NFI Payment Incentives Ending Effective October 1

In August, all NY–RAH-participating facilities were notified of CMS’s decision to discontinue the Nursing Facility Initiative (NFI) payment incentives, effective October 1, 2020. This change includes both the facility codes (G9679-G9684) and the practitioner code (G9685), which were created in 2016 for Phase Two of the NFI. If a facility or practitioner submits claims under these codes for services provided after September 30, their Medicare Administrative Contractor (MAC) will automatically reject them. For episodes that would normally extend beyond September 30, the facility can only bill through September 30, and not for the entirety of the episode. Additionally, practitioner confirmation visits must occur no later than September 30 for all facility episodes.

Facilities are encouraged to submit claims for services provided through September 30 to receive the additional reimbursement they are eligible for under Phase Two for onsite treatment of the six qualifying conditions. As a reminder, claims can be submitted up to one year after an episode and/or visit occurs, as is otherwise applicable Medicare claim submission policy.  

Following the project’s end, facilities can contact CMS at with questions about NFI billing and recoupment that cannot be resolved with their MAC. Facilities also may continue to reach out to Faiza Haq with any billing questions.  

Group B Clinical Intervention Extended Through December 31

CMS recently approved a three-month extension for Group B facilities to continue the clinical intervention component of the NFI project through December 31, 2020. The extension will allow for the proper transition and training on NY–RAH processes and workflows developed by the Quality Improvement Specialists (QISs). QISs and Clinical Project Specialists (CPSs) assigned to Group B facilities have been working with staff on implementing a sustainable QAPI Performance Improvement Project (PIP) since the fall of 2019 to reduce avoidable hospitalizations through improved workflows and clinical processes. While the payment incentives will end as of October 1 for all participating facilities, the extension will allow the QISs and CPSs assigned to Group B facilities to complete work interrupted by the COVID-19 pandemic. 

Participation Agreement Amendments
All Group B facilities need to sign a participation agreement amendment to continue to receive support from NY–RAH after September 30. The amendment is needed for NY–RAH project staff to have continued access to facility data and to update the end date of the expiring participation agreement signed in 2016. Please submit the signed amendment to Megan Burns by September 30 to continue benefitting from the work of the QIS and CPS during the extension period. If your facility does not wish to move forward with the extension, please also let NY–RAH know as soon as possible. NY–RAH will continue to be available as a resource over the next several months for all facilities should the need arise for technical assistance. 

Extension Period Workplan of QIS and CPS 
The QISs have been working with facility leadership to designate a project manager at each facility to take over the PIPs. During the extension period, the facility project manager will be trained on the data collection methodologies for the PIPs and will support any new Plan, Do, Study, Act (PDSA) cycle iterations as part of the handoff. In addition, the QISs are available to help facility leadership train staff on any other process improvement workflows that may have been identified during the infection prevention response to COVID-19.

The CPSs also will contact facility medical directors to discuss the NY–RAH Practitioner Documentation Assessment Guide, a publication designed to assist long-term care medical directors with reviewing the quality of practitioner documentation following an acute change of condition (ACOC), which NY–RAH will release shortly. The Guide includes the NY–RAH ACOC Documentation Assessment Tool, a one-page checklist designed to identify gaps in documentation in the standard Subjective, Objective, Assessment, and Plan (SOAP) note format. The SOAP note format encourages processes that require clinicians to maximize the use of critical thinking and problem-solving skills for documentation.

Phase Two Billings To Date Top $11 Million

Since Phase Two began in November 2016, the NY–RAH Data Team has been routinely analyzing claims data to monitor how NY–RAH facilities use the Phase Two facility payment incentives for the six qualifying conditions. To date, the NY‒RAH project’s 54 participating skilled nursing facilities have billed more than 8,000 facility episodes for nearly $11.5 million in total additional facility reimbursement. Fourteen facilities have earned between $250,000 and $500,000, with three additional facilities earning more than $500,000 in additional revenue solely due to their participation in the NY‒RAH project. 

In addition to the revenue earned, the Data Team analyzed the frequency that facilities billed each condition over the first three years of Phase Two (November 2016–September 2019). On average, facilities billed about 11.7 episodes per quarter. Facilities billed pneumonia, skin ulcers/cellulitis, and urinary tract infection (UTI) more often than other conditions, accounting for 81.8% or more of total episodes billed each year. In comparison, congestive heart failure, chronic obstructive pulmonary disease/asthma, and dehydration accounted for 18.2% or less of total billed episodes. Both pneumonia and UTI had relatively steady billing rates of episodes per 100 eligible beneficiaries in the first three years of the project, while the remaining four conditions experienced decreases in the frequency they were billed from Project Year 1 to Project Year 3. The Data Team intends to continue to monitor billing patterns through the end of the payment incentives. 

Please contact Courtney Zyla with any questions regarding facility billing or earned revenue.

Data Portal Entry Requirements Ending September 30

In coordination with the end of the NY–RAH project, the NY–RAH Data Team will eliminate the NY–RAH data portal entry requirement after September 30. The Data Team will send final quarterly reports in mid-October based on data entered through September 30 to all facilities that entered data for the third quarter (Q3) of 2020.

Since November 2016, CMS has required NY–RAH to submit facilities’ patient-level data each quarter for numerous data categories. To collect this information, facility data portal users entered resident demographic, hospital transfer, ACOCs, and advance directive (for Group B only) data into the NY–RAH data portal. The data in the portal also has been used to create the quarterly Hospital Transfer Report and Palliative Care Report (for Group B only). In the past, the Data Team provided approximately a three-week period after the end of the quarter for data portal users to enter data that informs these reports. The Data Team cannot offer this extension period for Q3 2020, so all participating facility data portal users are requested to enter all Q3 2020 data by September 30. 

The NY–RAH Data Team thanks all data portal users for diligently entering data throughout the project. The Data Team appreciates the work of facility staff who took the time to maintain accurate data in the data portal.

If you have any questions regarding the data portal, data entry, or reporting, please contact Courtney Zyla.

Thank You!

The NY–RAH Project Management Team and all QISs and CPSs sincerely thank our Group A and Group B participating facilities for their hard work, dedication, and engagement over the past four (or eight) years. NY–RAH understands the challenges that exist within the post-acute and long-term care industry, and we believe that the lessons learned through the NFI will help inform future projects and the work of policymakers and other organizations. Please do not hesitate to reach out to us with any questions or comments. 

      NY-RAH is supported by Funding Opportunity Number 1E1CMS331492-01-01 from the US
Department of Health and Human Services, Centers for Medicare & Medicaid Services. The
contents provided are solely the responsibility of the authors and do not necessarily represent
the official views of HHS or any of its agencies.