 Route of Current Reconciled Medication List Transmission. These items look at medication reconciliation on discharge and will affect the new quality measure, “Transfer of Health Information.”
- New item B1300 Health Literacy proposed as SPADE item in the 2020 proposed rule.
- C0100 Brief Interview for Mental Status (BIMS) will be required on discharge.
- C1310 Signs and Symptoms of Delirium will be required on discharge— even if unplanned.
- D0200 Resident Mood Interview (PHQ-9) will be replaced by D0150 Resident Mood Interview (PHQ 2-9). There will be two questions used as gateway questions and will determine if the rest of the questions need to be asked to reduce provider burden.
- New item D0700 Social Isolation supported by cross-setting reliability and feasibility.
- J0500 Pain Effect on Function will be replaced by J0520 Pain Interference with Therapy Activities as well as J0530 Pain Interference with Day-to-Day Activities.
- K0510 Nutritional Approaches will be replaced by (New item) K0520 Nutritional Approaches. This change added looking at nutritional approaches on admission as well as within the 7 day look back period.
- N0410 Medications Received will be deleted and replaced by N0415(admission) and N0420 (discharge) High-Risk Drug Classes: Use and Indication. This is a 2-part question—is the medication being taken and is there an indication noted?
- O0100 Special Treatments, Procedures and Programs was deleted and replaced by O0110 Special Treatments, Procedures and Programs. The items listed are broken out into like categories with an additional coding if it was provided on admission, while a resident and/or at discharge. IV Medications has been expanded to include specific questions while IV Access has been newly added.
As with any year of changes to the MDS item sets, it will be imperative for your interdisciplinary team to know how these new sections must be coded. CMS auditors are starting their audits based on the current MDS coding of PDPM items.
As LW Consulting, Inc. (LWCI) continues to conduct audits for MDS accuracy, we find multiple missed opportunities or lack of supporting documentation. Now is the time for you facility to be proactive rather than reactive. LWCI can help you prepare for these changes.
For more information, contact Terry Raser at 484-365-2680 or email TRaser@LW-Consult.com.