SNF PEPPER Released by CMS: Helps With Internal Medicare Audits (8/13) – TMF Health Quality Institute

 Skilled Nursing Facilities to Receive PEPPER

CMS is making available free provider-specific comparative data reports for SNFs nationwide. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a report that summarizes a SNF’s Medicare claims data in areas that may be at risk for improper Medicare payments. It compares the SNF’s statistics with aggregate national statistics to identify whether it may be at risk for improper Medicare payments. SNFs can use the data to support internal auditing and monitoring activities.

PEPPER is distributed by TMF® Health Quality Institute under contract with CMS. The first release of the SNF PEPPER (version Q4FY12) was completed on August 30, 2013. SNFs administered through short-term acute-care hospitals received their SNF PEPPER electronically. The SNF PEPPER file was uploaded to the File Exchange inbox of hospital QualityNet Administrators and user accounts with the PEPPER recipient role. QualityNet Administrators received download instructions in a separate email.

Free-standing SNFs and SNFs administered through long-term acute-care hospitals and inpatient rehabilitation facilities will receive their PEPPER in hard copy format via USPS first-class mail, shipped on August 30, 2013. The envelope is addressed generically to the Chief Executive Officer/Administrator. SNFs should be on the look-out for this envelope and ensure it is appropriately routed internally.

For more information on the SNF PEPPER, including training and resources for SNFs, the SNF PEPPER User’s Guide, and to access information about My QualityNet accounts and frequently asked questions, please visit

Do you have questions or comments about PEPPER or need help obtaining your report? We have a Help Desk available on or you may provide your feedback through ourfeedback form.

The main PEPPER training and resources webpage for SNFs is

Sept. 11 Free AHRQ Webinar on Building Teamwork in Long-term Care: Register Now AHRQ

TeamSTEPPSR in Long-Term Care: Learn the financial and safety benefits to implementing TeamSTEPPSR in Nursing Homes and LTC Facilities

The Agency for Healthcare Research and Quality (AHRQ) is hosting a free one-hour webinar on September 11 from 1 – 2 p.m. ET highlighting how teamwork improves safety and quality in long term care (LTC) settings. AHRQ’s teamwork training program, TeamSTEPPS®, has been tested in real-world settings and is designed to address:

  • The science of teamwork in LTC settings;
  • The resident safety and financial benefits of TeamSTEPPS in LTC;
  • Practical and proven application of the TeamSTEPPS program in LTC facilities.

Presenters will include:

  • Sharon Kostboth-Harper, Project Manager, Tealwood Senior Living;
  • Erin Howe, DNP, Assistant Professor, University of Rochester School of Nursing;
  • Michelle Pandolfi, MSW, Director of Consulting Services, QUALIDIGM.

Presenters will discuss the following objectives:


1. Learn how the TeamSTEPPS Curriculum has been adapted for the Long-Term Care setting

2. Discuss the financial and patient safety benefits of TeamSTEPPS in Long-Term Care

3. Highlight the importance of implementing TeamSTEPPS in Long-Term Care Facilities and encourage the LTC community to use TeamSTEPPS tools and resources

4. Review steps taken to reach the planning process and development of an implementation plan

5. Share the implementation and outcomes of TeamSTEPPS in a LTC setting


Registration is now open.

To review the TeamSTEPPS Long-term Care Curriculum, go here.

Advancing Excellence Campaign Announces 9 New Quality Goals and Updated Tools

WASHINGTON, D.C. — The Advancing Excellence Campaign has announced its completion of nine new quality goals and toolkits and will feature them in a free, informational webinar on September 10 at 3pm ET. The Campaign’s objective is to engage and challenge nursing homes to provide valuable data as well as make quality improvements. It envisions every nursing home resident in America experiencing person-centered quality of life as a result of a stable and empowered workforce, dedicated to improving clinical and organizational outcomes, and engaging in open communication and transparency.

“We are very excited to announce our nine quality goals and free toolkits,” said Dr. David Gifford, MD, MPH, SVP, Quality & Regulatory Affairs, AHCA and Co-Chair, Advancing Excellence Campaign. “This effort demonstrates the Campaign’s ongoing commitment to make nursing homes better places to live, work, and visit.”

More than 60% of the nation’s nursing homes have joined the Campaign. They participate by committing to work on at least one process and one clinical goal. The Campaign aspires to establish national standards and best practices in line with the new CMS Quality Assurance Performance Improvement requirements.

The Advancing Excellence Campaign is supported by 52 Local Area Networks of Excellence (LANEs). These state-level coalitions promote the Campaign and engage nursing homes in performance improvement. The LANEs disseminate Campaign information and resources and organize statewide projects to improve nursing home performance related to Campaign goals.

The nine new quality goals are:

Process Goals:

  • Improving staff stability;
  • Increasing use of consistent assignment;
  • Increasing person-centered care planning and decision making;
  • Safely reducing hospitalizations;

Clinical Goals

  • Using medications appropriately;
  • Increasing resident mobility;
  • Preventing and managing infections safely;
  • Reducing the prevalence of pressure ulcers; and
  • Decreasing symptoms of pain.

“These nine new quality goals, along with their toolkits, were developed by many of the most esteemed experts in their fields,” commented Cheryl Phillips, MD, SVP, Advocacy, LeadingAge and Co-Chair, Advancing Excellence Campaign. “The unprecedented collaboration behind Advancing Excellence is what makes such impressive, meaningful impact possible.”

Free resources, including implementation tools correlating to each goal, are available at

The Campaign will host a free, informational webinar on September 10, 2013, at 3pm EST. Registration information can be found online.

Keynote speakers will include Advancing Excellence Board members:

Cheryl Phillips, MD, SVP, Advocacy, LeadingAge, Washington, DC
David Gifford, MD, MPH, SVP, Quality & Regulatory Affairs, AHCA, Washington, DC
Mary Jane Koren, MD, VP, Long-Term Care Quality Improvement, The Commonwealth Fund, New York, NY

About Advancing Excellence: The Advancing Excellence in America’s Nursing Homes Campaign is a coalition of long-term care providers, caregivers, medical and quality improvement experts, government agencies and consumers working to make Nursing Homes better places to live, work and visit.

Kaiser Report Examines Financial Accountability of Nursing Homes (7/13)

Kaiser Family Foundation

The Kaiser Commission on Medicaid and the Uninsured has issued the report, Improving the Financial Accountability of Nursing Facilities. This report examines nursing facility expenditures by cost category to assess relative spending increases in areas such as nursing services, administrative costs, and profits.

The report also explores two financial policy options designed to improve nursing facility financial accountability and care quality: (1) reimbursement by cost category and (2) a standard medical loss ratio (MLR) option.

Access the report here.

Access a related fact sheet, Overview of Nursing Facility Capacity, Financing, and Ownership in the United States in 2011here.


The Centers for Medicare & Medicaid Services (CMS) recently released a revised version of the MDS 3.0 Resident Assessment Instrument (RAI) User’s Manual.

The changes were mostly clarifications and include:

Chapter 2

  • ADDED: If a resident goes from Medicare Advantage to Medicare Part A, the Medicare PPS schedule must start over with a 5-day PPS assessment as the resident is now beginning a Medicare Part A stay.  The 1st day of Medicare A becomes day 1 for the SNF PPS assessment. (Pg. 2-45)

Chapter 3

  • Hyperlinks updated
  • Coding Conventions:

REVISED: There are four date items (A2400C, O0400A6, O0400B6, and O0400C6) that use a dash-filled value to indicate that the event has not yet occurred. For example, if there is an ongoing Medicare stay, then the end date for that Medicare stay (A2400C) has not occurred, therefore, this item would be dash-filled. (Pg. 3-4)

  • C0100 Should the BIMS be conducted? Coding Tips:

NEW: Includes residents who use American Sign Language (ASL).           (Pg. C-2)

  • M0210 Unhealed Pressure Ulcers, Planning for Care:

REVISED: Pressure ulcer staging is an assessment system that provides a description and classification based on of anatomic depth of soft the extent of visible tissue damage. This tissue damage can be visible or palpable in the ulcer bed. Pressure ulcer staging and also informs expectations for healing times. (Pg. M-4)

  • M0210 Unhealed Pressure Ulcers, Coding Tips:

NEW:  Oral Mucosal ulcers caused by pressure should not be coded in Section M.  These ulcers are captured in item L0200C, Abnormal mouth tissue. Mucosal ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made.           (Pg. M-5).

REVISED: If a pressure ulcer is surgically closed (replaces “repaired”)  (Pg. M-5).

  • M0300D Stage 4 Pressure Ulcers Coding Tips:

NEW: Cartilage serves the same anatomical function as bone.  Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage 4. (Pg. M-15)

  • M0800 Worsening in Pressure Ulcer Status Since Prior Assessment Coding Tips:

NOTE: Term ‘numerical staging’ is substituted for worsened, current, and was, as appropriate. (Pg. M-26)

  • M1040HMoisture associated skin damage MASD:

REVISEDMoisture associated skin damage (MASD) is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. It is characterized by inflammation of the skin, and occurs with or without skin erosion and/or infection. MASD is also referred to as incontinence-associated dermatitis and can cause other conditions such as intertriginous dermatitis, peri-wound moisture-associated dermatitis, and peri-stomal moisture-associated dermatitis. Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown. (pg. M-35)

  • O0100M

Hyperlinks updated (Pg. O-5)

Chapter 5

 5.7 Correcting Errors in MDS Records That Have Been Accepted Into the QIES ASAP System.

  • Modification Request

REVISED: Effective May 19, a modification may now be used for typographical errors in the following items:

      • A0310: Type of Assessment; where there is no Item Set Code (ISC) change.
      • A1600: Entry Date
      • A2000: Discharge Date
      • A2300: Assessment Reference Date (ARD)
      • Clinical Items (B0100–V0200C)

NOTE: The ARD (Item A2300) can be modified when the ARD on the assessment represents a data entry/typographical error. However, the ARD cannot be altered if it results in a change in the look back period and alters the actual assessment timeframe.

An inactivation request is still required for errors in the following items:

      • A0200: Type of Provider
      • A0310: Type of Assessment; where there is an ISC change.

(Pg.5-10 &5-11)

Click here to access the updated manual.



CMS issues more in-depth survey guidelines to reduce readmissions; invites comments on assistant reporting

CMS issues final rule on Medicaid payments for preventable injuries and illness

The Centers for Medicare & Medicaid Services has revised the provider certification manual for hospitals, giving more in-depth guidelines around discharge planning. The goal is for hospitals to reduce readmissions by partnering with post-acute providers.

The update was made to the State Operations Manual, Hospital Appendix A.

Discharge planning evaluations should assess whether a patient’s post-discharge needs can be met in his or her next environment, such as a skilled nursing facility, the revision states. The evaluation also should consider whether the patient’s insurance would cover needed services in the next care setting. A discharge plan based on the evaluation must be developed and placed in the patient’s medical record in a timely fashion, the guidelines say.

The hospital is responsible for initial implementation of this discharge plan, including arranging the transfer, and providing information to the patient about the goal of treatment in the next setting. The revised guidelines also include new information about the requirement to give patients with skilled nursing needs a list of potential SNFs. Hospitals must disclose certain financial interests in these nursing homes.

The guidelines include a bulleted list of medical information that the hospital must give to the next care provider, such as a copy of the patient’s advanced directive, if there is one.

Blue boxes in the revised manual contain suggested best practices for discharge planning. Surveyors are not to cite hospitals for failing to adopt these practices. One suggestion is for hospitals to obtain input from SNFs and other post-acute providers when developing discharge planning policies and procedures. Click here to see the revisions to the manual and a related CMS memorandum.

In a separate action, CMS invited comments from nursing homes about feeding assistant reporting requirements. Providers have until June 17 to submit feedback about the requirement to keep a record of all paid feeding assistants. Click here for further information.

Updates on the Therapy Limitation and Manual Medical Review Process for Therapy Threshold

Posted 05/16/2013

This article will serve to notify providers of an update to the Manual Medical Review Process for claims impacted by the 2013 Therapy Threshold.

Effective with claims submitted on 4/1/13 and later are subject to subject to the Manual Medical Review Process will be reviewed by the Recovery Auditor (RA) Contractor. Supporting medical documentation must be submitted to the RA at the address indicated on the request. RAs will complete two types of review:

  • Prepayment Review – Claims submitted in the RA Prepayment Review Demonstration states will be reviewed on a prepayment basis (National Government Services states of Illinois and New York). A request will be generated from National Government Services for the supporting documentation once a claim for payment is submitted. Instructions regarding submission of that documentation will be included on the request indicating submission should be to the appropriate RA.
  • Post payment Review – In the remaining states National Government Services will issue payment on impacted claims. The appropriate RA will then issue a request for the supporting documentation on paid claims to complete the review post payment. Documents should be submitted to the RA.

As a reminder, medical documentation must be forwarded to the appropriate RA and not to National Government Services. Supplying documentation to National Government Services may result in a delay of a determination on your claim.

Please visit our Web site under Review Process > Medical Review to review the complete information related to the Manual Medical Review Process for Therapy Threshold for 2013.


FY2014 SNF PPS Proposed Rule: Draft Posted for Public Comment (5/13) CMS

SUMMARY: This proposed rule would update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2014, would revise and rebase the SNF market basket, and would make certain technical and conforming revisions in the regulations text. This proposed rule also includes a proposed policy for reporting the SNF market basket forecast error correction in certain limited circumstances and a proposed new item for the Minimum Data Set (MDS), Version 3.0.

DATES: To be assured consideration, comments must be received no later than 5 p.m. on July 1, 2013.

SNF PPS 2014 Draft Rule Proposes to:

  1. Add item O0420 to the MDS Item Set, “Distinct Calendar Days of Therapy”. Effective October 1, 2013, facilities would be required to record under this item the number of distinct calendar days of therapy provided by all the rehabilitation disciplines over the 7- day look-back period for the current assessment, which would be used to classify the resident into the correct Rehabilitation RUG category based on the requirements for number of days of therapy.
  2. Revise and rebase the market basket total cost data from 2004 to data reflective of FY 2010 based SNF market basket index for routine, ancillary, and capital-related expenses.
  3. Increase rates by 1.4 % including the multifactor productivity and the SNF market basket update.
  4. Discusses presumption of coverage for residents admitted directly from the hospital and who qualify for one of the upper 52 RUG levels provided that the services are also reasonable and necessary.
  5. Specifically invites public comments identifying HCPCS codes in any of these four service categories (chemotherapy items, chemotherapy administration services, radioisotope services, and customized prosthetic devices) representing recent medical advances that might meet the criteria for exclusion from SNF consolidated billing.
  6. Currently, the therapy payment rate component of the SNF PPS is based solely on the amount of therapy provided to a patient during the 7-day look-back period, regardless of the specific patient characteristics. The amount of therapy a patient receives is used to classify the resident into a RUG category, which then determines the per diem payment for that resident. CMS has contracted with Acumen, LLC and the Brookings Institution to identify potential alternatives to the existing methodology used to pay for therapy services received under the SNF PPS.

Here is the link for the full text of the proposed rule and instructions on where to submit comments:

MDS 3.0 Quality Measures (QM) User’s Manual v7.0 (4/13)

CMS has released version 7.0 of the QM User’s Manual, as well as an updated version 1.2 Quality Measure Identification Number by CMS Reporting Module table, which documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM.

The version 7.0 manual includes the following:
Chapter 1, QM Sample and Record Selection Methodology, includes information about definitions, selecting QM samples, short-stay record definitions, and long-stay record definitions.

Chapter 2, MDS 3.0 Quality Measures Logical Specifications, breaks down the definitions, including numerators, denominators, and potential exclusions, for the publicly reported short-stay QMs and long-stay QMs

Appendix A, Technical Details

Appendix B, Parameters Used for Each Quarter

Appendix C, Episode and Stay Determination

Appendix D, Measures Withdrawn from NQF Submission

Appendix E, Surveyor Quality Measures, defines the survey-only QMs that are not publicly reported.

Appendix F, Specifications for the Facility Characteristics Report

Download the manual and ID table below