On July 31st revisions to 2025 Skilled Nursing Facility Prospective Payment System, the QRP, SDOH, ICD-10 Code Mappings, and CMPs.
In April 2024, CMS proposed changes and updates to Medicare payment policies for Skilled Nursing Facilities, allowing 90-day comment periods for each proposed change. As a result, revisions to 2025 Skilled Nursing Facility Prospective Payment System, the Quality Reporting Program (QRP), new Social Determinants of Health (SDOH), ICD-10 Code Mappings, and CMS Civil Money Penalties (CMP) were finalized on July 31, 2024. Learn about the five main updates below and read the full rule here.
1. FY 2025 Updates to the SNF Payment Rates
Industry associates are disappointed with the aggregate impact of payment rate increases of 4.2% or $1.4 billion dollars and remain concerned with accessing monetary resources needed to address staffing shortages and fixed supply costs. Although the SNF PPS rate increases are less than desired, the SNF market base will be revised to reflect a 2022 base year from the current 2018 base year. An additional positive change is that CMS is updating the SNF PPS wage index using the Core-Based Statistical Areas (CBSAs) defined within the new Office of Management and Budget (OMB) Bulleting 23-01 to improve the accuracy of wages and wage-related costs for the area in which a facility is located.
2. Skilled Nursing Facility Quality Reporting Program
SDOH is an area to be included in the QRP through the MDS with a focus on living situations, food (2 items), ease of transportation, and utilities. Changes to the transportation item in the MDS include specifying the look-back period for lapse in transportation, simplifying the response options for the resident and requiring this information only upon admission and not upon discharge. Collecting this information will assist SNF’s to better address needs with residents, caregivers and community partners during the discharge planning process. The assessment of this additional information begins with residents admitted on October 1, 2025, and will be effective FY 2027.
3. Skilled Nursing Facility Value-Based Purchasing (VBP) Program
The SNF VBP program is a pay-for-performance program and as required by statute, CMS withholds 2% of SNFs' Medicare fee-for-service Part A payments to fund the SNF VBP Program. This 2% is referred to as the "withhold." CMS is then required to redistribute between 50% and 70% of this withhold to SNFs as incentive payments depending on their performance in the program. These updates include adopting a measure retention and removal policy to ensure the most appropriate metrics are used for assessing care quality; adopting a technical measure update policy that allows for edits to previously finalized SNF VBP measure specifications; and updating review and correction policies to ensure SNF’s can review and correct data used to calculate measure rates.
4. Changes in Patient-Driven Payment Model (PDPM) ICD-10 Code Mappings
CMS finalized changes to the PDPM ICD-10 code mappings to allow providers more accurate, consistent, and appropriate primary diagnoses that meet criteria for Skilled Part A stays. Certain codes previously coded in I0020B, as primary diagnosis will not map to medical management but will map to return to provider. These codes include E88.810 Metabolic Syndrome; E88.811 Insulin Resistance Syndrome, Type A; E88.818 Other Insulin Resistance; and E88.819 Insulin Resistance, Unspecified.
NTA component changes are in the stage of review and CMS asked for comments on potential future updates to the highly watched non-therapy ancillary (NTA) component of PDPM. After more than four years under PDPM, industry leaders see this as a good way to add items in the list of NTA comorbidities and the points assigned to each.
5. Nursing Home Enforcement
The final rule includes changes in CMS’ ability to impose more equitable and consistent CMP’s for regulatory non-compliance. This area commands immediate review and extensive in-house, interdepartmental discussions as the bottom-line impact could be financially crippling. The ability for CMS to impose same day and per instance penalties simultaneously and the ability for CMS to consider instances as multiple events rather than a singular event or date is astounding. Under current statues, CMS can impose one or the other, but not both. This changes in October of 2024 but will not be operationalized until March 3, 2025 when civil money penalties can be imposed in both per instance and per day situations, up to $10,000 each instance and each situation. Facilities are encouraged to consider the follow action steps:
- Identify your areas of weakness as evidenced by repeat deficiencies and/or complaints and communicate to all levels of team members.
- Review your last annual survey’s plan of correction to determine that you have done all that was committed to be done and continue with routine audits identified on plan of correction.
- Outsource mock surveys to prioritize areas of non-compliance, initiate facility-wide communication and assign action steps.
Be reminded that these regulations are effective October 1, 2024, but have staggered implementation dates per the Federal Register. Revisions in this rule are to ensure nursing homes comply with the unique requirements for participation for long term care facilities.
Polaris Group can help you navigate these changes through expert billing services, compliance consulting, and a variety of training and auditing solutions. To learn more please contact our team here.
