Reimbursement

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Aug 01 2026
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Beyond the Dashboard: Using iQIES to Drive Quality and Compliance in SNFs

The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program is a Centers for Medicare & Medicaid Services (CMS) program that awards incentive payments to skilled nursing facilities (SNFs) to encourage SNFs to improve the quality of care they provide to patients. CMS distributes four reports for this program each year: a Historical Results Workbook, two Full-Period Workbooks (one each for the baseline period and performance period), and a Performance Score Report. On July...
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Jul 01 2026
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From Quality to Financial Performance: How QMs Influence SNF VBP and Five-Star Ratings

Overview of The SNF VBP Program  The Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) is a Medicare pay-for-performance program that is intended to encourage SNFs to improve the quality of care they provide to their residents. All SNFs paid under Medicare Prospective Payment System (PPS) are included in SNF VBP program – enrollment is not optional, and data used for the SNF VBP quality measure (QM) calculations comes primarily from Medicare SNF Fee-For-Service (FFS) Part A...
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Nov 01 2025
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The Latest in the Lineup: The Skilled Nursing Facility Validation Program

The Centers for Medicare and Medicaid (CMS) audits of skilled nursing facility (SNF) Minimum Data Set (MDS) data are nothing new. The MDS 3.0 was implemented in 2010, and in 2014 CMS piloted MDS Focused Surveys in 5 states. The results of the pilot study prompted full implementation of MDS Focused Surveys nationwide, and these surveys continued through Fiscal Year (FY) 2017. Since then, CMS has instituted a different approach to reviewing MDS accuracy, and SNFs are now subject to a variety of...
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Aug 01 2025
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Medicaid PDPM Is Coming: What Skilled Nursing Facilities Need to Know

Beginning October 1, 2025, many nursing homes will adopt a new reimbursement model for Medicaid residents: the Patient-Driven Payment Model, or Medicaid PDPM. While PDPM has been in place for Medicare since 2019, this is the first time it’s being rolled out more widely for Medicaid across multiple states. Several states have already transitioned to Medicaid PDPM, with others will follow on October 1, 2025. As this model gains traction nationwide, facilities need to understand what’s changing...
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Maximizing-Case-Mix-Index-in-Respiratory-Therapy
Oct 01 2024

Maximizing Case Mix with Special Programs: Respiratory Therapy and Restorative Nursing

Case mix is essential in skilled nursing facilities as it impacts both reimbursement and the care provided. Two key programs that significantly impact case mix scores when properly implemented and documented are Respiratory Therapy and Restorative Nursing. Both programs offer substantial benefits to residents and facilities alike by ensuring accurate reimbursement and enhancing resident outcomes.    Respiratory Therapy Programs Respiratory therapy is vital for residents with respiratory...
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Strategic-Admissions
Sep 01 2024

Strategic Admissions: The Path to Optimized Medicaid Reimbursement

Medicaid reimbursement plays a significant role in the financial health of long-term care facilities, particularly those serving a high percentage of Medicaid residents. While it may not be the sole source of revenue, it is an important component that supports the sustainability of facilities and ensures they can continue providing care to residents who rely on Medicaid coverage.   Optimizing Reimbursement By focusing on three key areas – insurance verification, optimizing the Case Mix...
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Interim-Payment-Assessment
Jun 01 2024
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Interim Payment Assessment (IPA) – To do or not to do?

The Patient-Driven Payment Model took effect in October of 2019. Along with this change came the optional IPA. We are now five years into this change and questions still arise on when to complete an IPA. The decision of when to complete lies with the team at the facility. This team is not prescribed but identified by facility. The key question: does the 5-day PPS MDS completed on admission capture the current clinical picture being reimbursed (PDPM classification) or is an updated assessment...
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Resident-Interviews-Capturing-the-Data
May 01 2024
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Resident Interviews – What are you doing to capture the data?

Effective October 1, 2023, several resident interviews were added to or updated on the MDS. Interview items in Section A and changes to the interviews in Section D, J, and Q have been implemented. Each of the interviews can be a great steppingstone in your path to creating a plan of care that puts each resident’s needs and preferences in focus and allows staff to support individual resident goals. Interviews in Sections C and D can affect PDPM scores and increase reimbursement based on...
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Social-Determinants-of Health-A-Global-Initiative
Mar 01 2024
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Social Determinants of Health (SDOH) – A Global Initiative Important to Skilled Nursing Providers

The Centers for Medicare & Medicaid Services’ (CMS) Office of Mental Health report CMS Framework for Health Equity 2022 and 2032 states that health equity is defined by the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and...
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PDPM-Or -OSA-A-State-Level-Decision
Nov 01 2023
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OSA or PDPM? A State-Level Decision

As of Oct. 1, 2023, the Centers for Medicare & Medicaid Services (CMS) has retired the A0300 Optional State Assessment (OSA) from the federally required MDS 3.0 v1.18.11 that is submitted by nursing facilities. The OSA is now a separate optional MDS assessment that may be completed at the discretion of each state’s government. The OSA is used by State Medicaid Agencies to calculate a case-mix score. States have the option to utilize the OSA for the collection of RUGS data pertinent to the...
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Achieving Accurate ADLs With The OSA
Oct 01 2023
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Achieving Accurate ADLs with the OSA

Section G of the MDS 3.0 was retired October 1, 2023, yet the MDS nurse may still need to use the knowledge of accurately coding ADLs with an assessment called the Optional State Assessment (OSA).  State-Optioned OSA Although the option to choose an OSA from the federally-mandated MDS assessment was similarly retired in October, some states have opted to require SNFs complete an OSA for Medicaid reimbursement. The OSA is now a separate optional MDS assessment that is completed at the...
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Sep 07 2022
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MDS Changes Raise Medicaid Payment Questions

Tim Mullaney | September 7, 2022 | Excerpted from Skilled Nursing News The removal of a key section from the Minimum Data Set (MDS) will have massive repercussions, particularly for the future of nursing home reimbursements by states. ... The fate of Section G has been in question since the transition to the Patient-Driven Payment Model (PDPM), which made the section unnecessary from a Medicare reimbursement perspective. State-level Medicaid payments are another matter. Section G is used to...
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Jan 04 2022
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COVID-19 Effects on Dementia

Known Impact of COVID-19 on Dementia Patients As we start to shift our attention to the long term effects that this pandemic has had on our residents, a key area of focus is dementia outcomes.  Early on, many quick decisions were made to protect one of our most vulnerable patient populations. Recent studies have found that residents with dementia who contract COVID-19 have a higher risk of behaviors, depression, anxiety, impaired sleep, and worsening cognition long after the infection has...
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Sep 06 2021
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Prepare Your Team for FY2022

The Updated SNF PPS Final Rule Skilled nursing facilities should be preparing now for these upcoming changes. This On August 4th CMS rule refresh: Updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for the fiscal year 2022 Updates the diagnosis code mappings used under the Patient-Driven Payment Model (PDPM) Implements a recently-enacted SNF consolidated billing exclusion, and Includes a discussion of a PDPM parity adjustment that...
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Jun 14 2021

Is the Value Based Purchasing Program Changing?

The Centers for Medicare & Medicaid Services (CMS) issued its fiscal year (FY) 2022 proposed rule for the skilled nursing facility (SNF) prospective payment system (PPS) in April. CMS believes that scores on the one quality measure used in the SNF VBP program (30-day All-cause Readmissions) have been impacted by the COVID-19 pandemic, which would result in unfair payment incentives and inequitable payments. In fact, CMS further commented that SNFs performance during the public health...
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Mar 16 2021
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Non-Therapy Ancillaries: What are you missing?

The Non-Therapy Ancillaries (NTA) component of PDPM can significantly increase revenue depending on MDS and ICD-10 coding. Just 1 NTA point can have an average worth of anywhere from $18 to $55 per day. (difference of NE-NF and NA-NB). The general method for calculation of any NTA category is as follows: Points (1-8) are assigned to specific conditions. Points are added together for all conditions. The higher the total point value, the greater the payment (CMI). NF is the lowest grouper with a...
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Sep 23 2020
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PDPM ICD-10 Mapping Changes Effective Oct 1, 2020

With the beginning of fiscal year 2021 October 1, there will be the expected changes to our MDS and billing processes. This year the number of changes is limited due to the unprecedented public health emergency we are experiencing with COVID-19.  Despite that, we can expect updates to the PDPM ICD-10 Mapping Tool this year. The following changes will be effective October 1, 2020: Certain Cancer ICD-10 Codes- Previously specific cancer diagnoses that could require a major surgical procedure did...
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Sep 15 2020
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Covid-19 and Skilled Status

In late June, CMS addressed two issues and posted MDS 3.0 Final Item Sets (V1.17.2).  The two edits were changes to facilitate the calculation of Patient-Driven Payment Model payment codes on OBRA assessments for states that wish to have this calculation performed.  These two edits will be revised and go into production on October 1, 2020. The purpose of these changes?  To allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM ones and thereby inform their future...
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Jul 27 2020
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Mind Your PHQs

Some skilled nursing facilities (SNFs) are concerned about accurate payment when a resident unexpectedly discharges and the Brief Interview for Mental Status (BIMS) has not yet been completed.However, they should be just as concerned about the PHQ-9. The PHQ-9 identifies depressive symptoms to be captured on the MDS. The interview follows the same basic rules as the BIMS. Both interviews should be conducted, preferably on the day of or the day before the ARD. The provider cannot complete the...
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Jul 22 2020
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Medicaid Changes Coming in October 2020

In late June, CMS addressed two issues and posted MDS 3.0 Final Item Sets (V1.17.2).  The two edits were changes to facilitate the calculation of Patient-Driven Payment Model payment codes on OBRA assessments for states that wish to have this calculation performed.  These two edits will be revised and go into production on October 1, 2020. The purpose of these changes?  To allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM ones and thereby inform their future...
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Recent Blogs in All Topics

Aug 01 2026
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Beyond the Dashboard: Using iQIES to Drive Quality and Compliance in SNFs

The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program is a Centers for Medicare & Medicaid Services (CMS) program that awards incentive payments to skilled nursing facilities (SNFs) to encourage SNFs to improve the quality of...
Keep Reading
Jul 01 2026
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From Quality to Financial Performance: How QMs Influence SNF VBP and Five-Star Ratings

Overview of The SNF VBP Program  The Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) is a Medicare pay-for-performance program that is intended to encourage SNFs to improve the quality of care they provide to their residents. All...
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Jun 07 2026
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What Really Counts: How Quality Measures Shape Compliance, Reporting, and Performance

If your Facility-level and Resident-level MDS 3.0 Quality Measures (MDS 3.0 QM), the Skilled Nursing Facility MDS 3.0 Quality Reporting Program Quality Measures (MDS 3.0 SNF QRP QM), or Five Star QM reporting on Care Compare are missing the mark...
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May 01 2026
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Beyond the Scorecard: Turning Quality Measure Data into Action

Data coded on the Minimum Data Set (MDS) is collected during structured and defined time periods; what happens with the resident outside of those time periods cannot be captured on the MDS and will not impact your quality measures (QMs) apart from...
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Apr 01 2026

Care Planning to Reduce the Risk for Chemical Restraint

How can we turn care plans from an exercise in paper compliance that few staff understand, let alone review or utilize, to a workable document that helps us manage resident needs? When thinking about how to create an effective care plan for an “as...
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Mar 01 2026
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From Orders to Action: Aligning Care Plans and Psychotropic Medications

Critical Element Pathways (CEPs) are tools in the Long-Term Care State Operations Manual (SOM) that are developed by Centers for Medicare and Medicaid (CMS) and utilized by surveyors along with interpretive guidance to evaluate each facility’s...
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Feb 01 2026

F641 in Plain English – How Interview Accuracy Protects Your CMI

When surveyors look at MDS accuracy, they’re not just checking boxes – they’re looking at whether the assessment truly reflects the resident. F641 holds the interdisciplinary team and nursing leadership accountable for how the assessment is...
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Jan 01 2026
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From Coding to Compliance: Avoiding Pitfalls in the 2026 MDS Landscape

With the numerous regulatory bodies that govern long term care (LTC) and skilled nursing facilities (SNF), it is easy to feel like there is no end to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) “rules.” There are Federal,...
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Dec 01 2025
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Keeping Up with Quality Measures in 2026

Quality measures (QM) that are driven by MDS data are currently utilized for long term care (LTC) facilities and skilled nursing facilities (SNF) in several ways. These QMs are publicly reported via the Care Compare (CC) website and accompanying...
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Nov 01 2025
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The Latest in the Lineup: The Skilled Nursing Facility Validation Program

The Centers for Medicare and Medicaid (CMS) audits of skilled nursing facility (SNF) Minimum Data Set (MDS) data are nothing new. The MDS 3.0 was implemented in 2010, and in 2014 CMS piloted MDS Focused Surveys in 5 states. The results of the pilot...
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Oct 01 2025
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How the MDS is Utilized During the Survey Process

Have you ever wondered how the survey team determines which residents they will focus on during a standard survey in the skilled nursing facility/long term care facility (SNF/LTC)? The answers submitted to the Center for Medicare and Medicaid (CMS)...
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Sep 01 2025
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Fall MDS Updates are Here!

October 1 is typically when the Centers for Medicare and Medicaid Services (CMS) institutes changes to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) – and this year is no exception. CMS has rescinded a few things that were...
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Aug 01 2025
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Medicaid PDPM Is Coming: What Skilled Nursing Facilities Need to Know

Beginning October 1, 2025, many nursing homes will adopt a new reimbursement model for Medicaid residents: the Patient-Driven Payment Model, or Medicaid PDPM. While PDPM has been in place for Medicare since 2019, this is the first time it’s being...
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Jul 01 2025
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The Facility Assessment and Emergency Management Planning: The MDS Plays a Big Role

  What is the MDS Role in the Facility Assessment? F838 in the State Operations Manual (SOM) provides specific information for developing a Facility Assessment that must be reviewed and updated at least annually. A well-developed facility...
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Jun 01 2025
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MDS Nutrition – Not Limited to Section K

Often Section K on the MDS, associated CAAs, and care planning are relegated to the dietician to worry about. However, when we look at a comprehensive MDS, we can see that the information in Section K is only part of the resident's nutritional...
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May 01 2025
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Celebrating Skilled Nursing

National Skilled Nursing Week is held annually in May to recognize long-term care professionals that care for our residents in Skilled Nursing Facilities. This year’s National Skilled Nursing Week is May 11 - 17 and the theme is “Tapestry of Life”...
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Apr 01 2025
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MDS Errors: Steps for Correction

What does the NAC do when they identify an error on an MDS assessment? The answer is correct the identified error. Any error that incorrectly represents the resident's status needs to be corrected. One would think correcting an MDS error would be a...
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Mar 01 2025
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RAI and MDS Compliance: The Importance of the Administrator in the Lineup

With the Minimum Data Set (MDS), the Centers for Medicare and Medicaid (CMS) created a standardized, reliable, reproducible framework for assessing long term care resident status. As a result, MDS data plays a significant role in myriad areas of...
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Feb 01 2025

Laying the Foundation – Care Area Assessments to Care Plans

Because Care Area Assessments (CAAs) are not submitted to CMS, and the Resident Assessment Instrument (RAI) manual offers little guidance on how to complete a CAA when compared to the Minimum Data Set (MDS) instructions, CAAs are a segment of the...
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Jan 01 2025

Navigating the 2025 Winds of Change: New Survey Guidance

The 2025 new year has begun with a whirlwind of changes in Long-Term Care – starting with New Surveyor Guidance. CMS released an advanced copy of these State Operations Manual Appendix PP (Guidance for Skilled Nursing Facilities) updates in a...
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Dec 01 2024
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What is an MDS Coordinator?

"What do you do for a living?" It may not surprise you that when asked this question, most MDS Coordinators struggle to come up with an answer. The reality is that MDS Coordinators fully understand what this multifaceted job entails, but are at a...
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Nov 01 2024
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From the MDS to RAI System Management

With the introduction of the Minimum Data Set (MDS) through the Omnibus Budget Reconciliation Act (OBRA) of 1987, Centers for Medicare and Medicaid (CMS) implemented a method of standardized, comprehensive, and reproducible data collection for long...
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Oct 01 2024

Maximizing Case Mix with Special Programs: Respiratory Therapy and Restorative Nursing

Case mix is essential in skilled nursing facilities as it impacts both reimbursement and the care provided. Two key programs that significantly impact case mix scores when properly implemented and documented are Respiratory Therapy and Restorative...
Keep Reading
Sep 01 2024

Strategic Admissions: The Path to Optimized Medicaid Reimbursement

Medicaid reimbursement plays a significant role in the financial health of long-term care facilities, particularly those serving a high percentage of Medicaid residents. While it may not be the sole source of revenue, it is an important component...
Keep Reading
Aug 01 2024
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Internet Quality Improvement and Evaluation System (iQIES): A New Age

Just when we thought we had a handle on QIES (Quality Improvement and Evaluation System), the Centers for Medicare & Medicaid Services (CMS) transitioned to the Internet Quality Improvement and Evaluation System (iQIES) in 2023.   Reports...
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Jul 01 2024
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A Significant Change in Status Assessment – There are Options

The Resident Assessment Instrument (RAI) system includes a significant change in status assessment (SCSA). What might be forgotten is the State Operation Manual (SOM), Appendix PP, includes information that mirrors the RAI manual at 42 CFR...
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Jun 01 2024
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Interim Payment Assessment (IPA) – To do or not to do?

The Patient-Driven Payment Model took effect in October of 2019. Along with this change came the optional IPA. We are now five years into this change and questions still arise on when to complete an IPA. The decision of when to complete lies with...
Keep Reading
May 01 2024
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Resident Interviews – What are you doing to capture the data?

Effective October 1, 2023, several resident interviews were added to or updated on the MDS. Interview items in Section A and changes to the interviews in Section D, J, and Q have been implemented. Each of the interviews can be a great steppingstone...
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Apr 01 2024
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Section GG Documentation – Questions Still Abound

Section GG remains a popular discussion topic among the Nurse Assessment Coordinator (NAC) and other members of the interdisciplinary team (IDT). Many have questioned their own practices and processes, designed to support coding this section of the...
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Mar 01 2024
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Social Determinants of Health (SDOH) – A Global Initiative Important to Skilled Nursing Providers

The Centers for Medicare & Medicaid Services’ (CMS) Office of Mental Health report CMS Framework for Health Equity 2022 and 2032 states that health equity is defined by the attainment of the highest level of health for all people, where...
Keep Reading