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The Centers for Medicare & Medicaid Services surprised nursing home operators Friday by quietly posting a draft of updated Minimum Data Set specifications. The agency had said earlier this year it would not be releasing a new version until early next year.

CMS on Friday said a final version of the MDS 3.0 patient assessment tool will be released later this year. Changes will go into effect Oct. 1, 2023, as most recently announced in spring. 

“This is enormous,” Leah Klusch, executive director of the Alliance Training Center, told McKnight’s Long-Term Care News on Monday. “Getting it earlier is better. I think we now have probably 65% to 70% of what we need. We know what we’ll have to code, we have the end game. Now we have to figure out how we adapt it, and our record keeping and data formulation. That’s the toughest part.”

Experts said the content of Friday’s release of MDS 3.0 version 1.18.11 was consistent with a version first floated in 2020. That had been in the works for at least a couple of years but was withdrawn amid provider outcry during the early days of the pandemic.

Joel VanEaton

“It is striking that so much change, such as the elimination of Section G [Functional Status] and residual effects, will be required in such a relatively short amount of time,” said Joel VanEaton, executive vice president of PAC Regulatory Affairs and Education with Broad River Rehab, who first noted the changes in a blog Friday.

“Providers should regard this change to the MDS as the most significant since the implementation of MDS 3.0. The sheer volume of new data that providers will be required to collect in MDS 1.18.11 starting in October 2023 is significant and will require much in the way of preparation. To prepare for seven full pages of additional items to begin coding is no small task. Procrastinators, beware.”

A big ball rolling

VanEaton said that Friday’s release “was just the beginning” since it will create “massive residual effects” on other areas affected by the MDS, such as Care Area Assessments, quality measures and Five-Star ratings.

In addition to the MDS draft, CMS also on Friday published its Quality Reporting Program Quality Measure Calculations and Reporting User’s Manual Version 4.0. It governs measurements and risk-adjustments to be made to quality metrics reported beginning this October. 

Yet to be seen is how the new and changed MDS items will affect the payment process, Klusch added. In the past, she said, CMS has at times both kicked up payments for higher acuity treatments and simply exempted them from higher reimbursement.

Parts of the MDS have not changed at all — “not one letter” in the diagnosis section, for example, according to Klusch. But the sheer volume of material that will have to be collected for each patient, along with new specificity requirements, mean operators and their software providers have their work cut out for them in order to be ready by Oct. 1, 2023.

Some of the major revisions and item set changes include:

  • All of Section G has been eliminated (though Functional Limitation in Range of Motion and Mobility Devices have been retained). This will make obsolete the acuity adjustment to staffing stars based on the STRIVE study and RUGs 66 categorization. A big question will be how to make a shift from nurse aide documentation of the late-loss ADLs and the application of the rule of three to relying only on Section GG and usual function, said Van Eaton: “Lots of cross-training will be necessary.”
  • Items that will accommodate the Transfer of Health Information QRP quality measures have been added.They will require more granular specificity.
  • Items that will accommodate an additional five categories of Standardized Patient Assessment Data Elements (SPADEs) have been added. Providers will need to become proficient at coding additional and revised MDS items in sections A, B, C, D, J, K, N and O, VanEaton said. These new and revised items also will be required for SNF QRP compliance and to receive full market basket payment updates.
  • In one area where things might actually get shorter, the PHQ-9 was changed to PHQ-2 to 9, which could shorten the interview to two questions in some cases.
  • Section N0410 has been replaced with section N0415 High Risk Drug Classes: Use and Indication. The medication list has been significantly expanded and now includes hypoglycemics and antiplatelets.

VanEaton advised providers to download and review the 1.18.11 data set that was released Friday as quickly as possible. He also recommended consulting the 2019 document that gives a rationale for and general instructions regarding the new Transfer of Health (TOH) Information measures and additional SPADES that have been added to version 1.18.11.

The hard part starts

“This is going to be a large undertaking, to make sure we have the right education programs and the right supporting documentation and analysis, given where this industry is with staffing and a lot of these technical processes,” Klusch explained.

Leah Klusch
Leah Klusch

“The changes in the MDS software itself are going to be a financial burden on the MDS software industry,” she added. “There are a lot of things that are going to have to change or be reprogrammed.”

She said she was “a little surprised” at some of the aspects that have been deleted from the MDS, including some pertaining to physician visits and physician orders. She said “a whole new dynamic of documentation” has been added by requiring providers to note whether an elder needed a service at the beginning, during or end of a stay.

In addition, providers will be required to specify exactly who has a patient’s reconciled medication list, and then also document methods and routes of transmission.

New MDS duties

“These things are not a negative, but they’re changes the entire organization process will have to adjust to,” Klusch said. “So who will do that? Will it be the consultant pharmacist? A contractor? The director of nursing? We’re looking at a tremendous variety of applications. There’s going to be a lot more interaction between building staff and the pharmacy.”

Other more in-depth reporting involves settings a patient may be coming from or going to. There is also no longer just one checkmark to be made for dialysis patients, she noted. More information about chemotherapy, intravenous medications, medication classifications and other higher clinical areas will demand more too.

Key will be how changes are integrated into the PDPM structure, and whether classifications will change. The nursing and non-therapy ancillary areas will see the biggest number of changes, Klusch believes. 

“Some people may be looking at it now and saying we have a year, a little more than a year,” she said. “But a year isn’t very long to change systems.”

And while Friday’s release is a draft version, providers shouldn’t be lulled, the veteran consultant warned.

“Putting it out this early and in this level of format, without a lot of explanation or the invitation to comment, means to me that they’ve done the majority of their work and any changes we see on this may be just editorial since they’ve been working on this so long. I don’t think they’ll be congenial about not implementing it in October 2023.”