Questions and Answers/Wrap-Up – August 13 and 14, 2019


»» Okay. So as Brigitte said we have a slide
deck. You probably remember that she asked you to “like” the questions. And so you’ll
see the section, the question, and how many thumbs up it gone on the Slido. And as Brigitte
mentioned, I’m answering these questions on behalf of all of our colleagues, just to save
everybody from bouncing around. So these have had input from the whole team. So the first
question is, if a resident rehospitalized before three days of admission and comes back
to the SNF before three nights, what is the look-back for GG. And is the three days counted
as skipped days? So we made the assumption that this question relates to the provider
having started but not yet completed the 5-day assessment. Regarding the functional assessment,
the days that the facility has functional data either before or after the interrupted
stay that adds up to three days of data would be used to code GG.
For example, if a resident was admitted on Day 1 but left partly through Day 2, was gone
from the facility on Day 3, and returned partly through Day 4, you would use any functional
assessment data from that first day, the half a day of Day 2, the half a day of Day 4 and
Day 5 for coding Section GG. In terms of skip days, the midnight rule would
be in effect, and providers should follow the policy as described in the RAI User’s
Manual. Question 2. »» Are we allowed to ask questions?
»» No, no. (laughter) Save them. The question was are we able to ask questions in between.
Let’s go through these and then we’ll use any time for open mics. We’ll be around for
a bit afterwards as well before the next session. If a resident has an interrupted stay on Day
3 and we have not scheduled and completed the 5-day PPS, can we complete it after the
interrupted stay? And the answer is, since the window for scheduling the assessment are
days 1-8, the facility would still be in compliance with the assessment scheduling rules. Therefore
the provider in this instance can complete the 5-day after the interrupted stay if they
so choose. So you’re still within that window. Next question is, in Section GG picking up
an object, can that item be assessed for a resident seated in a wheelchair or do they
have to be in a standing position? Thanks much. And I know Anne says you’re welcome.
She’s who answered this question. The resident needs to be in a standing position in order
to code this item. Use the appropriate activity not attempted code if you’re coding with a
seated — if the resident’s not able to stand. A resident has been admitted to the hospital
for pneumonia where he has IV antibiotics. He’s admitted to the SNF for rehab due to
weakness and debility caused by pneumonia, which was treated. Would we use pneumonia
as the primary diagnosis for the SNF skilled stay? Would anybody like to guess what my
answer to this question might be? Use your clinical judgment. If you can’t decide, who
do you go to? The provider. So the ICD Code in I0020B is to reflect the code for the resident’s
primary medical condition and that best describes the reason why they need that skilled care
for the SNF Part A stay. Therefore the provider would enter that diagnosis code and address
what resulted in the admission to the SNF. The next question under PDPM, when a resident
is readmitted after 3 days from the hospital is the Variable Per Diem payment started over?
What do you think? This scenario is not an interrupted stay. So the Variable Per Diem
schedule and the PPS Assessment completion schedule again restart from Day 1. Where can
I find the slides online? This is an easy one. There is a link that is way too long
to read to you. So I’m going to suggest that you choose your favorite search engine and
search “SNF QRP Training.” And I did that right before I got up here to make sure it
would come to you. Brigitte do you want me to read the link? No. Okay. It’s the page
from which you registered. So if you’re here, you were able to get to that slide. For the
items that trigger the nursing component such as sepsis, are there any restrictions on the
actual ICD-10 codes accepted besides checking the item in Section I? Will there be any definitions
in the manual? The valid ICD-10 codes, which may be used to classify the patient into a
PDPM clinical category are available on the PDPM website.
The next question, resident is admitted on a Friday evening. The ARD has not been established
on a MDS and he is unexpectedly discharged on Sunday night. Since the patient is no longer
in the facility on a Medicare Part A stay the PPS Assessment cannot be completed. Is
this still applicable? The provider would follow the missed assessment policy and that’s
in Chapter 6 Section 6.8 of the RAI User’s Manual. The next question, will there be any
allowances for the BIMS or the PHQ9 in Section GG coding for residents that admit late in
September and have an IPA ARD set early in October to be able to utilize these responses
from the prior 5-day assessment? There’s no language in the manual that allows for reuse
of these responses, therefore it is not permitted. Next question. How will PDPM affect long-term
care Medicaid-only facilities? Questions about Medicaid go to your State agency. They’ll
be able to tell you whether this will have any impact. Next question. CMS allows two
individual users per facility to obtain access, but isn’t there a form that can be completed
to add more than just two? And the answer is, providers can call the help desk and request
a form and have greater than two users. The next question, did I hear that agency nursing
or contracted nursing or therapy could not be counted as a helper when coding? For purposes
of completing GG, a helper is defined as facility staff who are direct employees and facility
contracted employees such as rehab or nursing agency staff. It does not include individuals
hired or compensated or not by individuals outside the facilities’ management and administration
such as hospice, or nursing, or CNA students that are not employees. They have to be employees
or within the agency. Therefore when the helper assistance is required because the resident’s
performance is unsafe or poor quality, only consider facility staff when scoring the amount
of assistance provided. So the short answer is, can you count agency staff? Yes. If your
facilities’ paying them, you can count them. Next question, besides a car simulator or
a real car, is there any other way to do car transfer training? So this is for GG0170G,
Car Transfer. Use of an indoor car can be used to simulate outdoor car transfers. These
are half or full cars and would not need to have similar features to that of a real car,
that is if you have a car seat within a cabin of a car.
In the situation where the patient’s unable to perform a car transfer using a car or car
simulator, then you would use the appropriate activity not attempted code. Next question.
I thought the terminology for the 5-day assessment — I think they’re saying changed. I thought
the terminology was changed for the 5-day assessment to the initial. Is it being referenced
to a 5-day only? Please clarify. The name of the 5-day remains the 5-day PPS Assessment.
The reason why initial Medicare assessment was used in the Rule is because it’s a more
generic phrase. The 5-day is the initial Medicare assessment. For example if the name 5-day
were to change in the future, whatever name of that assessment is would still be referred
to as the initial Medicare assessment. All right. The next question. Please explain
again the implications of dashes. It was told that if we enter dashes or skip into the MDS
elements relevant to the SNF QRP that we may not meet the reporting threshold for APU,
as such be subject to a 2% rate penalty. Should we really be entering dashes? So the SNF QRP
requires the SNFs to submit quality measure and standardized resident assessment data
elements to CMS. For a given submission period, the MDS submitted
by a SNF needs to meet the APU minimum submission threshold of no less than 80% of the MDS assessments
having 100% complete completion of the required SNF QRP data elements. These are the data
elements needed to calculate the SNF QRP Quality Measures and are defined as standardized data
elements. Successful completion is the submission of actual resident data as opposed to the
non information response options dash. Please note that while the coding of a dash is an
optional response value for certain data elements, its use does not count toward meeting the
APU minimum threshold requirement. And again, failure to meet that may result
in a 2-percentage point reduction in the facilities APU. As CMS has said in the past and continues
to today, that the use of dashes should be rare. Next question. Is there somewhere that
has a listing of all the error numbers to know which — when you run them what they
mean? That is Section 5 of the MDS 3.0 Provider User’s Guide. So that’s not the RAI User’s
Manual. It’s the MDS 3.0 Provider User’s Guide that’s available on the QTSO website.
The next question is a Drug Regimen Review question. I’ve reviewed all of the X and notice
they were all answered as 0 from admin, maybe admission, a NT which is equivalent to the
number of stays that triggered the QM, 9 was coded. Why l would it trigger if NA? Is this
a non-acceptable answer? The answer is, we believe you’re referring to the SNF QRP Review
and Correct Report for the Drug Regimen Review SNF QRP QM. For the resident’s stay to be
included in the numerator, the total number of Medicare Part A stays in the denominator
must meet each of the two following. It needs to be that the facility has conducted the
Drug Regimen Review on admission, which resulted in one of the three following scenarios. No
potential or actual clinically significant medication errors were found. That would be
indicated by N2001 equals 0. Or potential or actual clinically significant medication
issues were found during the review, and that is N2001 equals 1. And then the physician
or physician-designee was contacted, and prescribed and recommended actions were completed by
midnight of the next calendar day, or, the resident was not taking any medications.
And then the second criteria is that appropriate follow-up occurred each time a potential or
actual clinically significant medication issue was identified during the stay, or there were
no clinically significant medication issues, or the resident was not taking meds. The stay
will not be included in the numerator if the stay does not meet these criteria and the
Review and Correct Report would then include an NT, meaning the individual was not included
in the numerator. The stay will be included in the denominator. So for this measure, do
we want them to trigger for this one? Yes, right. We want triggered on this one.
Then we have, for example, if N2001 is coded 1, yes, issues found during review, and N2002
is coded, no, indicating the provider did not contact the physician or their designee
by midnight the next calendar day and complete the actions, and N2005 is coded no, all identified
potential or actual clinically significant medication issues were not completed by midnight
of the next day, then the stay would not be included in the numerator. Additionally, if
a dash is entered for any of these three data elements, the resident will not be included
in the numerator. So if you put a dash, then that’s counted against you, right. You want
them in that numerator. Residents reviewing resident records with
NT, in other words those not triggered, is encouraged to identify if any of those data
elements were coded with a dash as entering a dash may affect your facilities’ APU. So
I think we hear that message kind of over and over in this, is a dash is not helping
you in an APU. Even though the system will accept it, it’s a problem. The SNF, again
where can you find the training is the next question. And again, that is SNF QRP Training,
and we will, when these questions are posted, certainly include that link.
The next question. If a resident is placed back on skilled care within 30-days after
being discharged from Part A that is not an interrupted stay, will the variable payment
schedule restart? Thank you. Yes, this is a new Part A stay and you’re welcome.
The next question, when will the self-care and mobility change scores show the risk adjusted
score in the review and correct? We expect that the risk-adjusted data will be available
on the Review and Correct Reports and Quality Measure Reports this Fall. The next question,
there is no option for unknown for prior device use if family is unavailable and resident
has dementia and is unable to answer. How should we code this? There are occasionally
times we honestly don’t know what the device is if the resident used prior to their hospital.
If you’re unable to determine that the resident used any devices prior to the current exacerbation,
illness, or injury check none of the above. Next question, on 10/1 when we do our IPAs
will A2400B still be the date Med A began? Yes. Next question. All GG examples in the
RAI are conducted by the nurse. Is there any reason a therapist could not complete this
assessment with an interview and other information from nursing care staff with resident and
family interview? And the answer is CMS anticipates that an interdisciplinary team of qualified
clinicians is involved in assessing the resident during the 3-day assessment period. Assess
the resident’s self-care performance based on direct observation, incorporating resident’s
self reports and reports from qualified clinicians, care staff and family documented in the resident
record during the 3-day assessment. And the next question. You said you can request
up to five errors on the error report on Slide 20 in the Reports program. However on the
slide, on Slide 14 view it looks like you only can select one. To select more than one
error, you press and hold the control and/or shift keys on your keyboard as you click to
select multiple errors on that. And the next question, it’s very frustrating to realize
that the relatively new Provider Threshold Report does not aid in determining our reporting
compliance, which I thought was the point. Please can we get a report that helps us ensure
reporting compliance? So I will tell you that I’ve had this discussion with folks a lot
during this training. So I want you to just kind of think about processes that go around
with the MDS. If you submit — if you received a report from CMS that said on the 31st of
December you were compliant, what can you still do after the 31st of December on many
of your assessments? Change the data. Right. CMS is giving you
this report, the SNF Provider Threshold Report details the status of the measures required
for the APU by the fiscal year. The idea is that you use this report in conjunction with
the other SNF QRP and CASPER reports to identify opportunities to correct assessments with
missing data. It’s important to note that those data elements that are designated as
Standardized Patient Assessments Data Element or SPADEs used to risk-adjust the QMs are
used in the SNF QRP. And these are not included in the Provider Threshold. As such, you guys
as providers need to proactively monitor compliance with submitting all required data elements
through the quality assurance and performance improvement programs.
So think about how you audit data maybe for payment items. My recommendation would be
that you’re auditing these data too. In those SPADE items, all of the data elements that
are used in the SNF QRP are compiled in one nice document on the Technical Information
page on the SNF QRP. You can actually get that whole list and maybe use that to proactively
assess your compliance from a data standpoint. All right. Next question. J2100, can we count
surgery in this scenario? Resident had surgery in prior hospital stay before Part A., was
admitted to a different SNF for 7 days initially. Resident leaves that SNF and goes back to
the hospital for… pneumonia? That’s a new one to me. I’ve been in this a long time.
I’ve never seen that — admits to our facility after a second hospital day. So I think we
thought that “PNA” was another surgery. (Laughter) So I think we’re going to reserve answering
this question. (Laughter) Maybe John will answer it when he comes up. You want to go
ahead? Okay. Let’s go on to the next one. We’ll come back
to this. The Interim PPS Assessment — because of the 5-day assessment, which assessments
are no longer necessary? The 14-day, the 30-day, the 60-day, the 90-day, the OMRA, the start
of therapy, end of therapy, start and end of therapy, and the swing bed clinical change.
But this is not because of the 5-day assessment. These assessments were removed because they’re
no longer needed under PDPM. Next question. What is the web address again for QTSO? It
is https://QTSO.CMS.gov. Next question. We actually only have two minutes
and twenty seconds left. The next question is, is data for SNF QMs always two years old
or only the data used for compliance. The data used in the QM Reports come from assessments
with the target dates from the selected time period. For the CASPER QMs, you can — the
begin date and the end date are prefilled with the most recent six-month prior period
for those measures to be calculated. You may enter alternative dates, if you choose.
For the SNF QRP QM Reports, the default value is the end of the most recent calculated quarter.
Again you can select a different end date from the list. The begin date is a read-only
file that’s going to populate exactly 12 months prior to whatever end date you pick. That
is all the questions that I have. Do you want to take a couple?
»» All right. I think it was like Question 26. Do you want to go back to that one? I
was right, cool. So J2100, can we count surgery in the scenario resident — pardon me — (comment
from the audience) Right. I was going to say. I’m pretty sure I already answered this one.
This is the question from earlier, right? So, yes. We already talked about this one.
No. You’re good. So 52 seconds, 51, other questions? Come on.
»» We have time for about one question. »» Don’t take him the mic though. I’m kidding.
(Laughter) »» All righty. I only have to run you out
for 28 more seconds. »» Hi John. When will the — is there a
timeline for release of the final Grouper information?
»» I want to thank you for that question, that’s an excellent question. 18 — and I
really appreciate you asking that — 15 — no. So we don’t have a date for that. Here’s the
basic story with that. Honestly, this is one of the first questions I thought I would get.
So this is the last question I’ll get, which is good. So here’s the basic story is, we
put out the Beta Grouper. We put out the draft specifications and things like that. And then
we ask for comments on, especially the Beta Grouper. We got a lot of great feedback on
it in terms of things that could have been improved, things that were either an error
or issues that people had. So we took all of that back, our programmers are working
through all of those various comments and trying to put out the final specs. Because
the difficulty is in trying to balance the amount of time we give for feedback from folks
on the beta versus the amount of time that we close those off and then actually begin
work and the final processing on the final Grouper that’s put out. Figuring out where
that balance point is is not always the easiest thing. And quite frankly speaking, I think
the main focus that we have is ensuring that the Grouper that we put out that would be
available for folks to use as of October 1, the free software that we put out there and
the voot and everything else, that that be as accurate as possible. I will say flat out
that that is our absolute primary goal is to ensure that that one that anyone can use
is accurate and that people can use it as of October 1. Obviously, we also are sensitive
to vendors who want to make sure that they can get their software tested and marketed
in time. So trying to balance those is rather difficult. Do we have a date for the final
Grouper? No. I would say we are in the final steps of trying to get it out there. Again,
there’s a lot of clearances and things that need to get done in a lot of these cases.
But we are trying to get it out there as soon as possible because we are trying to be as
sensitive as possible to the vendors in doing their own testing. Not a great answer, I know.
But the best I can do is that we are trying to get it out there as quickly as we can and
as accurately as we can. With that, thank you all very much for your questions. (Applause)

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