On August 6, 2024, CMS released the fiscal year (FY) 2025 Final Rule for skilled nursing facility (SNF) providers. Here are some highlights from the document.
SNF Market Basket
The rule finalized a rebasing and revising of the SNF market basket to reflect a 2022 base year. There will be a market basket increase of 3% (prior to the application of the forecast error adjustment and productivity adjustment). The rule also included a forecast error adjustment of 1.7 percentage points, resulting in a SNF market basket percentage increase of 4.7%, which will then be reduced by the productivity adjustment of 0.5 percentage points. This results in the adjusted FY 2025 SNF market basket update that equals 4.2% or approximately $1.4 billion in additional Medicare Part A payments to SNFs. The rule also finalized the update to the wage index used under the SNF prospective payment system (PPS) to reflect data collected during the most recent census.
ICD-10 Codes
The rule included changes to clinical mapping for four ICD-10 codes that previously mapped to Medical Management. These four ICD-10 codes will now map to Return to Provider and will not calculate a Health Insurance Prospective Payment System (HIPPS) code for the Patient-Driven Payment Model (PDPM). Those codes include: E88.10 Metabolic Syndrome, E88.811 Insulin Resistance Syndrome-Type A, E88.818 Other Insulin Resistance, and E88.819 Insulin Resistance, Unspecified.
NTA Component
The rule noted that CMS is exploring proposed changes to the nontherapy ancillaries (NTA) component and the conditions and services impacting the NTA score in the future. The current list of 50 conditions and services could be drastically reduced in the future in CMS rulemaking. It was noted that there are not any changes to the case mix values for any of the PDPM components from the current October 1, 2023 case mix index values.
SNF QRP
There also were updated requirements for the SNF Quality Reporting Program (QRP), including the collection of three new items and one modified item as standardized patient assessment data elements for the Social Determinants of Health (SDOH). These items will all be collected from the Minimum Data Set (MDS) assessments and will be required to be completed for all admission MDS assessments. This will require an MDS assessment update and impact all residents admitted to a SNF on or after October 1, 2025. The data elements will include: living situation, two items for food and one for utilities, as well as a modification to the current transportation item that will be expanded to include the prior 12 months. CMS expects to have education materials available for providers in mid-2025 to allow adequate time for education and preparation.
The rule also included a proposed validation process for the SNF QRP that would consist of a validation contractor who would choose up to 1,500 SNFs annually that would be required to submit medical records to validate SNF QRP measures. CMS is anticipating that the validation contractor will be able to coordinate the SNF QRP and SNF Value-Based Purchasing (VBP) validation processes. The validation process would consist of 10 medical records from each SNF selected. These 10 medical records would be used for both the SNF QRP and SNF VBP validation process. Failure to submit 100% of the requested records would automatically result in the SNF’s annual market basket percentage update being reduced by two percentage points. Per the rule, “The reduction would be applied to the payment update two fiscal years after the fiscal year for which the validation contractor requested records.” There were not any new policies regarding the public display of SNF QRP measure data and procedures for the SNFs to review and correct data and information prior to publication.
SNF VBP
There were updates to the requirements for the SNF VBP program, including adopting a measure selection, retention, and removal policy, a technical measure updates policy, and a measure minimum for FY 2028 and subsequent years. The review and correction policy also will be updated regarding the review and correction policy to accommodate new measure data sources in the future. The SNF VBP currently includes eight measures that cover a range of quality measure topics important for assessing the quality of care by SNF providers. There are not any new measures for FY 2025. Potential next steps for Health Equity in the SNF VBP program were included, but there have currently not been any decisions on how to proceed. Updates to the SNF VBP review and correction process to include applying the existing Phase One review and correction process to SNF VBP Program measures calculated using Payroll-Based Journal (PBJ) staffing data. Phase One corrections are limited to errors made by CMS or its contractors when calculating the measure rates. According to the rule, “For corrections to the underlying PBJ data to be reflected in the SNF VBP Program’s quarterly confidential feedback reports, the SNF must make any corrections to the underlying data within the PBJ system before the ‘snapshot date.’” The “snapshot date” is defined as 45 calendar days after the last day in each fiscal quarter. The current correction policy requires the SNF to identify the error for which it is requesting correction, explain the reason for requesting the correction, and submit documentation or other evidence, if available, supporting the request to the SNF VBP Program Help Desk.
The rule included updates to the instructions for requesting an extraordinary circumstance exception. Beginning with the FY 2025 program year, a SNF may request an extraordinary circumstance exception by sending and email with the subject line “SNF VBP Extraordinary Circumstance Exception Request” to the SNF VBP Program Help Desk that includes specific information about the provider and their circumstances. The full instructions can be found at the SNF VBP website or by emailing SNFVBP@rti.org.
CMPs
Nursing home enforcement issues addressed in the final rule included revisions to CMS’ existing enforcement authority to expand the number of and types of civil monetary penalties (CMPs) that can be imposed on long-term care (LTC) facilities, allowing for more per-instance (PI) CMPs to be imposed in conjunction with per-day (PD) CMPs. This update also expands the authority “to impose multiple PI CMPs when the same type of noncompliance is identified on more than one day.” This finalization also will allow CMS or the states “to impose a CMP for the number of days of previously cited noncompliance since the last three standard surveys for which a CMP has not yet been imposed to ensure that identified noncompliance may be subject to a penalty.” The revision would “allow for both PD and PI CMPs to be imposed for noncompliance findings in the same survey, as well as ensure that the amount of CMP does not depend solely on the date the most recent standard survey is conducted or the date that surveyors identified a finding of noncompliance.”
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