A:The Patient Health Questionnaire-9, or PHQ-2 to 9, is a widely used screening tool for depression, and in the context of nursing homes and PDPM it takes on even greater importance. This nine-question self-report tool screens for symptoms of depression in residents and provides a standardized severity score and a rating for evidence of a depressive disorder. 

The interview covers various aspects of depression, including mood fluctuations, sleep patterns, and appetite changes, among others. Completing the PHQ-2 to 9 effectively is crucial for accurate assessment and quality care under PDPM.

PDPM categorizes residents into payment groups. Clinical assessments, including the PHQ-2 to 9, can influence the placement of residents into the proper category. Accurate assessment is crucial to ensure residents receive the care they need, and that you are appropriately reimbursed for it.

Staff who are conducting interviews should follow guidance in Appendix D of the RAI, Interviewing to Increase Resident Voice in MDS Assessments. This guidance should be reviewed routinely, along with Steps for Assessment for conducting the PHQ-2 to 9. Interview techniques to include “disentangling” and “unfolding” will be important as indicators of moderate to severe depression (total severity score = ≥10). If identified through the PHQ-2 to 9, that can increase daily reimbursement by approximately $40 per PPS day to support the services that residents experiencing moderate to severe depression require.

Effectively addressing depression also can enhance your facility’s “Percentage of Residents Who Have Depression Symptoms” quality measure. This measure utilizes two questions from the PHQ-2 to 9 and considers the total severity score.

A: When there is an overpayment of $25 or more, the MAC will initiate the overpayment recovery process with a letter.

The demand letter should outline key information including the specifics of the overpayment, as well as the recoupment process. The current interest rate is 11.5% and will be applied to unpaid overpayment balances beginning on day 31 from the date of the demand letter.

The letter will discuss rebuttal rights and administrative appeal rights, and possibly instruct the state agency to withhold the federal share of any Medicaid payments until the full amount is recouped. Submitting a rebuttal does not stop recoupment activities. But submitting an appeal by day 30 from the date of the demand letter will stop the recoupment process. 

Even so, interest continues to accrue. If a redetermination appeal is received after day 30, but before day 120, the MAC is required to stop recoupment when it receives and validates your appeal. In this case, the MAC will not refund money already recouped, but will not continue recoupment until the redetermination process is adjudicated. 

Following an unfavorable or partially favorable redetermination decision, a reconsideration appeal may be filed with the Qualified Independent Contractor (QIC) within 60 days from the redetermination decision letter date to stop the recoupment process. After the QIC’s initial decision or dismissal, the recoupment process will resume for any overpayment amount not previously paid in full, regardless of whether the provider submits appeals at further appeal levels.

A: Failure to meet the requirements of the Skilled Nursing Facility Quality Reporting Program will result in a 2 percentage point reduction in the Annual Payment Update (APU). This can happen when the provider does not achieve an 80% threshold on the MDS reporting requirement. 

Essentially, no less than 80% of the MDS assessments for a given data submission period must have 100% completion of the required SNF QRP standardized data elements. 

To your point, a non-compliance letter will let you know that the threshold has not been met but does not describe the specific MDS data elements that were not submitted or “dashed.”  The data elements used for reporting assessment-based Quality Measures affecting FY 2024 APU determination include Section GG discharge goal, bowel continence, certain diagnoses, height, weight, falls with major injury, pressure ulcers/injuries and drug regimen review. 

Keep an eye on your SNF QRP QM reports. These are refreshed monthly and include facility-level and resident-level information for a single reporting period. Providers also have access to the SNF QRP Review and Correct report prior to each quarterly data submission deadline and the provided data should be reviewed for accuracy. Keep in mind that “triggering” for some measures is desirable while “triggering” for others is not. Erroneous records can be corrected as long as the deadline for corrections has not passed. 

Identifying which data elements are incomplete is necessary to review processes and avoid future situations where data may not be submitted. 

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.

A:There are no changes to the Patient Driven Payment Model calculations planned for Oct. 1. But updates to some data elements and your facility processes could theoretically impact reimbursement. 

Currently, the Patient Health Questionnaire (PHQ-9) or Resident Mood Interview in Section D of the MDS can contribute to increased reimbursement under the Nursing Component of PDPM if the total severity score for the interview equals 10 or greater. This depression “end-split” affects the Nursing Case-Mix Groups of Special Care High, Special Care Low, and Clinically Complex. The total severity score is the sum of the frequency responses for symptoms present. 

As of Oct. 1, the PHQ-9 will be revised to the PHQ-2 to 9. This will allow the mood interview to be stopped after the first two questions, depending on the resident’s responses. The positive here is that this may shorten the time the appointed staff member spends completing the Resident Mood Interviews. The question that remains is whether this shortened interview may lead to fewer residents with a total severity score of 10 or greater, and thus a dip in reimbursement. 

For example, one may not be bothered by “little interest or pleasure in doing things,” or “feeling down, depressed, or hopeless,” — the two questions posed in the PHQ-2. But, if one was bothered by “feeling tired or having little energy,” or “poor appetite or overeating,” these questions will not be asked if the interview is concluded early. 

Also, with the removal of Section G from federally required assessments, Section GG will stand as the assessment of functional abilities, and facilities should refocus efforts on GG assessment practices. 

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.

A: Insufficient Documentation is a broad error category that can include many different issues. The most prevalent is missing documentation to support Case Mix Group (CMG) components. 

Briefly, this means that something impacting reimbursement was reported on the MDS, but documentation was not present (or not provided) to validate the condition, care or service. Remember that MDS coding is often complicated and must adhere to the RAI coding requirements. 

Other examples of insufficient documentation include inadequate or missing orders, missing signature logs, missing therapy plans of care, and inadequate or missing physician certification/recertifications — a low-hanging fruit that can lead to quick denials. 

This emphasizes the importance of ardent claim review or “triple-check” processes for providers. Careful attention should be paid to ensuring the CMGs for each HIPPS code are clearly supported in the patient record. Additionally, ensure physician certification/recertification requirements are met. 

In an attempt to lower the SNF improper payment rate, CMS recently implemented the SNF 5-Claim Probe and Educate Review. If the Medicare Administrative Contractor identifies an improper payment, it will adjust payment, as appropriate, in addition to providing education. 

If you feel your review process is robust and your claims are clean, consider the effectiveness of your ADR response.  Organize documentation to facilitate ease of review by the contractor and allow sufficient time for staff with clinical and MDS coding expertise to review the claim and related documentation for accuracy before submission. 

Eleisha Wilkes, RN, is a clinical consultant with Proactive Medical Review. Send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.

A: A knowledgeable and organized LPN can be a valuable addition to your MDS department and fulfill many of the position’s responsibilities. But there are some requirements that only an RN can meet.

Federal regulations at §483.20(h)-(i) tell us that a registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals and sign and certify that the assessment is completed.

Nursing homes are left to determine who should participate in the assessment process, how the assessment process is completed, and how the assessment information is documented, while remaining in compliance with regulations and the instructions in the RAI manual. 

“Appropriate participation of health professionals” can involve multiple interdisciplinary team members, not limited to a social services designee, dietician, activity director, and, you guessed it,
LPNs/LVNs. 

Many facilities have successfully employed LPNs in lead MDS positions. In these cases, it’s up to the facility to determine how the RN will coordinate and complete the process. 

If you are lucky enough to have more than one nurse in the MDS department, only one needs to be an RN who will sign all MDS assessments as they are completed. Other facilities rely on varying RN nurse managers to meet this requirement, such as the director of nursing, assistant director of nursing, etc. 

Do make sure that this requirement is taken seriously. Civil monetary penalties will be imposed if anyone other than an RN signs the MDS as completed at Z0500. 

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com

A: Currently, the SNF VBP program only uses the SNF 30-day all-cause readmission measure. The measure includes Medicare Part A beneficiaries who are admitted to directly from the hospital and have an unplanned readmission to the hospital within 30 days of the prior hospital discharge. 

What is sometimes overlooked are the residents who discharge after a short stay, back to the community for example, and are subsequently readmitted to the hospital from home. If the readmission occurs with 30 days, it is included in the calculation. This means you need to monitor hospitalizations during the SNF stay and also focus on safe discharge planning and post-discharge follow-up practices. 

The Centers for Medicare & Medicaid Services provides confidential feedback reports to your SNF through the CASPER reporting system, and there is a review and correction process that allows for correction requests to be accepted. 

Two percent of each SNF’s Medicare Part A payment is withheld to fund the VBP program. Some 60% of that amount is then redistributed to SNFs in incentive payments. The measure will be reinstated after a COVID-era suppression, and the following measures are soon being added to make the SNF VBP more robust (with proposals at top left coming later):

• Healthcare-Acquired Infections Requiring Hospitalization (FY 2026)
• Total Nursing Hours per Resident Day (FY 2026)
• Baseline period FY 2022; performance period FY 2024
• Discharge to Community (FY 2027)
• Baseline period FY 2021-2022; performance period FY 2024-2025

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.

A: Not exactly, but the Centers for Medicare & Medicaid Services may be taking a sooner-rather-than-later approach.

While not yet finalized, CMS issued a proposed rule in December 2022 that would, in part, amend existing regulations for Medicare Parts A, B, C and D regarding the standard for an “identified overpayment” and remove the “reasonable diligence” standard. As it stands, providers have a reasonable diligence period to investigate and quantify any Medicare overpayments that might have been received within a 6-year lookback period. Without this, providers may have much less time to quantify and refund a Medicare overpayment. 

How much time, exactly? That remains to be seen. Existing law requires providers to report and return the overpayment by the later of: (1) the date which is 60 days after the date on which overpayment was identified; or (2) the date any corresponding cost report is due, if applicable.

CMS proposes to replace “reasonable diligence” with language that gives the terms “knowing” and “knowingly” the same meaning given those terms in the False Claims Act if a supplier has identified an overpayment if it has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment. Obviously, it will be challenging to determine or “identify” the extent of potential overpayments within the 60-day period and without clarification on what “identified” means in this regard. 

Your compliance program and self-monitoring efforts will be as important as ever to avoid overpayment scenarios before they happen. CMS does not have a basis for estimating the impact associated with this amendment. When finalized, provisions will take effect beginning Jan. 1, 2024.

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.

A: Except for items using a dash-filled value to indicate an event has not yet occurred, i.e. the Medicare stay end date, a dash shows an item was not assessed. 

Almost all MDS 3.0 items allow a dash (—) value to be entered, and this most often occurs when a resident is discharged before the item could be assessed. Even though there will be times when dashes are unavoidable, the Centers for Medicare & Medicaid Services expects the use of dashes to be rare.

You and other members of your interdisciplinary team should always strive to thoroughly assess all residents to ensure an accurate assessment. Dashing MDS items can lead to ineffective care planning and financial repercussions. 

Resident interviews in MDS sections C and D are a great example. These interviews must be conducted during the assessment reference period. If they aren’t, the interviews must be dashed. Had the interviews been conducted and reported according to RAI requirements, PDPM reimbursement for a Medicare beneficiary could have been increased if the resident exhibited cognitive impairment and/or indicators of depression. 

Additionally, be wary of unnecessarily dashing items used for SNF QRP data, including items in Section GG. Not only can a lack of information in this section lead to PDPM reimbursement concerns, but trends in dash use also can negatively affect the Annual Payment Update. For a given data submission period, submitted MDS assessments must meet the APU minimum data completion threshold of no less than 80% of MDS assessments having 100% completion of the required SNF QRP data elements. 

A: Perhaps. The Informal Dispute Resolution (IDR) process gives nursing homes one informal opportunity to dispute cited deficiencies after any survey of Federal requirements for participation. 

Facilities also have the opportunity to request and participate in an Independent IDR if CMS imposes civil money penalties (CMPs) against the facility and these penalties are subject to being collected and placed in an escrow account pending a final administrative decision.

With either of these processes, you must understand the Federal Requirements outlined in 42 C.F.R. §488.331 and 488.431 to make sure that you adhere to the directives and understand when you can and cannot dispute cited deficiencies.

For example, for the IDR process, the request must be submitted in writing within the same 10-day window that would be used for a plan of correction, along with a specific explanation of what’s being disputed. 

Facilities may not use the IDR process to challenge any other aspect of the survey process, such as scope and severity assessments of deficiencies, with a few exceptions: perceived inconsistencies of the survey team; or alleged shortcomings of the IDR process itself. 

Regarding the IIDR process, you must request an Independent IDR within 10 calendar days of receipt of the offer and should submit the request in writing to the proper agency or entity, as appropriate.

Your request also should include copies of any documents such as facility policies and procedures, resident medical record information that is redacted for confidentiality, and other information useful in disputing the survey findings.