It’s been a little over a month since the Q4FY21 release of the Skilled Nursing Facility (SNF) Program for Evaluating Payment Patterns Electronic Report (PEPPER).
Have you downloaded your reports yet? Reviewed with your team?
If not, first things first: To obtain your SNF PEPPER, the CEO, president, administrator, compliance officer, quality assurance/performance improvement officer, or other authorized user within your organization (selecting a job title closest to their title) should:
- Review the Secure PEPPER Access Guide.
- Review the instructions and obtain the information required to authenticate access. Note: A new validation code will be required. This will be either a patient control number (found at form locator 03a on the UB-04 claim form) or a medical record number (found at form locator 03b on the UB-04 claim form) for a traditional Medicare Part A Fee-for-Service patient who received services from July 1, 2021, through Sept. 30, 2021 (“from” or “through” dates on a paid claim). Additionally, as a second option, a contact from the Provider Enrollment, Chain, and Ownership System (PECOS) will be sent an email and provided with a validation code to use to access the PEPPER from the portal. The validation code may be shared with others in the facility as deemed appropriate. SNFs that are swing-bed units of short-term acute care hospitals will use validation codes provided to Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) Security Administrators to access their PEPPER from the PEPPER Portal.
- Visit the PEPPER Resources Portal.
- Complete all the fields.
- Download your PEPPER.
Now we are good to go!
To begin let’s consider the reason for PEPPER reports.
Remember that the Program for Evaluating Payment Patterns Electronic Report (PEPPER) was designed in part to help guide SNFs’ auditing and monitoring activities.
Why, you ask?
The Government Accountability Office designated Medicare as a program at high risk for fraud, waste and abuse.
Payments to skilled nursing facilities have been identified as vulnerable to abuse. In 2012, the Office of Inspector General found that approximately 25% of SNF claims were billed in error.
The OIG encourages SNFs to develop and implement a compliance program to protect their operations from fraud and abuse. Beginning in 2013, according to statutory language in “Section 6102” of the Affordable Care Act, SNFs are required to have a compliance program. As part of its compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billed.
What Is PEPPER?
National SNF claims data was analyzed to identify areas within the SNF prospective payment system (PPS) that could be at risk for improper Medicare payment.
These areas are referred to as “target areas.”
PEPPER is a data report that contains a single SNF’s Medicare claims data statistics (obtained from the UB-04 claims submitted to the Medicare Administrative Contractor [MAC]) for these target areas.
All SNFs that have sufficient data to generate a report receive a PEPPER, which contains statistics for these target areas.
The report shows how a SNF’s data compares to aggregate jurisdiction, state and national statistics. Statistics in PEPPER are presented in tabular form and in graphs that depict the SNF’s target area percentages over time.
All the data tables, graphs and reports in PEPPER were designed to assist SNFs with the identification of potentially improper payments
Who receives PEPPER?
PEPPER is available for SNFs. PEPPERs are also available for short- and long-term acute care inpatient prospective payment system (IPPS) hospitals, critical access hospitals (CAHs), inpatient psychiatric facilities, inpatient rehabilitation facilities, hospices, partial hospitalization programs, and home health agencies (the format of the reports and the target areas are customized for each type of provider).
What is new in this year’s report?
PDPM has now been in use for almost two years. The PEPPER Team determined that the PDPM High Utilization Codes target area was not associated with the highest paying PDPM codes.
In response, the PEPPER Team is retiring this target area and replacing it with two new target areas:
- High Physical Therapy and Occupational Therapy Case Mix target area
- High Speech Language Pathology Case Mix target area
Great, so what exactly does this mean?
PEPPER determines outliers based on preset control limits. The upper control limit for all target areas is the national 80th percentile. Areas at risk for under-coding also have a lower control limit, which is the national 20th percentile.
PEPPER draws attention to any findings that are at or above the upper control limit (high outliers) or at or below the lower control limit (low outliers; for areas at risk for under-coding only).
How are these areas defined and what are the suggested interventions?
High Physical Therapy and Occupational Therapy Case Mix (new as of the Q4FY21 release)
- Definition: N: count of SNF claims where the first character of the Health Insurance Prospective Payment System (HIPPS) code, representing the physical and occupational therapy component, is one of the following: C, D, F, G, J, K, N, or O; D: count of all SNF claims
- Suggested interventions if at/above 80th percentile: This could indicate issues with the MDS coding of patients’ functional score. The SNF should review nursing and therapy documentation in the medical record to ensure the appropriateness of MDS coding, specifically as it relates to the ten items in Section GG, which is used for the PT and OT component.
- Suggested interventions if at/below 20th percentile: This could indicate issues with insufficient medical record documentation, which is needed to accurately reflect patients’ functional scores. The SNF should review the accuracy or completeness of the medical record with members of the nursing and therapy staff, specifically as it relates to the 10 items in Section GG, which is used for the PT and OT component
High Speech Language Pathology Case Mix (new as of the Q4FY21 release)
- Definition: N: count of SNF claims where the second character of the HIPPS code, representing the SLP component, is one of the following: C, F, I, or L; D: count of all SNF claims
- Suggested interventions if at/above 80th percentile: This could indicate issues with the MDS coding of any of the five patient characteristics included in the SLP component: acute neurologic condition, SLP-related comorbidity, cognitive impairment, swallowing disorder, or mechanically altered diet. The SNF should review documentation to ensure that all SLP-component patient characteristics coded on the MDS are substantiated in the medical record.
- Suggested interventions if at/below 20th percentile: This could indicate issues with insufficient medical record documentation, which is needed to accurately reflect any of the five patient characteristics included in the SLP component: acute neurologic condition, SLP-related comorbidity, cognitive impairment, swallowing disorder, or mechanically altered diet. The SNF should review the accuracy or completeness of the medical record documentation with members of nursing, therapy and other staff to ensure that all patient characteristics associated with SLP components are adequately captured on the MDS.
In closing, as you review reports, trends and practices with your teams, also keep in mind the following key point: A SNF can use PEPPER to compare its claims data over time to identify areas of potential concern and to identify changes in billing practices. However, PEPPER does not identify the presence of improper payments.
It should be used as a guide for auditing and monitoring efforts, an opportunity to open conversations on trends across teams, and an avenue to assess clinical practice.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected]
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
