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Long-term care facilities, staff and more than half the states in the US should start preparing immediately for extensive changes to the Minimum Data Set, resident assessment experts said this week.

The Centers for Medicare & Medicaid Services last week released a draft of long-awaited update to MDS 3.0. Section G, used by many states to determine Medicaid reimbursement, is gone. Added were additional intake questions and a need for more robust documentation from hospitals referring residents. The changes, pending public comment and final draft reactions, will be official in October 2023.

Gloria Brent, president and CEO of MDS Consultants, called it a “bombshell” that A 0300 A, Optional State Assessment, was removed in the new draft. It’s a tool needed by states that still calculate RUG scores for payment purposes. The draft makes it no longer available.

“Without Section G, they don’t have a score,” said Brent. “If you take away the opportunity for the software to put in Section G, which would be A 0300, the OSA, what are the states going to do to generate an algorithm that calculates a score for the nursing homes to get reimbursed by Medicaid using Case Mix Index methodologies?

“The states can request the draft be changed to allow for A 0300 to be placed back in the MDS, but if the states don’t know this is a problem, they’re not going to lobby for it. And when Oct. 1, 2023, comes around, they’re going to be rather dismayed that the late loss ADLs in section G are not available to generate a RUG score that, outside of therapy, is the foundation of Medicaid reimbursement in more than 50% of the nursing homes in the United States.”

More than 30 states will be affected by the change, she said.

“The way the MDS is right now, CMS may not realize to the extent that this is going to affect the state reimbursement for Medicaid,” Brent added. “They have generated absolutely no avenue to which there is a compatibility between RUG score generation for case mix index management and completing the MDS. 

“The draft must change or the states must change in order for it to work.”

Brent said a year may not be enough time for states to convince CMS to reinstate the OSA.

“If the federal government does not change the MDS, then the states are going to have to figure out how to change their reimbursement for nursing homes,” she said. “If the feds change the MDS, the nursing homes are going to have to figure out how to get more staff to do the additional MDS’s that will be required to meet the state reimbursement.

“Either way the nursing homes don’t win.”

Draft reveals work ahead

There are other significant changes in the draft that could require further refinement or interpretation to understand potential impacts on reimbursement.

Planning, however, needs to begin now, said Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for the American Association of Post-Acute Care Nursing, whose organization published a comprehensive look at every proposed change. She highlighted extra questions about ethnicity and race, for example, and new ones about transportation.

“I see policies having to be updated, staff training having to be done, I see communication with physicians needing to occur because they need to know about these changes because it might require additional documentation on their part,” Stewart told McKnight’s Long-Term Care News on Wednesday. “Same with hospitals, because they’re not going to know why you’re asking for more documentation.”

For example, said Stewart, policies that mention the PHQ-9 mental health assessment, used in the current MDS, will have to implement PHQ2-9 from the draft MDS, potentially shortening the questionnaire potentially to two questions. 

“So if you had a policy that said we need a PHQ-9 on admission and quarterly because we collect that data on the MDS, now if they don’t have the first two symptoms of the PHQ9, which is considered the PHQ-2, then you can stop with the first two questions,” she added. 

Brent said administration of the PHQ-9 would now allow a skip pattern. If question D0150A2 (little interest or pleasure in doing things) and D0150B2 (feeling down, depressed, or hopeless) were recorded as a two or a three, then the PHQ-9 interview is ended, resulting in skipping the remaining seven questions. 

But the Nursing Component of a Patient Driven Payment Model score is calculated on the overall score for all nine questions. If the interview is stopped after two questions, the scoring associated with that threshold is no longer available to coders.

“Will the PDPM Score take into account the indicators of depression any longer?” Brent asked.  “How is PDPM going to change to generate a score for Medicare dollars? How will CMS fix that? Probably they have the answers, they just haven’t shared them with us yet. It will be interesting to see how this changes from draft to final. The long-term care industry certainly needs to provide CMS with feedback.”