The Centers for Medicare and Medicaid Services (CMS) has posted a
second edition of the
COVID-19 Public Reporting Tip Sheet. This resource will help providers understand CMS’ public reporting approach to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) to account for CMS quality data submissions that were either optional or excepted from public reporting due to the COVID-19 public health emergency (PHE). The impact on CMS’ Care Compare website refreshes are also outlined. This eight-page tip sheet serves as a companion document to the
first edition tip sheet published in October 2020.
This tip sheet is directed towards people familiar with the SNF QRP program. CMS offers a 20-30-minute online
Introduction to the SNF QRP course for unfamiliar staff. The course includes how to obtain permissions to submit MDS assessments, access provider preview reports (PPR), Review and Correct (R&C) reports, and SNF QM (quality measures) reports.
Background
The SNF QRP was established under the Improving Medicare Post-Acute Care Transformation Act of 2014, which requires the Secretary to publicly report quality measures (QMs) on a CMS website that relate to the care provided by SNFs across the country. Currently, Care Compare for nursing homes and SNFs report on several quality-of-care measures for the SNF QRP that are derived from the following sources:
- Minimum Data Set (MDS) 3.0/Resident Assessment Instrument.
- Medicare Fee-For-Service claims.
During the COVID-19 public health emergency, CMS established temporary changes to the SNF QRP data submission requirements to assist SNFs while they directed resources toward caring for residents and ensuring the health and safety of residents and staff. SNF QRP MDS data submission for October-December 2020 was deemed optional while CMS temporarily excepted providers from submitting such data from January through June 2020.
The requirement for timely quality data collection and submission resumed on July 1, 2020, with new MDS admission and discharge records occurring on or after that date.
Timely submission and acceptance requirements of MDS data to meet the 80-percent compliance threshold to avoid the two-percentage point (2 percent) reduction in the annual payment update are unchanged. The compliance threshold calculation is based on the number of MDS assessments submitted for use in the calculation of the SNF QRP QMs. To be compliant, at least 80 percent of these assessments must contain complete data (i.e., have all data elements used to calculate the SNF QRP QMs). There are no submission requirements for Medicare claims data outside of the submission of the Medicare bill.
The updated fact sheet also contains helpful tables outlining the quarters SNF QRP MDS assessment data were optional or excepted, the modified performance periods used for public reporting of MDS- and claims-based measures. The public reporting of claims-based measures resumed in January 2022 while the claims-based measure public reporting will resume in July 2022.