Every spring, the American Association of Post-Acute Care Nursing (AAPACN) anticipates the Skilled Nursing Facility Prospective Payment System (SNF PPS) proposed rule. The Centers for Medicare & Medicaid Services (CMS) provides a 60-day comment period. After a review of the comments, the Final Rule is published in late summer. Historically, AAPACN has impacted policy changes, remapping ICD-10 codes for the Patient-Driven Payment Model (PDPM) and advocating for our 20,000-plus members. This go-round, we advocate policy refinement across several key areas, with a strong emphasis on ICD-10 mapping, ensuring strong discharge plans with health-related social needs, and supporting the retirement of the health equity adjustment (HEA) in the SNF Value-Based Purchasing (VBP) program.
Advocate for a SNF-Specific Wage Index
One of AAPACN’s core concerns lies in CMS’s continued use of hospital inpatient wage data to calculate the SNF wage index. Although CMS justifies this practice by citing the absence of SNF-specific wage data, we challenge that assumption. Since 2016, SNFs have submitted Payroll-Based Journal (PBJ) data that is not only comprehensive but also audited for accuracy by state surveyors and CMS contractors.
AAPACN asserts that this existing PBJ data gives CMS the opportunity to build a wage index that reflects the true labor costs in SNFs. The result could be more equitable and accurate reimbursements, particularly for facilities struggling with rising wages or changes in their wage index. AAPACN encourages CMS to prioritize developing SNF-specific wage data.
Maintain Beneficiary Access: ICD-10 PDPM Mappings
AAPACN supports the intent to refine the PDPM ICD-10 code mappings, especially when certain diagnoses no longer align with skilled care requirements. However, we encourage CMS to ensure these changes do not limit the access by beneficiaries to post-acute extended care in the SNF. Chapter 8 in the Medicare Benefit Policy Manual states that a patient’s diagnosis should never be the sole factor in determining the need for skilled services. AAPACN wants to ensure the remapping would not prevent medically necessary care from being received exclusively based on an appropriately assigned diagnosis code. We recommend that CMS retain certain medical management categories for diagnoses that may directly affect the skilled needs of the resident. Additionally, we continue to advocate for the remapping of muscle weakness to medical management and suggest expansion to the speech language pathology comorbidity ICD-10 codes.
Retain Section R with Revisions
CMS proposes to remove four social determinants of health (SDOH) items related to living situation, food, and utilities. AAPACN asks CMS to retain these items due to the importance of understanding a resident’s health-related social needs and thus ensure a safe discharge back to the community. However, we suggest narrowing the scope of this data collection, from admissions within the last 366 days to the last 101 days. With the average skilled length of stay under 30 days, this change would capture only short-stay residents and align more closely with the 100-day Medicare benefit period. Furthermore, we oppose penalizing facilities for dashing these items. Rather, we advocate using this information in the Discharge to Community care area assessment.
Additionally, AAPACN calls for CMS to reassess the effectiveness of local contact agency follow-ups, citing widespread reports of slow or ineffective support for residents interested in community discharge.
Support More Flexibility: SNF Quality Reporting Program Reconsideration Requests
CMS also proposes to redefine “extenuating circumstances” as “extraordinary circumstances” in the reconsideration request process, a move AAPACN supports. However, the proposed 30-day window to file such requests is viewed as unrealistic during true emergencies. Facility leadership must prioritize resident safety during events that would be considered an extraordinary circumstance. We recommend that CMS adopt a more flexible case-by-case approach to deadline extensions in these scenarios.
Allow for Review Period: SNF Quality Reporting Program Data Submission
CMS is considering shortening the QRP data submission deadline from 4.5 months to 45 days post-quarter. Although not a proposal, CMS posted a request for information (RFI) on this consideration that could be proposed in the future. AAPACN opposes this move, noting that many facilities currently meet the 45-day timeline, but it does not allow for self-review and correction of the data.
We suggest aligning the QRP submission deadline with CMS’s own timeline for Five-Star Quality Rating data pulls, about 80 to 90 days post-quarter. AAPACN also encourages CMS to address not just provider deadlines but also the agency’s timeliness in sharing QRP data back with facilities.
Examine Future Measures: SNF QRP RFI
CMS is requesting feedback on potential new SNF QRP measures, including those tied to interoperability, well-being, nutrition, and delirium. AAPACN presents a cautious but constructive stance:
- Interoperability: SNFs lack the financial and technical infrastructure to lead this charge. CMS should look to states, hospitals, and vendors to drive interoperability.
- Well-being: AAPACN does not believe a standardized question can adequately capture a resident’s overall well-being, noting this is already a requirement of OBRA ’87 and a primary focus on annual health inspections. We also recommend reinstating the full Patient Health Questionnaire (PHQ)-9 mood interview, noting the loss of critical data since CMS moved to the PHQ-2 to 9.
- Nutrition: AAPACN notes that although healthy eating is important, SNFs must navigate diverse needs including cultural and personal preferences, therapeutic diets, and preexisting conditions. We urge CMS not to penalize SNFs for resident health conditions rooted in lifelong dietary habits.
- Delirium: AAPACN recognizes delirium as a serious condition, but we oppose including it as a quality measure, arguing that its rapid onset and external triggers make it difficult to control or meaningfully quantify at the facility level.
Consider the Opportunity to Improve: Health Equity Adjustment
CMS also proposes the removal of the HEA from the SNF VBP program, and AAPACN agrees fully, noting that SNFs are ill-equipped to resolve deeply rooted health disparities late in a person’s life. More importantly, the current HEA methodology—withholding 2% of Medicare payments before redistributing them inequitably—disadvantages SNFs with low-volume Medicare that may care for a majority of Medicaid or dual-eligible residents. AAPACN advocates for more reports and training on SDOH before the data is used in an incentive program.
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