Encore Keynote - June 2021


June 2021
Encore Rehabilitation’s monthly publication, designed to give you updates on trends we are seeing in the SNF/LTC industry.   


Depression, Quality Measures, and Clinical Approaches
Depression QM Defined: 
Percent of Residents Who Have Depressive Symptoms
QM Trigger Conditions: 
  • Little interest or pleasure in doing things or feeling down, depressed, or helpless half or more of the days indicated within the MDS assessment.
  • Interview or staff assessment score indicates 
  • presence of depression.

SNF Reporting Impact: QM, 5 Star, Nursing Home Compare, Survey Measures, Reported in CASPER


Clinical Impact: Participation in therapy, achievement of therapy goals, feeling of success and achievement, objective outcome scores, potential discharge destination.
What can the IDT do?
  • Develop an understanding of the Interprofessional roles in the provision of care to the SNF client with mental health or depressive diagnosis.
  • Collaboration of Nursing, MD, Psychiatry, Therapy, 
  • Pharmacy can lead to:
  • Identifying and addressing impairments that can  lead to rehospitalization and/or readmission
  • Medication reduction
  • Behavior management
  • Identification and treatment of barriers
  • Effective care planning
  • Treatment of impairments that support discharge plan

Clinical Approaches

  • Mindfulness; approaches, activities, apps
  • Exercise
  • Meditation
  • Muscle Relaxation
  • Sensory
  • Deep Breathing
Depression and COVID:
Many COVID survivors report feeling emotionally scarred by their time spent in ICU, high levels of anxiety, depression, and post-traumatic stress disorder.  Healthcare interdisciplinary teams who are aware of the psychological impact of COVID can establish appropriate treatment plans of care and provide services, minimizing the impact of depression with post-COVID patients. 

A recent presentation by CMS’ John Kane CMS presented data showing that “some metrics exhibited clear changes between FY 2019 and FY 2020, beginning just before or concurrent with PDPM implementation.” One of the metrics identified was the Percentage of Stays with Depression which saw an increase from an average of 4.2% pre-PDPM to 11.5% post-PDPM.


CMS released the FY2022 SNF Proposed Rule in April.
Some of the proposed changes include:

SNF PPS payment update of 1.3 percent, an increase in payments of $444 million, compared to FY 2021. This estimated increase is attributable to a 2.3 percent market basket increase factor, less the 0.8 percent forecast error correction, with an additional 0.2 percentage point reduction for multifactor productivity adjustment, and a $1.2 million decrease due to the proposed reduction to the SNF PPS rates to account for the recent blood-clotting factors exclusion (see below).  These impact figures do not incorporate the SNF VBP reductions that are estimated to be $184.25 million in FY 2022. 

Recalibration of the PDPM Parity Adjustment: As part of the transition from RUG-IV to PDPM, CMS sought to ensure the new system remained budget neutral, preserving parity with the previous case-mix index system.  CMS did this by taking the case-mix indexes produced for PDPM and multiplying them by an adjustment factor, to ensure payments would be equal to total actual payments under RUV-IV, assuming no changes in the population, provider behavior and coding.   

As part of the PDPM implementation, CMS has monitored PDPM utilization data and found that the data has differences from what was projected. CMS identified an inadvertent increase in SNF spending since implementing PDPM. They observed slight decreases in the average CMI for the PT and OT rate components for both the full and subset FY 2020 populations as compared to what was expected and observed significant increases in the average CMI for the SLP, Nursing, and NTA components for both the full and subset FY 2020 populations as compared to what was expected, with increases of 22.6 percent, 16.8 percent, and 5.6 percent, respectively, for the full FY 2020 SNF population.  

CMS believes that, based on the data from this initial phase of PDPM, a recalibration of the PDPM parity adjustment is warranted to ensure that the adjustment serves its intended purpose to make the transition between RUG-IV and PDPM budget neutral. As a result of this analysis, the resultant PDPM parity adjustment factor would be lowered from 46 percent to 37 percent for each of the PDPM case-mix adjusted components.  

If this were applied to FY 2022, CMS estimated it would result in a reduction in SNF spending of 5.0 percent, or approximately $1.7 billion.   It is not yet proposing the adjustment; but CMS indicates that if this adjustment were to be implemented, CMS would consider a multi-year implementation of the reduction.  

CMS seeks comment on its methodology and on a potential multi-year implementation of the reduction.

Use of the Three-Day Waiver
  • SNFs will need to ensure they have well-documented reasons for using the three-day stay waiver since the regulations around who is considered a skilled patient were unchanged.
  • The three-day waiver does not necessarily pertain to COVID-19 patients, he noted, but rather was focused on all patients due to such factors as whether hospitals were taking in new patients or the effects of COVID on the hospital population.
  • That means SNFs need to ensure they have top-notch documentation when they skill patients in-house, covering how the patient went from non-skilled to skilled.


In FY2022 SNF PPS proposed rule CMS is proposing the following changes to the PDPM ICD-10 code mapping.
  • D57.42 “Sickle-cell thalassemia beta zero without crisis” and D57.44 “Sickle-cell thalassemia beta plus without crisis” propose to change the assignment of from medical mgment to “Return to Provider”.
  • K20.81 “Other esophagitis with bleeding”, K20.91, “Esophagitis, unspecified with bleeding, and K21.01 “Gastro-esophageal reflux disease with esophagitis, with bleeding” change from  “Return to Provider” to “Medical Management”
  • M35.81 “Multisystem inflammatory syndrome”, change from “Non-SurgicalOrthopedic/ Musculoskeletal” to “Medical Management”
  • P91.821 “Neonatal cerebral infarction, right side of brain,” P91.822, “Neonatal cerebral infarction, left side of brain,” and P91.823, “Neonatal cerebral infarction, bilateral.” Change from RTP to “Acute Neurologic”
  • U07.0, “Vaping-related disorder,” change from “Return to Provider” to “Pulmonary”
  • G93.1 “Anoxic brain damage, not elsewhere classified” be changed to “Acute Neurologic” from “Return to Provider,”


Market Expertise
Our goal at Encore is to help our partners be the providers of choice in their markets through joint marketing efforts. Thanks to our partnership with Advisory Board, we can develop census by completing a competitive analysis to create a customized marketing strategy.
Other resources are:
  • Personalized marketing materials
  • Best practices community referral strategies
  • Program Development
  • 30+ Clinical Programs
  • Patient discharge surveys 
  • Patient Success Stories
  • Facility report cards
Reach out to your RVP for more information!


For more information:
[email protected]