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PEPPER Report and 5 Star Ratings: Why Your Long-Term Care Facility Should Care

Monitoring data in long term care can be the key to success.

Five Star Ratings and PEPPER Reports are two data sources your organization needs to review to stay on top of industry changes. The Centers for Medicare & Medicaid Services (CMS) recently released revisions to the 5 Star Technical Users’ Guide, and with the January 2021 refresh, your 5-star rating may be changing.

5 Star Technical Users’ Guide Revisions Overview

Our team reviewed the changes that were made and pulled out some you need to be aware of.

1. New Website

The Nursing Home Compare website was retired and now is being replaced by the new Care Compare Website. The January 2021 refresh will resume the health inspections’ calculation from survey results that occurred after March 3, 2020. The infection control focused surveys will be included in the calculations. These surveys’ citations will count towards the total weight, similarly to how compliant survey citations are counted. These changes also mean the Special Focused Facility (SFF) program will be updated. This will remove the abuse icon for facilities that no longer meet the criteria.

2. Reporting Staff

In the January 2021 refresh, if you did not report staffing for the November 14, 2020 deadline, or if you reported four or more days in a quarter with no registered nurse coverage, then your staffing rating will be suppressed. It will show “Not Available” for the January, February, and March refreshes on Care Compare.

3. Data to be Used in Rating

Starting with the April 2021 refresh, the staffing data submitted by February 14, 2021, will be used for the 5-star ratings. At this point, if you did not report staffing for October-December 2020 or reported four or more days in a quarter with no RN coverage, your staffing rating will be reduced to one star.

4. Quality Measures

This refresh will resume the quarterly updates of most of the Quality Measures (QMs). This update will look at data from July 2019-June 2020. There will be two measures that will not update in January 2021. These are part of the SNF Quality Reporting System (QRP). They are residents with pressure ulcers/injuries that are new or worsening and the rate of a successful return to home and community from the SNF.

Let Blue help navigate your organization through these updates. We offer quarterly review services of your Quality Measures before the end of the quarter to ensure the coding of the QM trigger is accurate. We can review the need for education about pulling up MDS assessments, coding, and implementing daily practices to make your facility proactive about the QM process.

PEPPER Report: Is Your Organization Accessing this?

The PEPPER Report stands for Payment Patterns Electronic Report. The CMS provides this free provider level report to compare services used and billing at state and national levels. According to the PEPPER Report Website: 0-19% of Kentucky facilities, 20-39% of Ohio facilities, and 60-79% of Indiana facilities access these reports.

The PEPPER Report reviews three years of data statistics for each CMS target area. This report covers:

  • Ultra-High Therapy RUG (Phasing out with the change to PDPM)
  • Change of Therapy Assessment (COT) (Phasing out with the shift to PDPM)
  • Non-therapy RUGS with High ADL (Phasing out with the shift to PDPM)
  • Therapy RUGS with High ADL (Phasing out with the shift to PDPM)
  • 20 Day Episodes of Care
  • 3-5 Day Readmission
  • 90+ Day Episodes of Care

Why the PEPPER Report Matters

This report can help identify areas of potential overpayments and underpayments. It can show if the facility is continuing treatment beyond the point where services are necessary. The report can show if patients are discharged prematurely or readmission after three nights and resetting of the per diem occurs. Medicare Administrative Contractor (MAC) and Recovery Audit Contractor (RAC) can use this data to target facilities for further audits.

What Your Organization Should Do

The PEPPER report’s information can be used by the facility to help you target auditing and reviewing areas. Do you need to check your claims for medically necessary of services? Are you reviewing readmission for appropriateness for a skilled level of care? Was the discharge appropriate, and were the needed services set up upon discharge?

Blue’s Post-Acute Care Team offers an array of auditing and problem-solving services to help you with your PEPPER Report findings:

  • RAC audit preparedness
  • Documentation review
  • MDS coding review
  • Review of GG coding process
  • Review/education of the discharge
  • Medical necessity review

To get more information from the Post-Acute Care team, you can sign up to receive our newsletters and notifications for new blog posts. For any questions, please contact your local Blue & Co., LLC Advisor.

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