The Centers for Medicare & Medicaid Services has updated MDS 3.0 items (version 1.17.2) along with related technical data specifications. But providers could be left in “limbo” as they await for more information regarding the changes from their state Medicaid agencies, according to one expert.
The changes will support the calculation of Patient Driven Payment Model payment codes on OBRA [Omnibus Budget Reconciliation Act] assessments when not combined with the five-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets. The change was not possible with item set version 1.17.1, CMS explained in a recent notice.
“Please confirm with your State Medicaid Agency if your State will be requiring the calculation of the PDPM payment codes on the OBRA assessments when not combined with a 5-day SNF PPS assessment,” CMS wrote.
The update is geared for states eager to transition to PDPM from Medicaid, according to Robin Hillier, CPA, LNHA, STNA, RAC-MT, financial consultant and founder of RLH Consulting.
“For states like Ohio, where we are, this update allows the state to continue to calculate RUG scores from OBRA assessments without requiring the additional work of completing an Optional State Assessment with each OBRA assessment, as was originally going to be required for Medicaid case mix. So this update allows states flexibility in the design of Medicaid case mix methodologies, without requiring any additional burden from providers,” Hillier explained to McKnight’s.
She added that the update will allow states to collect both PDPM and Resource Utilization Group scores simultaneously, allowing informed decisions to be made in the future as states consider changing their case mix methodologies.
Providers will need to work with state Medicaid agencies to identify if their state will be requiring these items to calculate the PDPM payment codes, according to Jessie McGill, RN, RAC-MT, curriculum development specialist, with the American Association of Post-Acute Care Nursing.
McGill added that many of the changes appear straightforward, noting the addition of the Section GG, Functional Abilities items used to calculate the function scores for PT, OT, and nursing components, item I0020 to identify the primary clinical category, and J2100 to identify prior surgery requiring active SNF care.
“The challenge to understand these changes come from the current coding instructions, which are directed toward a skilled stay — not a long-term stay, leaving many unanswered questions,” McGill said.
Providers left in limbo
While it appears CMS is making a simple fix to allow states to calculate a PDPM payment code in order to make informed further payment model decisions, McGill said the agency has not not shown providers exactly how it plans to transition items focused on the skilled Medicare Part A stay to the long-term care resident.
“This update leaves providers in limbo, as they await information from states on whether or not their Medicaid agency will require this information and if so, awaiting instructions from CMS on how these skilled-focused items will be altered for long-term care residents,” McGill said.
Meanwhile, questions remain regarding the instructions on the V1.17.2 NC item set for section GG, pending the release of the V1.17.2 RAI User’s Manual, according to McGill. She said it’s not clear if the “coding instructions for section GG, column 1, on an OBRA not combined with a 5-Day PPS assessment, would come from the State Medicaid agency, or follow the RAI manual.”
“Column 1 currently has additional coding instructions which directs the provider to assess functional abilities prior to the resident ‘benefitting from treatment interventions.’ It is not yet clear if these coding instructions will be applied when completing for an OBRA assessment,” McGill said.
McGill explained that MDS item I0020 instructions will change to “Indicate the resident’s primary medical condition category, complete only if A0310B = 01 or if state requires completion with an OBRA assessment.”
“However, this item was originally developed solely for skilled residents, on page I-1, the current RAI User’s Manual instructs, “Indicate the resident’s primary medical condition category that best describes the primary reason for the Medicare Part A stay,’” she said.
“This does not easily translate to residents on a long-term care stay in the nursing home. It is unclear if additional instructions will be added in the RAI User’s Manual or if instructions will come from the state,” McGill added.
McGill explained that updates to J2100 adds instructions for completion if required by the state with an OBRA assessment. She noted, however, the item is also directed specifically toward the skilled stay with instructions to identify “surgical procedures that occurred during the inpatient hospital stay that immediately preceded the resident’s Part A admission.”
This item only serves as a gateway question, if answered yes, the provider must identify the type of surgery in items J2300-J5000. This is further complicated by coding instructions that the surgery coded here must be ‘documented by a physician … in the last 30 days and must have occurred during the inpatient stay that immediately preceded the residents Part A admission,’” McGill explained.