Skilled Nursing Facility Prospective Payment System FY 2025 (SNF)

The Centers for Medicare and Medicaid Services (CMS) recently issued the final rule for the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) FY 2026. CMS is publishing this final rule in accordance with the statutory requirements to update Medicare payment policies and rates for SNFs on an annual basis. Here is a summary of major provisions.

Patient-Driven Payment Model (PDPM)

• CMS proposed several changes to the PDPM ICD-10 code mappings to allow providers to provide more accurate, consistent, and appropriate primary diagnoses that meet the criteria for skilled intervention during a Part A SNF stay and maintain consistency with the latest ICD-10 coding guidance.
• This year, CMS proposed changing the clinical category assignment for 34 new ICD-10 codes that were effective 10/1/2024.

SNF Value-Based Purchasing (VBP) Program

• CMS is finalizing adopting a new reconsideration process that will allow SNFs to appeal CMS’ initial decisions for Review and Correction requests prior to CMS making any affected data publicly available, beginning with the FY 2027 program year.
• CMS is removing the SNF VBP Program’s Health Equity Adjustment from the Program’s scoring methodology.

SNF Quality Reporting Program (QRP)

• CMS is finalizing its proposal to remove four standardized patient assessment data elements from the Minimum Data Set (MDS) under the social determinants of health category beginning with the FY 2027 SNF QRP: (1) One item for living situation (R0310); (2) Two items for Food (R0320A and R0320B), and (3) One item for utilities (R0330) beginning with residents admitted on or after October 1, 2025, as previously finalized.
• CMS did not change any quality measures
• CMS also finalized amending the SNF QRP reconsideration policy and process. CMS will allow SNFs to request an extension to file a request for reconsideration and is updating the bases on which CMS can grant a reconsideration request.

The American Health Care Association (AHCA) created a summary outlining key provisions and impacts on members. This requires your AHCA/NCAL log-in to view. AHCA will also host a webinar on the rule tomorrow, August 7 at 3:30 PM EST. It is free for AHCA/NCAL members.