FY 2021 SNF Final Rule Clinical Highlights

Thoughtware Alert Published: Aug 04, 2020
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The 2021 skilled nursing facility (SNF) prospective payment system (PPS) final rule was released July 31, 2020. There were some updates to the Patient-Driven Payment Model (PDPM) but no changes related to the current COVID-19 pandemic. CMS did extend its appreciation of the numerous comments and suggestions for revisions to current policies under the SNF PPS, but it noted the pandemic wouldn’t be addressed in the final rule but may be taken into consideration in the future. There were no changes to the current consolidated billing exclusions.

Although the SNF final rule doesn’t have any effect on the public health emergency (PHE) or the current waivers, it’s important to note the three-day stay and spell of illness waivers are in effect until at least October 26, 2020. As that date draws closer, there will be a decision regarding whether to extend the PHE for an additional 90 days. CMS acknowledged the suggestions for revised policies for SNF PPS related to COVID-19 and will take them into consideration even though they’re not addressed in this final rule. Some issues not addressed in the final rule include isolation of COVID-19 patients, potential nontherapy ancillary (NTA) or billing add-on for COVID-19-positive patients, and making the current telemedicine waivers permanent. We’ll provide additional information as it’s released moving forward.

The PDPM updates were additions and deletions of ICD-10 codes used to map the primary reason for skilled care to the appropriate PDPM clinical category. The current ICD-10 clinical category mapping doesn’t provide an option of a major surgical procedure in the prior inpatient stay for numerous cancer diagnoses. CMS has added surgical clinical category options of “May be Eligible for the Non-Orthopedic Surgery Category” and “May be Eligible for One of the Two Orthopedic Surgery Categories” to the clinical mapping of several cancer diagnoses when a major surgical procedure is identified in section J of the Minimum Data Set (MDS). Those diagnosis codes include C15.3 through C26.9, C33 through C39.9, C40.01 through C41.9 (including C410), and C46.3 through C46.9. There also were updates to these diagnosis groups since these conditions sometimes require a major surgical procedure: D37.09 through D39.9, D3A.00 through D3A.8, D40.0, D40.11 through D44.9, D48.3 through D48.4, D48.61 through D48.7, and D49.0 through D49.7.  

Glucose-6-phosphate dehydrogenase deficiency without anemia (ICD-10 code D75.A) currently maps to the clinical category of “Cardiovascular and Coagulations.” Effective October 1, 2020, this condition will map to the clinical category of “Medical Management.”  

Currently, specific fracture codes map to the surgical default category of “Orthopedic Surgery” or “Major Joint Replacement and Spinal Surgery” without a major surgical procedure. CMS is changing the clinical category to “Non-Surgical Orthopedic” with a major surgical procedure option “May be Eligible for One of the Two Orthopedic Surgery Categories” for these ICD-10 codes: S32.031D, S32.19XD, S82.001D, and S82.002D through S82.002J. The following codes will map to “Return to Provider”: S82.009A, S82.013A, S82.016A, S82.023A, S82.026A, S82.033A, S82.036A, and S82.099A. Currently, ICD-10 codes M48.00 through M48.08 for spinal stenosis don’t allow for a major surgical procedure option. Effective October 1, 2020, there will be an added surgical option for these conditions. Currently, Z48 surgical aftercare codes map to “Return to Provider” or “Medical Management” even if a major surgical procedure was captured in section J of the MDS. Although Z48 codes are unspecific, CMS acknowledges that aftercare of some major nonorthopedic surgeries is best described using Z48 codes with that acknowledgment there will be an added surgical option to the following aftercare codes: Z48.21 through Z48.24, Z48.280, Z48.288, Z48.298, Z48.811 through Z48.813, Z48.815, and Z48.816. CMS indicated that these changes will allow for a more accurate clinical category assignment.

Stakeholders requested CMS to address the NTA component as it relates to ICD-10 codes T82.310A through T85.89XA. These initial encounter codes map to the NTA comorbidity of “Complications of Specified Implanted Device or Graft.” The request from stakeholders was to also include those ICD-10 codes with a seventh digit of D (subsequent encounter) or S (sequela) for subsequent care. CMS has added the subsequent encounter for use in the ICD-10 code mappings to this comorbidity. The sequela wasn’t added.

Updates to the SNF Value-Based Purchasing Program (SNF VBP Program) reveal the majority of the elements remain constant. The unchanged elements include use of the SNF 30-Day All-Cause Readmission Measure, scoring policies, payment policies, the review process, the incentive payment multipliers, and performance benchmarks. CMS updated the definitions of “Performance Standard” and “SNF Readmission Measure” and included a data suppression policy for low-volume SNFs, as well as allowed for reporting on a successor website to Nursing Home Compare. The final updates to the SNF VBP Program include finalizing the 2023 benchmarks and allowing a 30-day phase one review and correction deadline for the baseline period quality measure report. This updates the current process, which allows only a 30-day review and correction period for the performance report.

There weren’t any updates in the final rule related to the SNF Quality Reporting Program.

In regard to the recently published SNF final rule, we recommend providers watch for an updated clinical category and NTA mapping tool from CMS that includes the ICD-10 updates noted above. We also recommend touching base with your software vendor to ensure they’re aware of the changes.

For more information, reach out to your BKD Trusted Advisor™ or use the Contact Us form below.

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