Skilled Nursing Facility Quality Reporting Program Coding Section GG

Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, DNS-CT judy@judywilhide.com 909-800-9124 www.judywilhide.com Skilled Nursing Facility Quality Reporting Program Coding Section GG January 2018 NC & VA Source Documents www.judywilhide.com JudyWilhide.com (c) 1

Section GG: Big Picture Determine usual performance during first 3 days of PPS stay Set at least one goal on PPS 5 day Determine usual performance during last 3 days of complete PPS stay. Admission GG Discharge GG JudyWilhide.com (c) 2

Section GG: Functional Assessment Self Care Eating Oral hygiene Toileting hygiene Sit to lying Lying to sitting on side of bed Sit to stand Chair/bed to chair transfer Toilet transfer Mobility Walking Walk 50 ft with 2 turns Walk 150 ft Wheelchair Wheel 50 ft with 2 turns Wheel 150 ft Self-Care and Mobility Rating Scale 06: Independent independent 05: Setup or clean-up assistance Helper assists only prior to or following the activity. 04: Supervision or touching assistance VERBAL CUES or TOUCHING/ STEADYING as resident completes activity. 03: Partial/moderate assistance Helper does LESS THAN HALF 02: Substantial/maximal assistance Helper does MORE THAN HALF 01: Dependent Helper does ALL of the effort. Or the assistance of 2 or more helpers required If activity was not attempted, code reason: 07, Resident refused 09, Not applicable: resident did not perform this activity prior to the current illness, exacerbation, or injury 88, Not attempted due to medical condition or safety concerns: activity was not attempted due to medical condition or safety concerns JudyWilhide.com (c) 3

GG0130: Steps for Assessment Assess the resident s self-care status based on direct observation resident s self-report family reports direct care staff reports documented in the resident s medical record during the assessment period. Assessment period first 3 days of the Part A stay starting with the date in A2400B Last 3 days of Part A stay ending with date in A2400C Admission GG Performance Baseline admission functional status, based on clinical assessment that occurs soon after admission, prior to the person benefitting from treatment interventions to get true baseline functional status on admission. If treatment has started a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. Discharge GG Performance Discharge functional status, based on clinical assessment that occurs as close to the time of the resident s discharge from Medicare Part A as possible. Not required if resident has an unplanned discharge to an acute-care hospital, or if the SNF PPS Part A Stay is less than 3 days. Unplanned, or To hospital, or SNF stay < 3 days JudyWilhide.com (c) 4

Both: Admit & DC Fxl Performance If performance varies during assessment period, report usual performance, not most independent or most dependent. A provider may need to use the entire 3-day assessment period to obtain the resident s usual performance. Coding Tip Changes for Oct 1, 2017 Eating Fingers may be considered utensils Eating refers to food and fluids during meals Chair/bed transfer If 2 staff assist with mechanical lift, code 01, dependent Wheelchair Use If resident walks and is not learning how to mobilize in a wheelchair, and only uses a wheelchair for transport between locations within the facility, code the wheelchair use as 0, No. Code yes for wheelchair use for residents who used a wheelchair prior to admission or are anticipated to use a wheelchair during the stay, even if the resident is anticipated to ambulate during the stay or by discharge. JudyWilhide.com (c) 5

Wheelchair Use Wheel 150 feet: Mr. M uses a manual wheelchair. He usually can self-propel himself about 60 to 70 feet but needs assistance from a helper to complete the distance of 150 feet. Coding: Wheel 150 feet would be coded 02, Substantial/Maximal assistance. Rationale: The helper provides more than half of the effort to complete the activity of wheel 150 feet. (GG-38) Walking Walk 150 feet: Mr. R has only walked about 30 feet during the 3-day assessment period. Coding: Walk 150 feet would be coded 88, Activity not attempted due to medical or safety concerns. Rationale: The activity was not attempted. (GG-33) Sec GG discharge goals: added language Goals may be determined based on the resident s admission functional status, prior functioning, medical conditions/comorbidities, discussions with the resident and family concerning discharge goals, anticipated length of stay, and the clinician s consideration of expected treatments, and resident motivation to improve DC Goals can be: Higher Lower Same Required to code at least one goal. CanŲt use 07, 09, or 88. JudyWilhide.com (c) 6

What if they don t meet their goal(s)? 1. No financial penalty 2. They will post it on the internet eventually (Medicare.gov) 3. There is no mechanism in GG for plans of care that change over the course of care SNF-QRP Measures begin collection Oct 1, 2018 Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury M0800 will be removed from the MDS Worsening Pressure Ulcers for QRP will include: Stage 2 Stage 3 Stage 4 Unstageable due to non-removable dressing Unstageable due to slough/eschar Unstageable due to Deep Tissue Injury Number at any of these stages present is greater than that stage present on admission Drug Regimen Review Conducted with Follow-Up for Identified Issues JudyWilhide.com (c) 7

QRP Measures begin collection Oct 1, 2018 Change in Self-Care Score for Medical Rehabilitation Patients Totals scores for Admit and DC Change in Mobility Score for Medical Rehabilitation Patients Total scores for Admit and DC Discharge Self-Care Score for Medical Rehabilitation Patients Compares observed score to expected score Discharge Mobility Score for Medical Rehabilitation Patients Compares observed score to expected score QRP Additions to the MDS Oct 1, 2018 JudyWilhide.com (c) 8

Additional Self-Care Items Additional Mobility Items JudyWilhide.com (c) 9

Additional Waking Items JudyWilhide.com (c) 10

What s going on here? Skilled Nursing Facility Quality Reporting Program (SNF-QRP) JudyWilhide.com (c) 11

Post Acute Care Quality Reporting System SNF-QRP IRF-QRP PAC-QRP HHA-QRP LTCH-QRP Overlap in services and expertise Significantly different costs No clear evidence regarding appropriateness of care or outcomes. SNF IRF Hip Fracture HHA PAC costs vary eightfold across the country, costs rising, comparative quality unknown LTCH JudyWilhide.com (c) 12

Post Acute Settings SNF IRF HHA LTCH Require skilled therapy 5xW or skilled Nsg 7xW # of facilities: 15,000 Therapy 15 hr wk (3 hr day) 2 disc MD 3xW # of facilities: 1166 Be homebound Require intermittent skilled therapy or nsg # of facilities: 12,311 Stay > 25 days, rehab, resp ther, head trauma, pain mgt # of facilities: 420 Standardization Endgame Refine PAC rules Standardize items Reshape Payment & Reward System Stop RUG system Build payment system based on resident characteristics and outcomes Decision making Collect data Valid comparisons Analyze data Start PAC-QRP Begins Begin standardization process for certain items on PAC assessment tools QRP measure data collection begins Big Picture JudyWilhide.com (c) 13

Many QRP Measures: Adding, changing, retiring - now and for several years MDS MDS MDS Claim Claim Claim Fxl Status Fall maj injury New/Worsening Pressure ulcer All these started Oct 1, 2016 Medicare Spending per Beneficiary Potentially Preventable Unplanned Rehospitalization Successful Discharge MDS Based Unique QRP Measures Claims Based Unique QRP Measures MDS-based QRP measure collection method PPS 5 Day Falls w/major Injury Admission Fxl Abilities & Goal(s) Covariates for worsened PU Falls w/major Injury: Any OBRA or scheduled PPS or PPS DC in the Part A stay Discharge Fxl Abilities Falls w/major Injury New/worsened PU PPS Discharge JudyWilhide.com (c) 14

Special allowance in the law for discharge functional abilities Discharge Fxl Abilities Falls w/major Injury New/worsened PU PPS Discharge This is why DC GG is not on ALL PPS DC/OBRA DC combos! CMS shall not collect discharge functional abilities on incomplete stays. That would not give valid, reliable, usable data to satisfy PAC-QRP goals. SNF-QRP MDS-Based Measure Specifications JudyWilhide.com (c) 15

QRP Collection Method: Calculated for each qualifying stay New Assessment Any OBRA/Schedule d PPS New Section GG PPS 5 Day MDS Fxl Ability & Goal(s) Fall Major Injury Risk adjustments for New/Worsened Pressure Ulcers Fall Major Injury Part A PPS DC New/Worsened PU Falls w/major Injury DC Fxl Abilities** on qualifying discharges Fall with Major Injury SNF-QRP Initial 5 day Maj injury 14 Day 30 Day SNF PPS Discharge Falls w/major injury includes a look-back scan of OBRA or scheduled PPS MDS for the Part A stay. The fall w/major injury could be on any assessment in the stay. JudyWilhide.com (c) 16

Falls Major Injury SNF-QRP MAJOR INJURY Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. New/worsened Pressure Ulcers SNF-QRP Does not use M0800 for calculation! M0300 ONLY Initial/5 Day Obtain covariates 14 Day 30 Day SNF Discharge JudyWilhide.com (c) 17

New/worsened pressure ulcer SNF-QRP On a PPS DC: Number present Stage 2: M0200B1 Stage 3: M0200C1 Stage 4: M0200D1 > > > Greater than number present on admission Stage 2: M0200B2 Stage 3: M0200C2 Stage 4: M0200D2 New/worsened Pressure Ulcers - PPS DC: triggers M0300B1 > M0300B2 JudyWilhide.com (c) 18

Covariates reported on PPS 5 day PVD (I0900) 5 1 Bed Mobility > 2, limited (G0110A1) 4 Low BMI: (weight * 703 / height 2 )K0200A & B New/worse PU SNF- QRP 3 2 Diabetes (I2900) Bowel Continence > 2, frequently (H0400) dashes in these items on PPS 5 day do not count towards 2% APU penalty Residents with admission & discharge functional assessment and care plan that addresses function New Assessment New Section GG PPS 5 Day MDS Fxl Ability & Goal(s) Part A PPS DC DC Fxl Abilities** on qualifying discharges JudyWilhide.com (c) 19

Residents with admission & discharge functional assessment and care plan that addresses function Complete Stay Admit & DC GG appropriately completed Two ways to get into the numerator: higher scores are better Incomplete Stay: Death in Facility Unplanned Discharge Discharge to hospital SNF stay < 3 days Admit GG appropriately completed Judy Wilhide Brandt 2017 2% APU Penalty Judy Wilhide Brandt 2017 JudyWilhide.com (c) 20

MDS Based Data collection period for penalties: Data Collected Penalties Apply Oct, Nov, Dec 2016 FY 2018 CY 2017 FY 2019 CY 2018 FY 2020 Phase In And so forth 80% of all MDSs submitted must contain 100% of the data elements required to calculate the 3 MDS Based QRP measures. The 2% reduction is not calculated per quarter, it is calculated per calendar year Judy Wilhide Brandt 2017 Dashes in Column 2 will not count towards the 2% APU penalty if at least one goal Dashes in Column 1 (and in Discharge Performance on Discharge GG) will count towards the 2% APU penalty Judy Wilhide Brandt 2017 JudyWilhide.com (c) 21

H1, Q1, RR1, SS1 May not have dashes. Type of WC/Scooter in RR1 & SS1 are not active if Q1 = 0, no. Judy Wilhide Brandt 2017 Example SNF has 30 Part A Discharges a month in CY 2017. 360 SNF stays ended in 2017. Each SNF stay could have many OBRA and/or PPS scheduled MDSs, depending on length of stay. Of all the MDSs submitted for these 360 SNF stay, 80% of them must have no dashes in the appropriately completed QRP MDS based calculator fields. Let s say average length of stay is 35 days. That would be at a minimum, 4 required PPS MDSs: 5 day 14 day 30 day Part A PPS DC (alone or combined with OBRA DC) Total. 1,440 assessments for those 360 SNF stays with length of stay 35 days. 20% of 1440 = 288 No more than 288 assessments could have a dash in a QRP QM field. If we did not submit a PPS DC when required, that s one of the 288. Judy Wilhide Brandt 2017 JudyWilhide.com (c) 22

See Handout If the Medicare Part A stay is ongoing, there will be no end date to report. Enter dashes to indicate that the stay is ongoing. The end of Medicare date is coded as follows, whichever occurs first: Date SNF benefit exhausts or Date of last day covered as recorded on the effective date from the Notice of Medicare Non-Coverage (NOMNC); or The last paid day of Medicare A when payer source changes to another payer (regardless if the resident was moved to another bed or not); or Date the resident was discharged from the facility (see Item A2000, Discharge Date). JudyWilhide.com (c) 23

SNF Quality Reporting Program 1. SNF Facility Level QM Report 2. Resident Level QM Report 3. Review and Correct Report Casper Reports These measures will be publicly reported by October 2018 Finding the QRP Reports Judy Wilhide Brandt 2017 JudyWilhide.com (c) 24

Judy Wilhide Brandt 2017 Judy Wilhide Brandt 2017 JudyWilhide.com (c) 25

Judy Wilhide Brandt 2017 SNF FACILITY-LEVEL QUALITY MEASURE REPORT The SNF Facility-Level Quality Measure Report provides facility-level qualitymeasure values for a select 12-month period. SNF quality measure valuesare compiled from the following sources: MDS 3.0 assessment data Medicare Fee-For-Service (FFS) claims and Eligibility Files The CASPER Reports Submit criteria page (Figure 13-2) for the SNF Facility-Level Quality Measure Report presents Begin Date and End Date criteria options. JudyWilhide.com (c) 26

SBF Facility Level QRP Quality Measures Data SNF RESIDENT-LEVEL QUALITY MEASURE REPORT The SNF Resident-Level Quality Measure Report identifies each resident with assessment records identifying 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. The report displays each resident s name and indicates how/if the resident s assessment affected the SNF s quality measures. JudyWilhide.com (c) 27

The SNF Review and Correct Report allows SNF providers to review their quality measure (QM) data to identify if there are any corrections or changes necessary prior to the quarter's data submission deadline, which is 4.5months after the end of the quarter. NOTE: Correction periods for each quarter end as follows: Q1 (1/1-3/31) August 15 Q2 (4/1-6/30) November 15 Q3 (7/1-9/30) February 15 Q4 (10/1-12/31) May 15 Correction period deadlines for calendar year (CY) 2017 are due May 15, 2018. However, providers are encouraged to verify their MDS submissions on at least a quarterly basis. The SNF Review and Correct Report provides a breakdown, by measure andby quarter, of the provider s QM data for four rolling quarters. The report also identifies the open/closed status of each quarter s data correction period as of the report run date. SNF-QRP Quality Measure calculations are performed weekly and on the first day of each quarter. Review and Correct Report JudyWilhide.com (c) 28

Non- Compliance Letters Letter sent in July to SNFs that were below the 80% threshold compliance with reports for Oct, Nov & Dec of 16 Called "FY2018 Non Compliance Notification Sent via mail and was placed in Casper Inbox Next one will be sent in spring 2018 for noncompliance with cumulative CY 17. FY2018 Non-Compliance Notification If you got one, & had no appeal, your SNF will take a 2% reduction in Part A payments for all of FY 2018 Explanation of SNF-QRP Claims Based Measures in FY 2017 JudyWilhide.com JudyWilhide.com (c) 29

Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNFQRP Calculates risk-adjusted potentially preventable and unplanned readmission (PPR) rate for each PAC provider using hospital claims. Potentially preventable condition categories: Inadequate management of chronic conditions; Inadequate management of infections; and Inadequate management of other unplanned events. Accidents, injury Risk adjustment/exclusions very similar to the other two hospitalization measures for 5 star & QRP (All done by same 2 contractors: RTI and ABT) JudyWilhide.com PPR conditions: Examples ICD codes will come from hospital claims Acute exacerbation of CHF related conditions: hypertensive heart disease/chronic kidney disease Acute exacerbation in COPD/respiratory conditions Diabetic crisis HTN unmanaged Septicemia Cellulitis Impaction Pressure ulcers Flu Pneumonia UTI C-diff Dehydration/electrolyte imbalance/acute renal failure JudyWilhide.com JudyWilhide.com (c) 30

Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNFQRP No simple form numerator/denominator of observed PPR over predicted Numerator is risk-adjusted estimate of the number of unplanned hospital readmissions that occurred within 30 days of PAC discharge. Risk-adjusted for patient/resident characteristics Within PAC-stay readmission excluded: hospital to SNF to hospital Because they don t currently have a method to apply it to all PAC settings This is a primary difference between this one and the one in the Five Star system Data from calendar year 2013 data was used to develop the SNF PPR measure. JudyWilhide.com Exclusions: < 18 DC AMA (from SNF DC disposition code on claim) Not continuously enrolled in Part A for 12 months prior to the SNF stay or 30 days after Prior hospitalization for nonsurgical tx of cancer Exclusions: SNF stays with problematic data (Jacked up claims data, upstream, in SNF, or downstream) Pts transferred to a federal hospital (DoD, VA, Prison, etc), or foreign hospital (Medicare claims data won t be complete) JudyWilhide.com JudyWilhide.com (c) 31

Discharge to Community- Post Acute Care SNF QRP - Definitions Successful Discharge: No unplanned hospitalizations (Acute or LTCH) No death from any cause Within 31 days from SNF Discharge Community, defined as home/self-care, with/without HHA, based on Patient Discharge Status Codes 01, 06, 81, and 86 on the SNF Medicare claim. JudyWilhide.com Risk adjustment/exclusions similar to previous claims based measures Discharge to Community Post Acute Care SNF QRP - Definitions Exclusions unique to this measure DC to psych hospital (community may be inappropriate due to mental health) DC to law enforcement/court Medicare A benefits exhaust (DC destination may be r/t exhaustion) For SNF residents with multiple SNF stays during the one year window, each stay is eligible for inclusion in the measure. Data from CY 2013 were used to develop this measure. JudyWilhide.com JudyWilhide.com (c) 32

Medicare Spending per Beneficiary- Post-Acute Care SNF QRP (MSPB-PAC SNF) Designed to benchmark resource use of provider against expected spending as predicted through risk adjustment. Not a simple sum of costs Begins upon admission to SNF and ends after 30 day associated services period after SNF discharge. Certain services excluded as clinically unrelated to SNF care (ex: Dialysis, tx for preexisting cancers) Mirrors hospital MSPB measure that has been used in Hospital Value- Based Purchasing (VBP) Program since FY 2015 JudyWilhide.com Medicare Spending per Beneficiary- Post-Acute Care SNF QRP (MSPB-PAC SNF) Payment standardized and risk-adjusted. Removes geographic payment differences, incentive payment adjustments, and other add-on payments that support broader Medicare program goals including indirect graduate medical education (IME) and hospitals serving a disproportionate share of uninsured patients (DSH) Risk adjusted for covariates including the clinical case mix categories, HCC indicators, age brackets, indicators for originally disabled, ESRD enrollment, and long-term care status, hospice status JudyWilhide.com JudyWilhide.com (c) 33

Claims-based Measures Casper Reports Claims-based Measures Casper Reports JudyWilhide.com (c) 34

To Begin Collection 2018: See Handout Measures to begin collection October 2018 (MDS based) Changes in Skin Integrity: Pressure Ulcer/Injury(will replace New/worsened pressure ulcers) Change in Self-Care Score for Medical Rehabilitation Patients Change in Mobility Score for Medical Rehabilitation Patients Discharge Self-Care Score for Medical Rehabilitation Patients Discharge Mobility Score for Medical Rehabilitation Patients Outcome measure: On Part A PPS Discharge assessment, presence of stage 2, 3, 4 or unstageable pressure ulcers that were not present on admission. Estimates the risk-adjusted change in self-care score between admission and discharge for the 7 self care items in Section GG. Estimates the risk- adjusted change in mobility score between admission and discharge for 15 mobility items in Section GG Estimates the percentage of SNF residents who meet or exceed an expected discharge self-care score, using national data & resident characteristics, not the discharge goals set upon admission. Estimates the percentage of SNF residents who meet or exceed an expected discharge mobility score, using national data & resident charateristics, not discharge goals set upon admission. JudyWilhide.com (c) 35

SECTION GG: OCTOBER 2018 DRAFT JudyWilhide.com (c) 36

Drug Regimen Review Conducted with Follow-Up for Identified Issues SNF QRP MDS Based Begin collection Oct 2018 JudyWilhide.com Questions/Discussion See Handout for SNF-QRP MDS-based measures beginning Oct 2018 JudyWilhide.com (c) 37

SNF-QRP Purpose: As part of PAC-QRP, to enable interoperability and access to longitudinal information for such providers to facilitate coordinated care, improved outcomes, and overall quality comparisons. SNF providers are encouraged to report QRP data through 2% APU reduction for failure to report required data to calculate MDS-based QRP measures. Specifically, if more than 20% of the calculator fields are not appropriately completed for the reporting period (now a calendar year) the SNF bears a 2% reduction in Part A SNF payment for an entire fiscal year. Claims-based measure collection is passive. No required SNF reporting. No 2% penalty applies. All QRP measures will be published on NH Compare at Medicare.gov. SNF-QRP Website: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/ NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program- IMPACT-Act-2014.html Wilhide Consulting Respect the Aged 2005 Edmonds Rd. Virginia Beach, VA 23451 909-800-9124 judy@judywilhide.com www.judywilhide.com

Discharge Section GG not required when PPS DC combined with OBRA DC AND one of the following is true: Discharge unplanned, or Discharge to hospital, or SNF stay< 3 days Wilhide Consulting Respect the Aged SNF - QRP Part A PPS Discharge Original Medicare A? yes Part A Stay End? yes Part A Stay End in Death? no Part A PPS Discharge Required Physical Discharge on or one day after Part A stay end date? Combine Part A PPS yes Discharge note with OBRA Discharge no yes no Part A PPS Discharge not Required Part A PPS Discharge not Required Do stand alone Part A PPS Discharge 2005 Edmonds Rd. Virginia Beach, VA 23451 909-800-9124 judy@judywilhide.com www.judywilhide.com