A change coming to a key depression screening tool in the Minimum Data Set could affect how skilled nursing facilities assess residents for mood disorders and how they are reimbursed for related care.
Clinicians should remain vigilant for missed diagnoses — and the potential for reduced Medicare payment rates as the switch takes place, industry experts said.
The change is part of an update to the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, version 1.18.11, which will become effective on Oct. 1. At that time, the Patient Health Questionnaire-9 (PHQ-9), a set of nine questions that help clinicians identify signs and symptoms of depression, will transition to the PHQ-2 to 9. This sets a gateway at which residents must affirm high-frequency mood problems in an initial set of two questions before clinicians can proceed to seven remaining questions.
Capturing signs and symptoms
It is on those remaining questions that providers often capture conditions or concerns for which they might be able to earn additional reimbursement. For some, the switch could mean a major hit to daily rates.
The change creates a push-pull effect at a time when the Centers for Medicare & Medicaid Services is encouraging SNFs to accept and treat residents who present with mental and behavioral health needs and substance abuse disorders, said Jessie McGill, RN, RAC-MT, curriculum development specialist at American Association of Post-Acute Care Nurses (APACN).
“When we have residents that have the signs and symptoms of mood disorder and possible depression, we want to be able to put interventions in place and we want to be able to reimburse for additional interventions that those residents need,” McGill said.
That’s where a somewhat contradictory force comes into play, she said.
“We have a really strong initiative from CMS with the federal Center for Excellence for Behavioral Health in Nursing Facilities and they’re providing a lot of information and resources for skilled nursing facilities. At the same time, we’re seeing this change,” she said, adding that this may hinder reimbursements when residents’ signs and symptoms are not severe enough.
The validity of both the PHQ-9, which has been in use since 2010 and the PHQ-2 are well-supported by research, McGill noted, but there is a risk that facility staff may simply stop at the PHQ-2 mood disorder screening, even though there are many reasons a resident with undiagnosed depression may not demonstrate symptoms in response to those two threshold questions, she said.
Undertreatment risks
“I think one of the main concerns I have is that symptoms of depression can be under-recognized and then undertreated if we don’t have strong systems in our facility to recognize those,” McGill said.
The PHQ screenings require direct resident interviews, and in order to lower the risk for missed diagnoses during the transition, McGill recommends that SNF clinicians lean on good interviewing techniques when administering the PHQ-2 questions.
“We need to use all the resources that CMS gives us,” for successful resident interviews, including Appendix D in the Resident Assessment Instrument (RAI) Manual, and CMS’ Video for Interviewing Vulnerable Residents, she said.
Clinicians may also wish to implement more, or other, screening tools that detect depression as needed, she added. They will be able to proceed with staff assessment of mood, for example, in cases where the resident cannot answer the two questions for reasons such as language barrier or noncompliance, she noted.
“There should always be assessment and observation and treatment above and beyond the MDS. And so, not letting the PHQ-2 limit what you can do for possible mood disorder, but really keep that open dialogue and close communication with the primary care physician,” she said.
“There are other avenues that the facility can use to help identify the symptoms, especially if they feel that a resident may have slipped through the cracks with the PHQ-2,” she added.
Impact on reimbursement
The depression questionnaire transition may also impact scoring in the PDPM methodology that determines provider reimbursement, observers added.
The screening tool transition will have “critical payment implications for the Nursing component of the Patient Driven Payment Model (PDPM),” Nelia Sakai Adaci, RNC, BSN, COO of The CHARTS Group in Lakewood, NJ, wrote in a blog post by the AAPACN.
Without completing the full interview in the PHQ-9 or the D0500 (Staff Assessment of Resident Mood (PHQ-9-OV)), “there is no chance to obtain a Total Severity Score that is 10 points or higher,” Sakai Adaci said.
“Without the 10-point Total Severity Score add-on for residents who would have gotten it using the full resident mood interview, that could reduce payment rates an average of $50 to $55 per resident per day for the Clinically Complex, Special Care Low, or Special Care High categories of the Nursing component,” she wrote.
“Even though there’s a lot of research that supports the PHQ-2 as a valid tool, that doesn’t mean we’re not going to see an impact on the reimbursement,” McGill said.
“If the facility is starting to identify that they’re not getting reimbursed for residents in cases where the physician is agreeing with them that there is a mood disorder,” McGill added, “then that’s evidence that CMS may need to revisit how the PHQ-2 to 9 impacts PDPM reimbursements.”
CMS’s SNF MDS 3.0 RAI v1.18.11 Guidance Training Program is available for use as preparation for the Oct. 1 implementation of MDS 3.0 version 1.18.11.
