Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Spotlights and Announcements
Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Spotlights and Announcements
Now available! Our new Provider Data Catalog makes it easier for you to search and download publicly reported data. We’ve also improved Medicare’s Compare sites.
Updates
November 3, 2023
Reminder of Upcoming Data Submission Deadline
The submission deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is approaching. Minimum Data Sets (MDS) assessment data and data submitted to the Centers for Medicare & Medicaid Services (CMS) via the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) for April 1 – June 30 (Q2) of calendar year (CY) 2023 are due with this submission deadline.
All data must be submitted no later than 11:59 p.m. on November 15, 2023.
It is recommended that the applicable Centers for Medicare & Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) reports and NHSN analysis reports are run prior to each quarterly reporting deadline to ensure that all required data were submitted. We encourage you to verify all facility information prior to submission, including CMS Certification Number (CCN) and facility name.
View the list of measures required for the November 15, 2023 deadline on the SNF Quality Reporting Program Data Submission Deadlines webpage.
For submission information, visit:
Swingtech sends informational messages to SNFs that are not meeting Annual Payment Update (APU) threshold on a quarterly basis ahead of each submission deadline. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CCN along with any requested email updates.
October 26, 2023
Register for CMS’ 2023 CMS Health Equity Confidential Feedback Reports Live Q&A
On November 16, 2023 at 2:00 p.m. ET, the Centers for Medicare & Medicaid Services (CMS) will host a live Q&A session regarding the Health Equity Confidential Feedback Reports released on October 16, 2023. The Q&A session will give participants an opportunity to ask and learn about answers to commonly asked questions regarding the report’s methodologies and interpretations from CMS subject matter experts.
Register for the live Q&A session here: https://us06web.zoom.us/webinar/register/WN_CgvglG96SLu7BmfXi60j_Q
Already have questions about the Health Equity Confidential Feedback Reports? Please send questions to CMSHealthEquityCFRSession@ketchum.com by November 2, 2023, for potential inclusion in the Q&A session. Please note that CMS will answer as many questions as time permits and some questions will not be asked verbatim. CMS will post all questions and answers on each of the PAC Training & Education pages sometime after the webinar.
Prepare for the Live Q&A Webinar:
To prepare for the November 16 live Q&A session, please review the October 16, 2023 Online Webinar recording, with slides, a transcript, and a Fact Sheet providing an overview of the Health Equity Confidential Feedback Reports available in the “Downloads” section on each of the following PAC Training & Education pages:
- Home Health Quality Reporting Training & Education webpage.
- Inpatient Rehabilitation Facility Quality Reporting Training & Education webpage.
- Long Term Care Hospital Quality Reporting Training & Education webpage.
- Skilled Nursing Facility Quality Reporting Training & Education webpage.
October 25, 2023
Care Compare October Release of SNF QRP Data – Now Available
The October 2023 release of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).
For more information, please visit the SNF QRP Public Reporting website.
October 23, 2023
The PDF file labeled “MDS3.0RAIManualv1.18.11R.Errata.v2.October.20.2023” is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The errata document contains revisions to the MDS 3.0 RAI Manual version (v)1.18.11R to provide clarity and additional guidance in Section D and Chapter 6 to support item D0100, Should Resident Mood Interview be Conducted? serving as a gateway item for the Resident Mood Interview (PHQ-2 to 9©) and D0500, Staff Assessment of Resident Mood (PHQ-9-OV©). Minor revisions also included are corrections to language in Section Q to provide proper guidance on Care Area Assessment (CAA) requirements, corrections to language in Chapter 2 to provide proper guidance on combining Omnibus Budget Reconciliation Act (OBRA) discharge assessments, an updated Internet Quality Improvement & Evaluation System (iQIES) warning error message in Chapter 5, updated screenshots in Section A and Section O, and an updated MDS Item Matrix. The errata document also includes all issues from previous MDS 3.0 RAI Manual v1.18.11R errata releases.
Changed manual pages are marked with the footer “October 2023 (R).”
The errata document begins with a table that lists all identified revisions and the pages to which they have been applied. Following the table are the actual corrected replacement pages for insertion into the printed manual.
October 20, 2023
UPDATED: Final MDS 3.0 Item Sets version 1.18.11 v6
The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. Changes in this version (listed below) align the item sets with the Errata V3.01.3 for MDS Data Specifications V3.01.1 (FINAL) (PDF) posted September 21, 2023, on the Minimum Data Set (MDS) 3.0 Technical Information page. For a full list of changes to the final posted item sets since v1, see the Item Set Change Table Supplement that accompanies the posting. The MDS Item Sets v1.18.11 were effective beginning October 01, 2023.
M0300G1 on NPE Replaced erroneous skip pattern <Skip to N2005, Medication Intervention> with the correct one: <Skip to N0415, High-Risk Drug Classes: Use and Indication>.
O0300A on NP and NQ Corrected transposition of verbs in skip patterns (changed <Skip> to <Continue> in choice 0 and <Continue> to <Skip> in choice 1).
O0400 on NC and NQ Removed completion language <Complete only when A0310B = 1 (complete O0400D2 when required by state)>.
O0400 on NP and SP Removed completion language <Complete only when A0310B = 1>.
O0420 on NC, NP, and NQ Removed completion language <Complete only when A0310B = 1>.
October 16, 2023
NOW AVAILABLE: CMS Post-Acute Care Health Equity Confidential Feedback Reports with Online Webinar and Fact Sheet
As part of our commitment to advance health equity and strengthen the Medicare Program, the Centers for Medicare & Medicaid Services (CMS) have released two Health Equity Confidential Feedback Reports to post-acute care (PAC) providers: the Discharge to Community (DTC) Health Equity Confidential Feedback Report and the Medicare Spending Per Beneficiary (MSPB) Health Equity Confidential Feedback Report. To provide insight on outcome differences across social risk factors, the Health Equity Confidential Feedback Reports stratify these two PAC Quality Reporting Program measure outcomes by Medicare-Medicaid dual-enrollment status (duals and non-duals), as well as patient race/ethnicity (Non-White and White patients). This data is meant to provide feedback to providers about their performance for certain populations who may have been historically disadvantaged. These reports are educational for providers, and to identify opportunities for providers to focus their internal quality improvement initiatives to provide all individuals their best opportunity to achieve their best potential health outcomes.
CMS released the PAC Health Equity Confidential Feedback Reports through the Internet Quality Improvement & Evaluation System (iQIES) reports folders. To locate your Health Equity Confidential Feedback Reports in iQIES, please follow the instructions listed below:
- Log into iQIES at https://iqies.cms.gov/ using your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) user ID and password. If you do not have a HARP account, you may register for a HARP ID.
- From the Reports menu, select My Reports.
- From the My Reports page, locate and select the Health Equity Confidential Feedback Reports folder link.
- Displayed for you is a list of reports available for download.
- Select the report name link to view the Health Equity Confidential Feedback Report data
Additionally, CMS posted an Online Webinar recording with slides, transcript, and Fact Sheet providing an overview of the Health Equity Confidential Feedback Reports on each of the following PAC pages:
- Home Health Quality Reporting Training & Education webpage;
- Inpatient Rehabilitation Facility Quality Reporting Training & Education webpage;
- Long Term Care Hospital Quality Reporting Training & Education webpage; and the
- Skilled Nursing Facility Quality Reporting Training & Education webpage.
October 13, 2023
SNF Provider Preview Reports – Now Available
The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the January 2024 refresh.
For more information, please visit the CMS SNF QRP Public Reporting website.
October 2, 2023
Notice of Upcoming SNF QRP Measure Removals
The Centers for Medicare & Medicaid Services (CMS) is alerting Skilled Nursing Facility (SNF) providers of upcoming measure removals from the SNF Quality Reporting Program (QRP). The following quality measures are planned for removal from the iQIES Review and Correct Reports, Facility-Level Quality Measure (QM) Reports, and Resident-Level QM Reports in January 2024:
- Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
- Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients
- Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients
Once removed from reports, users will no longer have access to any data or measure results for these measures.
These measures will last appear in the April 2024 Provider Preview Reports for the July 2024 Refresh of SNF QRP data. Starting with the October 2024 Release, these measures will be removed from Care Compare and Provider Data Catalog. Once removed, the historic publicly reported measure data will continue to be available in the Nursing Homes Including Rehab Services Data Archive files on the Provider Data Catalog.
Please direct any questions on these measure removals or questions related to quality measures on the SNF QRP Reports to the SNF QRP help desk at SNFQualityQuestions@cms.hhs.gov.
September 26, 2023
NEW RESOURCE AVAILABLE: BIMS and BIMS Summary Score Explainer Video
A brief explainer video, BIMS and BIMS Summary Score: Stopping and Coding an Incomplete Interview is now available for SNF Providers. This resource can be accessed through the Skilled Nursing Facility Quality Reporting Program Training page.
September 22, 2023
NEW RESOURCES AVAILABLE: Cue Cards for Administering the BIMS in Writing, PHQ-2 to 9, Pain Assessment Interview, and Interview for Daily and Activity Preferences
These resources can be accessed through the Skilled Nursing Facility Quality Reporting Program Training page.
September 15, 2023
COMING SOON: CMS Health Equity Confidential Feedback Reports
Next month, The Centers for Medicare & Medicaid Services (CMS) will release two new Health Equity Confidential Feedback Reports to post-acute care (PAC) providers in the Home Health (HH), Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Skilled Nursing Facility (SNF) settings: the Discharge to Community (DTC) Health Equity Confidential Feedback Report and the Medicare Spending Per Beneficiary (MSPB) Health Equity Confidential Feedback Report. The PAC Health Equity Confidential Feedback Reports will stratify the DTC and MSPB measures by dual-enrollment status and race/ethnicity.
An educational webinar recording and fact sheet providing an overview of the Health Equity Confidential Feedback Reports will also be released next month.
September 08, 2023
The PDF file labeled “MDS3.0RAIManualv1.18.11R.Errata.September.8.2023” is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The errata document contains revisions to pages in Chapter 4 of the MDS 3.0 RAI Manual version (v)1.18.11R that better align the Care Area Assessments (CAAs) with the Care Area Trigger (CAT) specifications, as well as a revision to Section D that corrects the Coding Instructions guidance for item D0160. Total Severity Score.
Changed manual pages are marked with the footer “October 2023 (R).”
The errata document begins with a table that lists all identified revisions and the pages to which they have been applied. Following the table are the actual corrected replacement pages for insertion into the printed manual.
September 07, 2023
SNF QRP Table for Reporting Assessment-Based QM and Standardized Patient Assessment Data Elements and Data Collection and Final Submission Deadlines Affecting FY 2025 and FY 2026 posted
The FY 2024 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule (88 FR 53200) revised data collection and submission requirements for the SNF Quality Reporting Program (QRP) affecting the Fiscal Year (FY) 2025 and FY 2026 QRPs. An update to the SNF QRP Annual Payment Update (APU) Table for reporting assessment-based quality measures (QMs) and standardized patient assessment data elements to the Centers for Medicare & Medicaid Services (CMS) affecting FY 2025 APU determination has been revised and is now available. The changes to the table reflect the data elements that will be required to meet the APU minimum data completion threshold for the current and final quarters of FY 2025. The SNF QRP Data Collection and Final Submission Deadlines for the FY 2025 SNF QRP has also been revised and is now available.
Additionally, the SNF QRP APU Table for reporting assessment-based QMs and standardized patient assessment data elements to CMS affecting FY 2026 APU determination and the SNF QRP Data Collection and Final Submission Deadlines for the FY 2026 SNF QRP are now available. We also note that the FY 2024 SNF PPS final rule (88 FR 53272) finalized the requirement for SNFs to report 100 percent of the required quality measures data and standardized patient assessment data collected using the MDS on at least 90 percent of all assessments submitted beginning with the FY 2026 QRP (1/1/2024 through 12/31/2024).
The revised FY 2025 SNF QRP APU Table and the FY 2026 SNF QRP APU Table can be accessed via the Downloads section of the SNF QRP Measures Information webpage. The revised FY 2025 SNF QRP Data Collection and Final Submission Deadlines and the FY 2026 SNF QRP Data Collection and Final Submission Deadlines can be accessed via the Downloads section of the SNF QRP Data Submission Deadlines webpage.
September 7, 2023
SNF QRP FAQs for FY 2024
An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the SNF QRP in Fiscal Year (FY) 2024 and includes other useful resources available to providers.
The FAQ document can be accessed via the Downloads section of the SNF Quality Reporting FAQs webpage.
September 6, 2023
SNF QRP Quality Measure Calculations and Reporting User’s Manual V5.0, Change Table, Risk Adjustment Appendix File, Imputation Appendix File, and HCC ICD-10 Crosswalks – Now Available
The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Quality Measure Calculations and Reporting User’s Manual Version 5.0 and accompanying documents are now available. These documents serve as an update to the specifications used to calculate quality measures that are included in the SNF QRP effective October 1, 2023.
For more information, please visit the CMS SNF QRP Quality Reporting Measures Information website.
September 1, 2023
SNF QRP Listening Session: Possible Expansion of MDS Data Submission to All SNF Patients Regardless of Payer - Feedback Accepted Through 9/28/2023
Acumen LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) is accepting feedback on the topics discussed during the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Listening Session held on August 29th, 2023. The discussion topics are posted in the Downloads section of the SNF QRP Measures and Technical Information webpage for reference. Feedback can be sent to: SNF-listening-session-2023@acumenllc.com, and will be accepted through 5pm ET on September 28, 2023.
August 28, 2023
REGISTRATION CLOSED: SNF QRP Listening Session: Expanding MDS Data Submission to All SNF Patients Regardless of Payer
Date/Time: Tuesday, August 29th from 12pm-1:30pm ET
Acumen LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) is hosting a public, virtual listening session. On behalf of CMS, we are seeking feedback from administration and management staff, software vendors, and clinical staff on the expansion of collection and submission of Minimum Data Set (MDS) assessment data used for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) to include all residents receiving short-term skilled care in a SNF regardless of their payer. Currently, the SNF QRP only collects data on Medicare Part A fee-for-service (FFS) residents, which represents less than 50% of the SNF resident population. Due to the declining numbers of beneficiaries with Medicare FFS benefits, collecting data on all residents, regardless of payer, supports CMS’ mission to ensure quality care for all individuals and provides the most robust and accurate representation of quality in the SNF setting. In 2020, CMS formally proposed collecting data on all residents receiving SNF services beginning with the Fiscal Year (FY) 2022 program year. While several commenters noted that collecting data from all payers gives consumers a more complete picture of quality of care provided within a SNF, there were other commenters who did not support the proposal. Therefore, we are exploring how SNF QRP data reporting for all-payers can be implemented. Registration is now closed.
Prior to the listening session, you are encouraged to prepare to speak to the following topics during the call:
- Collecting accurate payer information
- Definition of skilled services for non-Medicare FFS residents
- Current MDS data collection practices for non-Medicare FFS residents admitted for skilled-stay
- Pros and cons of all-payer data collection and submission
- MDS assessment instrument considerations to accommodate all-payer data collection and submission
August 24, 2023
UPDATED: Final MDS 3.0 Item Sets version 1.18.11 v5
The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. All item sets have been replaced with revised versions. The list below highlights all substantive changes or corrections since the final versions were first posted on April 3rd. Additionally, a number of other items (not listed) have had small changes to their formatting. This will be the final version of the MDS Item Sets v1.18.11 that will be effective beginning October 01, 2023.
A1005 on IPA Corrected erroneous lettering of final subitem (changed A1005Z [wrong] to A1005Y [correct]).
A1200 on NC and NQ Corrected erroneous numbering scheme for responses (changed from 0-4 [wrong]) to 1-5 [correct]).
A2121 on NQ Corrected typo (<Referenc>) in choice 0.
B1300 on NPE Changed completion language to remove <Complete only if A0310G = 1>.
D0100 on NPE Changed completion language to remove <If A0130G=2 Skip to D0700. Otherwise.>
D0100 on NPE Corrected incorrect skip pattern in choice 0.
D0100 on IPA Removed erroneous skip pattern language.
D0150B on NQ Removed <or appearing> from item language.
D0700 on NPE Changed completion language to remove <Complete only if A0310G = 1>.
D0700 on ND Added completion language <Complete only if A0310G = 1>.
GG0130, Column 3, on NPE Changed completion language to remove <and A2105 is not = 04>.
GG0170, Column 3, on NPE Changed completion language to remove <and A2105 is not = 04>.
GG0170, Column 3, on SD Corrected capitalization in item title from <stay> to <Stay> (on first page of two).
I0020 on IPA Corrected numbering of final option from 99 to 13.
J0530 on SD Removed erroneous option 0 and corrected typo (<activites>) in question that the resident is being asked.
J0600 on NP Corrected label for boxes from <Enter Code> to <Enter Rating>.
J1400 on NP Corrected typo (inserted missing closing parenthesis at end of item text).
M0300 on SP Added missing item title to heading at top of page.
M0300C on NPE Corrected typo (removed period at end of item).
M1040 on NC Corrected typo in label in the gray area above subitem A (made <Problems> plural).
O0300A on NP and NQ Corrected transposition of verbs in skip patterns (changed <Skip> to <Continue> in choice 0 and <Continue> to <Skip> in choice 1).
O0400 on NC and NQ Changed completion language to add <complete O0400D2 when required by state)>.
O0500 on IPA, NP, and SP Removed extra box at left (items O0500D–O0500J had eight boxes for only seven items in the list) and realigned boxes on left with items on right.
X1100E on SD Restored this subitem, which was missing in previous version.
August 23, 2023
POST-EVENT MATERIALS AVAILABLE: The SNF MDS 3.0 RAI v1.18.11 Guidance Training Program
A Post-Event Q&A document from the SNF MDS 3.0 RAI v1.18.11 Guidance Training Program is now available.
For more information, please visit the SNF Quality Reporting Program (QRP) Training page.
August 22, 2023
NOW AVAILABLE: Final MDS 3.0 RAI User’s Manual version 1.18.11
The final Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version (v)1.18.11 is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The MDS 3.0 RAI User’s Manual v1.18.11 will be effective beginning October 01, 2023.
This version of the MDS 3.0 RAI Manual contains substantial revisions related to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), which requires that standardized assessment items be collected across post-acute care (PAC) settings. Standardized data will enable cross-setting data collection, outcome comparison, exchangeability of data, and comparison of quality within and across PAC settings. Additionally, the language of the manual has been updated throughout to be gender neutral. Guidance and examples in numerous chapters and appendices have been revised for clarification and to reflect current regulations and best practices. Due to the scope of the revisions, CMS will not issue Replacement Pages for v1.18.11; those wishing to continue using a physical copy of the manual are encouraged to print the new version.
A document listing all changes from the MDS 3.0 RAI Manual v1.18.11 draft version to the final version is available for reference in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page.
August 22, 2023
New Minimum Data Set (MDS) 3.0 Frequency Report Website
Effective August 21, 2023, MDS 3.0 Frequency data will be available from a new location on the data.cms.gov website (https://data.cms.gov/quality-of-care/minimum-data-set-frequency). This new website replaces the previous MDS 3.0 Frequency Report webpage which was decommissioned on August 1, 2023.
Users will find very similar information on this new website to that which was provided on the historical MDS 3.0 Frequency Report webpage, including an overview of the data that are accessible from the website, explanatory text that identifies the methodology for calculation of those data, and the item response frequency data. Enhanced functionality on the new website allows users to view the Frequency data online, including filtering functionality of the data to meet the user’s needs. This new website also allows users to download and save the Frequency data in Comma Separated Value (CSV) or CSV for Excel files by calendar quarter. The downloadable files contain MDS 3.0 Frequency data for all states and the Nation by the calendar quarter report period. Downloadable CSV files will be available for all calendar quarters beginning with Calendar Year (CY) 2020 (Q1, 2020) through Q2, 2023. As each new calendar quarter begins, data for the prior calendar quarter will be made available on the website. For example, Q3, 2023 data will be available for download approximately mid-late October, 2023.
The CSV files contain the following data elements:
• Geographical Location – this column identifies the State or National location for which the MDS 3.0 Frequency data are reported.
• Report Date – this column identifies the Calendar Quarter and Year for which the MDS 3.0 Frequency data are reported (e.g., Q1, 2022).
• MDS Item Question/Description – this column identifies the item ID and section description as displayed on the MDS assessment instrument, followed by the item specific description for which the data are reported. Example: A0800: Identification Information – Gender.
• MDS Item Response – this column contains item responses that correspond to the assessment item. Each response for an item is listed on a separate row so that counts and percentages are displayed for each response by geographic location.
• Percent – this column contains the percent of responses for each item, geographical location, and reporting quarter.
• Total Residents – this column identifies the number of times each response was answered for an item grouped at a state and national level for the reporting quarter.
With this migration to the new webpage, active MDS items for which the frequency counts are calculated for the report periods above are included in the CSV files and retired items have been removed. As new items are added to the MDS assessment instrument, they will be included in the downloadable files if the item/response value are appropriate for the MDS 3.0 Frequency calculations.
iQIES Service Center
If you have any questions regarding this information, please contact the QIES/iQIES Service Center by phone at (800) 339-9313 or send an email.
August 15, 2023
UPDATED: Optional State Assessment (OSA) Item Set and OSA Manual
The Optional State Assessment (OSA) Item Set and OSA Manual have been updated, and the updated versions are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. Some items, listed below, have been corrected, and a number of other items have had small changes to their formatting. Screenshots in the manual have been updated, where needed, to reflect these changes.
The OSA is not a Federally required assessment; rather, it may be required in some States for payment purposes. Each State determines whether the OSA is required and if so, when the assessment must be completed. For questions regarding completion of the OSA, please contact your State Survey Agency.
The following corrections were made:
A0700 The word <patient> was changed to <recipient>.
C0300A Erroneous numbering (1–4) was changed to the correct numbering (0–3).
C0500 The wording of the instruction was changed from <Enter Code> to <Enter Score>.
O0100 The label above subitem Z was corrected from <Other> to <None of the above>.
August 14, 2023
Final MDS 3.0 RAI User’s Manual Version 1.18.11
Earlier today, messaging was posted on several CMS pages announcing the “Final” version of the MDS 3.0 RAI User’s Manual version 1.18.11. This messaging and the associated file was posted in error and is not the Final version the MDS 3.0 RAI User’s Manual version 1.18.11. CMS expects to post the final version before the end of August.
August 9, 2023
Reminder: SNF Quality Reporting Program: Non-Compliance Notifications
CMS provided notifications to Skilled Nursing Facilities (SNFs) and non-Critical Access Hospital (CAH) Swing Beds (SBs) that were determined to be out of compliance with SNF Quality Reporting Program (QRP) requirements for calendar year (CY) 2022, which will affect their fiscal year (FY) 2024 Annual Payment Update (APU). Non-compliance notifications were distributed by the Medicare Administrative Contractors (MACs) and placed into facilities’ My Reports folders in iQIES on July 20, 2023. If you received a letter of non-compliance you may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 18, 2023. If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notification letter and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.
Please note: Any reconsideration containing protected health information (PHI) will not be processed. All PHI must be removed in order for a reconsideration to be reviewed.
August 4, 2023
Reminder of Upcoming Data Submission Deadline
The submission deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is approaching. Minimum Data Sets (MDS) assessment data and data submitted to the Centers for Medicare & Medicaid Services (CMS) via the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) for January 1 – March 31 (Q1) of calendar year (CY) 2023 are due with this submission deadline.
All data must be submitted no later than 11:59 p.m. on August 15, 2023.
It is recommended that the applicable Centers for Medicare & Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) reports and NHSN analysis reports are run prior to each quarterly reporting deadline to ensure that all required data were submitted. We encourage you to verify all facility information prior to submission, including CMS Certification Number (CCN) and facility name.
View the list of measures required for the August 15, 2023 deadline on the SNF Quality Reporting Program Data Submission Deadlines webpage.
For submission information, visit:
Swingtech sends informational messages to SNFs that are not meeting Annual Payment Update (APU) threshold on a quarterly basis ahead of each submission deadline. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CCN along with any requested email updates.
August 4, 2023
REGISTRATION OPEN: SNF QRP Listening Session: Expanding MDS Data Submission to All SNF Patients Regardless of Payer
Date/Time: Tuesday, August 29th from 12pm-1:30pm ET
Registration Link: Registration can be completed online through Webex.
Acumen LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) is hosting a public, virtual listening session. On behalf of CMS, we are seeking feedback from administration and management staff, software vendors, and clinical staff on the expansion of collection and submission of Minimum Data Set (MDS) assessment data used for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) to include all residents receiving short-term skilled care in a SNF regardless of their payer. Currently, the SNF QRP only collects data on Medicare Part A fee-for-service (FFS) residents, which represents less than 50% of the SNF resident population. Due to the declining numbers of beneficiaries with Medicare FFS benefits, collecting data on all residents, regardless of payer, supports CMS’ mission to ensure quality care for all individuals and provides the most robust and accurate representation of quality in the SNF setting. In 2020, CMS formally proposed collecting data on all residents receiving SNF services beginning with the Fiscal Year (FY) 2022 program year. While several commenters noted that collecting data from all payers gives consumers a more complete picture of quality of care provided within a SNF, there were other commenters who did not support the proposal. Therefore, we are exploring how SNF QRP data reporting for all-payers can be implemented. Space is limited to the first 1,000 registrants.
Prior to the listening session, you are encouraged to prepare to speak to the following topics during the call:
- Collecting accurate payer information
- Definition of skilled services for non-Medicare FFS residents
- Current MDS data collection practices for non-Medicare FFS residents admitted for skilled-stay
- Pros and cons of all-payer data collection and submission
- MDS assessment instrument considerations to accommodate all-payer data collection and submission
August 3, 2023
Decommissioning of the MDS 3.0 Frequency Report Website
Effective August 1, 2023, the Minimum Data Set (MDS) 3.0 Frequency Report webpage (https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data-Set-3-0-Frequency-Report) is no longer supported and has been decommissioned. A replacement webpage where users can access the MDS 3.0 Frequency report data will be made available in the near future. Additional information about the new webpage will be forthcoming.
Any questions regarding this information should be directed to the iQIES Service Center via email at iqies@cms.hhs.gov or by phone at (800) 339-9313.
August 2, 2023
POST-EVENT MATERIALS AVAILABLE: The SNF MDS 3.0 RAI v1.18.11 Guidance Training Program
Post-event materials are now available for the Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) v1.18.11 Guidance Training Program. Post-event materials include the recorded coding workshop sessions, PDF versions of the coding workshop presentations, and supplemental materials.
For more information, please visit the SNF Quality Reporting Program (QRP) Training page.
July 31, 2023
PPS and Consolidated Billing for SNFs; Updates to the QRP and VBPP for Federal FY2024 (CMS-1779-F)
On July 31, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1779-F) that provides updates to the fiscal year (FY) 2024 Skilled Nursing Facility Quality Reporting Program (SNF QRP). This rule includes two new measures, one measure modification, and three measure removals. The new measures include the Discharge Function Score measure and the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure. CMS is also modifying the COVID-19 Vaccination Coverage among Healthcare Personnel measure to report the number of HCP who are up to date with recommended COVID-19 vaccinations per the latest CDC guidance. In addition, CMS is removing three measures including the Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function; the Application of the IRF Functional Outcome Measures: Change in Self-Care Score for Medical Rehabilitation Patients measure; and the Application of the IRF Functional Outcome Measures: Change in Mobility Score for Medical Rehabilitation Patients measure. Additionally, we are changing the data completion threshold for the Minimum Data Set data items and will begin the public reporting of the Transfer of Health (TOH) Information to the Patient-Post-Acute Care (PAC) and Transfer of Health Information (TOH) to the Provider-PAC measures. Finally, we provide a summary of the comments received for the principles for selecting and prioritizing SNF QRP quality measures and concepts and the update on CMS continued efforts to close the health equity gap.
The rule went on display at the Federal Register and will be available at: https://www.federalregister.gov/public-inspection
July 26, 2023
Care Compare July Refresh of SNF QRP Data – Now Available
The July 2023 refresh of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).
For more information, please visit the SNF QRP Public Reporting website.
July 20, 2023
SNF QRP: Non-Compliance Notifications
The Centers for Medicare & Medicaid Services (CMS) is providing notifications to Skilled Nursing Facilities (SNFs) and non-Critical Access Hospital (CAH) Swing Beds (SBs) that were determined to be out of compliance with SNF Quality Reporting Program (QRP) requirements for calendar year (CY) 2022, which will affect their fiscal year (FY) 2024 Annual Payment Update (APU). Non-compliance notifications will be distributed by the Medicare Administrative Contractors (MACs) and will be placed into facilities’ My Reports folders in Internet Quality Improvement and Evaluation System (iQIES) on July 20, 2023. If you receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 18, 2023. If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notification letter and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.
Please note: Any reconsideration containing protected health information (PHI) will not be processed. All PHI must be removed in order for a reconsideration to be reviewed.
July 14, 2023
UPDATED RESOURCE AVAILABLE: BIMS Video Tutorial
The Centers for Medicare & Medicaid Services (CMS) is offering an updated video tutorial for the Brief Interview for Mental Status (BIMS) which is collected on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) v1.18.11. This training asset demonstrates the BIMS interview and associated coding.
This resource can be accessed through the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Training page.
July 14, 2023
SNF Provider Preview Reports – Now Available
The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the October 2023 refresh.
For more information, please visit the CMS SNF QRP Public Reporting website.
July 07, 2023
UPDATED: Final MDS 3.0 Item Sets version 1.18.11 v4
The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The Interim Payment Assessment (IPA), Nursing Home Prospective Payment System (PPS) (NP), and Swing Bed PPS (SP) Item Sets have been replaced with revised versions; the remaining item sets remain unchanged from the last posted version. The MDS Item Sets v1.18.11 will be effective beginning October 1, 2023.
The Item set edits are noted below.
IPA item set
O0500 contained an additional response box which was removed
A1005 response option Z. was changed to response option Y.
NP item set
O0500 contained an additional response box which was removed
SP item set
O0500 contained an additional response box which was removed
June 23, 2023
UPDATED: Final MDS 3.0 Item Sets version 1.18.11 v3
The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The Nursing Home Comprehensive (NC) and Nursing Home Quarterly (NQ) Item Sets have been replaced with revised versions; the remaining item sets remain unchanged from the last posted version. The MDS Item Sets v1.18.11 will be effective beginning October 1, 2023.
The change that was made involved A1200. Marital Status. It was noted that the item response code numbering was changed in error on the NC and NQ item sets only. This has been corrected.
June 07, 2023
UPDATED: Final MDS 3.0 Item Sets version 1.18.11
The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual webpage. The Nursing Home Prospective Payment System (PPS) (NP), Nursing Home Part A PPS Discharge (NPE), and Swing Bed Discharge (SD) Item Sets have been replaced with revised versions; the remaining item sets remain unchanged from the last posted version. The MDS Item Sets v1.18.11 will be effective beginning October 1, 2023.
The item set edits are noted below and on the revised MDS 3.0 Item Set Change History v1.18.11v2.pdf. These edits are also reflected in the Final MDS Data Submission Specifications V3.01.0 posted on the Minimum Data Set (MDS) 3.0 Technical Information webpage.
NPE item set
B1300: Completion language removed
D0100: Part of the completion language was removed
D0700: Completion language removed
ND item set
D0700: Completion language added
SD item set
X1100E: added to item set
May 15, 2023
REGISTRATION OPEN: The SNF MDS 3.0 RAI v1.18.11 Guidance Training Program
The Centers for Medicare & Medicaid Services (CMS) is offering a virtual training program that provides instruction on the updated guidance for the Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) v1.18.11 Manual and Item Set. This training consists of a series of recorded presentations intended to be reviewed prior to a live virtual event. Registration is only required for the live virtual training event.
For more information and to register for the event, please visit the SNF Quality Reporting Program (QRP) Training page.
May 4, 2023
Reminder of Upcoming Data Submission Deadline
The submission deadline for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is approaching. Minimum Data Set (MDS) assessment data and data submitted to the Centers for Medicare & Medicaid Services (CMS) via the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) for October 1 – December 31 (Q4) of calendar year (CY) 2022 are due with this submission deadline. The annual NHSN measure Influenza Vaccination among Healthcare Personnel is also due with this deadline.
All data must be submitted no later than 11:59 p.m. on May 15, 2023.
It is recommended that applicable Centers for Medicare & Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) reports and NHSN analysis reports are run prior to each quarterly reporting deadline to ensure that all required data were submitted. We encourage you to verify all facility information prior to submission, including CMS Certification Number (CCN) and facility name.
View the list of measures required for the May 15, 2023 deadline on the SNF Quality Reporting Program Data Submission Deadlines webpage.
For submission information, visit:
Swingtech sends informational messages to SNFs that are not meeting the Annual Payment Update (APU) threshold on a quarterly basis ahead of each submission deadline. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@swingtech.com and be sure to include your facility name and CCN along with any requested email updates.
April 26, 2023
Care Compare April Refresh of SNF QRP Data – Now Available
The April 2023 refresh of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).
For more information, please visit the SNF QRP Public Reporting webpage.
April 24, 2023
NOW AVAILABLE: OSA Item Set and OSA Manual
The Optional State Assessment (OSA) Item Set, OSA Manual, and OSA Change History table are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual webpage. The OSA is not a Federally required assessment; rather, it may be required in some States for payment purposes. Each State determines whether the OSA is required and if so, when the assessment must be completed. For questions regarding completion of the OSA, please contact your State Survey Agency.
April 14, 2023
SNF Provider Preview Reports – Now Available
The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the July 2023 refresh.
For more information, please visit the CMS SNF QRP Public Reporting webpage.
April 4, 2023
PPS and Consolidated Billing for SNFs; Updates to the QRP and VBP Program for Federal FY 2024 (CMS-1779-P)
On April 4, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1779-P) that provides updates to and proposals for the fiscal year (FY) 2024 Skilled Nursing Facility Quality Reporting Program (SNF QRP). This rule includes three new measure proposals, one measure modification proposal, and three measure removal proposals. The new measure proposals include the Discharge Function Score measure; the CoreQ: Short Stay Discharge Measure; and the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure. CMS is also proposing to modify the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure to report the number of HCP who are up to date with recommended COVID-19 vaccinations per the latest Centers for Disease Control and Prevention (CDC) guidance. In addition, CMS is proposing the removal of three measures including the Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function; the Application of the IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients; and the Application of the IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients. We are also proposing changes to the data completion thresholds for the Minimum Data Set (MDS) data items and to begin the public reporting of the Transfer of Health (TOH) Information to the Patient-Post-Acute Care (PAC) and TOH Information to the Provider-PAC measures. Finally, we are seeking information on principles for selecting and prioritizing SNF QRP quality measures and concepts and providing an update on CMS’ continued efforts to close the health equity gap.
The proposed rule went on display at the Federal Register and is available at: https://www.federalregister.gov/public-inspection
April 3, 2023
NOW AVAILABLE: Final MDS 3.0 Item Sets version 1.18.11
The final Minimum Data Set (MDS) 3.0 Item Sets version v1.18.11 are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The MDS Item Sets v1.18.11 will be effective beginning October 01, 2023.
April 3, 2023
NOW AVAILABLE: Draft MDS 3.0 RAI User’s Manual version 1.18.11
The draft Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version (v) 1.18.11 is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual webpage. The MDS 3.0 RAI User’s Manual v1.18.11 will be effective beginning October 01, 2023.
This version of the MDS 3.0 RAI Manual contains substantial revisions related to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), which requires that standardized assessment items be collected across post-acute care (PAC) settings. Standardized data will enable cross-setting data collection, outcome comparison, exchangeability of data, and comparison of quality within and across PAC settings. Additionally, the language of the manual has been updated throughout to be gender neutral. Guidance and examples in numerous chapters and appendices have been revised for clarification and to reflect current regulations and best practices. Due to the scope of the revisions, the Centers for Medicare and Medicaid Services (CMS) will not issue Replacement Pages for v1.18.11; those wishing to continue using a physical copy of the manual are encouraged to print the new version.
Page Last Modified:
11/03/2023 08:54 AM