Harmony Healthcare Blog

SNF PPS Final Rule FY2019: Principal Diagnosis and Expected Decline

Posted by The Harmony Team on Tue, Oct 30, 2018

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Close up of the profile of a young female doctor or nurse taking patient notes on the ward-1The Final Rule is in play and a recent webinar conducted by Kris Mastrangelo spurred some relevant questions that require sharing.  One of these questions spurs thought on the included and excluded diagnoses for the SNF Value-Based Purchasing Rehospitalization metric.

  1. Are there any diagnoses that are considered when rehospitalization penalties occur? For example, a Cancer diagnosis who has no advance directive, and is not hospice may quickly return to the hospital for emergent care. 

    Yes, there are diagnoses that impact the rehospitalization 

    Patients with a principal diagnosis for the prior proximal hospitalization and the medical treatment of cancer are excluded from the measure.  

    Patients with a principal diagnosis for the prior proximal hospitalization and the medical treatment of other diagnoses with the surgical treatment of their cancer are included in the measure.  

    The rationale is that these admissions have a very different mortality and readmission risk from the rest of the Medicare population, and outcomes for these admissions do not correlate well with outcomes for other admissions, as determined in the development of the HWR measure.

    Additional exclusions include:
    • SNF stays where the patient experienced one or more intervening Post-Acute Care admissions (IRF or LTCH) that occurred either between the prior proximal hospital discharge and SNF admission or after the SNF discharge within the 30-day risk window.
    • SNF admissions where the patient experienced multiple SNF admissions after the prior proximal hospitalization within the 30-day risk window.
    • SNF stays where the patient did not have at least 12 months of Fee For Service Medicare Part A enrollment before the proximal hospital discharge.
    • SNF stays where the patient was discharged from the SNF against medical advice.
    • SNF stays in which the principal diagnosis for the prior proximal hospitalization was for “rehabilitation care; fitting of prostheses and for the adjustment of devices.”
    • SNF stays in which the prior proximal hospitalization was for pregnancy
  1. How is expected decline evaluated? Some end of life chronic diagnoses with poor functional outcomes/expectations based on clinical conditions exemplified by poor FEV, Mobility impairment, pressure ulcers indicating skin failure, may result in re-hospitalization demanded by family despite staff awareness of end of life status. Can facilities maximize risk/loss in more ways than good documentation in these complex circumstances?

    The heightened presence of the MD and NPP in the SNF, Advanced Directives, educating families on the facilities capabilities in providing “skilled care” in the facility, end of life discussions and hospice services.  The SNF must ensure they accurately code the MDS to apply the risk adjustments. 

The phone is off the hook with questions and we hope to see you at harmony18, the 7th annual LTPAC Interdisciplinary Symposium.  

Interested in learning more? Join us at harmony18, our 7th annual interdisciplinary LTPAC symposium.  This year’s symposium features former NFL and Super Bowl player, Joe Andruzzi; Inspirational Charity Founder, Ellie Anbinder; AHCA Sr. VP, Dr. David Gifford; an entire panel on PDPM; and more!  10 continuing education hours for all disciplines.  November 1-2, 2018 at Mohegan Sun Resort and Casino.

Click Here to Register. Room block expires October. 

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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