The Centers for Medicare & Medicaid Services (CMS) publicly posted the fiscal year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule. The rule updates Medicare Part A per-diem payment rates as well as proposing other key policy changes. Since the 2019 SNF PPS Final Rule, CMS has demonstrated a clear emphasis on quality. The FY 2020 rule continues this theme with a heavy emphasis on the expansion of the QRP including proposal to finalize Standardized Patient Assessment Data Elements (SPADEs).

Let’s walk through some of the changes:


  • SNF QRP.
    • The proposal which would be effective 2022, includes two MDS-based SNF QRP quality measures (QMs): Transfer of Health Information to the Provider-PAC and Patient-PAC. This would require the sharing of medication reconciliation information with next-level providers and the patient/family.
    • Since initially introduced in the FY 2018 SNF PPS Proposed Rule, CMS has been vetting proposed SPADEs through Technical Expert Panels and Open-Door Forums to ensure reliability and validity. Current MDS items along with a new data set to satisfy reporting of SPADEs is back on the table. In addition to currently available MDS items, this proposal would result in the addition of over 60 SPADE items to the 5-day (or initial assessment as CMS proposes it be called under PDPM) and Part A PPS Discharge Assessment.
    • CMS is proposing that SNF QRP no longer be limited to Part A fee-for-service but expand to cover all SNF payers. Effective FY 2020, the proposal seeks to exclude base-line nursing home residents in the claims-based Discharge to Community-PAC SNF QRP measure. They are defining base-line nursing home residents as “SNF residents who had a long-term NF stay in the 180 days preceding their hospitalization and SNF stay, with no intervening community discharge between the NF stay and hospitalization.”
  • The Patient-Driven Payment Model (PDPM). There has been much speculation about the IPA and PDPM transition, but the proposed rule was relatively quiet on PDPM. The main PDPM updates were on the definition of group therapy and process for timely ICD-10-CM updates.
    • CMS clearly acknowledged the significant benefits of group and concurrent as well as the therapist clinical decision-making abilities as to the best mode of delivery. To align with In-patient Rehab Facility (IRF) regulations, CMS has proposed to adopt the IRFs group definition which defines group therapy as “a qualified rehabilitation therapist or therapy assistant treating two to six patients at the same time who are performing the same or similar activities.”
    • CMS has also introduced a “subregulatory” process for “nonsubstantive” updates to the ICD-10-CM codes used for PDPM clinical classification in order to ensure the most current ICD-10-CM codes are available to providers. Substantive changes would continue to follow the same process of notice and comment rule


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  • CMS proposes to obtain more granular standardized patient assessment data on the initial MDS and planned and unplanned discharges:
    • Cancer Treatment: Chemotherapy (IV, Oral, Other). Cancer Treatment: Radiation.
    • Respiratory Treatment: Oxygen Therapy (Intermittent, Continuous, High-Concentration Oxygen Delivery System).
      • “Continuous (whether the oxygen was delivered continuously, typically defined as > =14 hours per day);
      • Intermittent;
      • or High-concentration oxygen delivery system,”
    • Respiratory Treatment: Suctioning (Scheduled, As needed).
      • Scheduled indicates suctioning based on a specific frequency, such as every hour;
      • As needed means suctioning only when indicated.”
    • Respiratory Treatment: Tracheostomy Care.
    • Respiratory Treatment: Non-invasive Mechanical Ventilator (BiPAP, CPAP).
    • Respiratory Treatment: Invasive Mechanical Ventilator.
    • Intravenous (IV) Medications sub elements (Antibiotics, Anticoagulants, Vasoactive Medications, Other).
    • Transfusions.
    • Dialysis to include sub elements:
      • Hemodialysis
      • Peritoneal dialysis
    • Intravenous (IV) Access sub elements:
      • Peripheral IV
      •  Midline
      • Central line)
    • CMS proposes to replace the existing K0510 with the renumbered K0520 on the 5-day MDS and on planned and unplanned discharges to obtain the following:
      • Nutritional Approach: Parenteral/IV Feeding.
      • Nutritional Approach: Feeding Tube.
      • Nutritional Approach: Mechanically Altered Diet.
      • Nutritional Approach: Therapeutic Diet.
    • CMS proposes to add N0420 (high-risk drug classes: use and indication) on planned and unplanned discharges to obtain the following standardized patient assessment data:
      • High Risk Drug Classes: Use and Indication. Includes the following medication classes: anticoagulants; antiplatelets; hypoglycemics (including insulin); opioids; antipsychotics; and antibiotics.”

    * Medical Condition and Comorbidity category:

    • Pain Interference:
      • Pain Effect on Sleep
      • Pain Interference with Therapy Activities
      • Pain Interference with Day-to-Day Activities

    * Impairment category:

    • Hearing. CMS proposes to use the same single hearing data element (B0200) that is currently on the MDS.
    • Vision. CMS proposes to use the same single vision data element (B1000) that is currently on the MDS.

    * Proposed new category – Social Determinants of Health:

    Seven proposed elements:

    • Race and Ethnicity.
    • Preferred Language and Interpreter Services.
    • Health Literacy.
    • Transportation.
    • Social Isolation.

    Melissa Ward
    VP of Clinical and Regulatory Affairs