Phase Two

Project Structure

During the first two years of Phase Two, GNYHA Foundation continued to partner with the Icahn School of Medicine at Mount Sinai (Mount Sinai) to employ the Registered Nurse Care Coordinators (RNCC) that serve as educators and consultants to 27 of the 29 nursing facilities that participated in Phase One and continued into Phase Two, also known as Group B nursing facilities. Thirty-one Group A nursing facilities were added as the new cohort in Phase Two and do not have a RNCC provided by the NY–RAH project; they instead test payment reform initiatives to treat six clinical conditions in place at the facility. Group B nursing facilities are also eligible for these payment reform incentives. In years three and four, the RNCC role was replaced by Quality Improvement Specialists (QISs) to further promote sustainable quality improvement activities and use data to drive change throughout the facility.

The goal of Phase Two is to test the different care models to determine which provides the highest quality of cost-effective care. Research Triangle International, the evaluation contractor for CMS in Phase One, will continue to evaluate the Initiative.

How do the payment incentives work?

Facility Payment Tools
Facility Payment Incentives

Research shows that six conditions are linked to approximately 80% of potentially avoidable hospitalizations among LTC facility residents.

  • Pneumonia
  • Dehydration or Fluid/Electrolyte Disorder
  • Congestive heart failure (CHF)
  • Urinary tract infection (UTI)
  • Skin ulcers or cellulitis
  • COPD or asthma

To create an incentive for facilities to invest more time and resources than is currently required to furnish services and treat beneficiaries in-house without transferring to the hospital, the first component of the model is a new code category billable by the skilled nursing facility under Medicare Part B for the treatment of the above six conditions only.

Facility Chart Audit Tool
Facility Chart Audit Tool

The NY–RAH team created the Facility Chart Audit Tool in early 2018 to ensure that all claims billed under the facility payment incentive codes (G9679-G9684) are compliant with CMS Nursing Facility Initiative (NFI) criteria. The Excel-based tool uses built-in logic to provide instant feedback based on the data entered (e.g., resident information; dates for the episode, documentation, and billing; clinical criteria, etc.). All facilities are encouraged to use to the tool to track potentially billable episodes and determine which episodes they can bill. Facilities can use the tool retroactively to review a sample of charts and proactively to track episodes in real time. Please read through the instructions tab carefully to understand how to use the tool.

The most updated versions of the tool (versions 3.1 and 3.2) include reference columns that auto-populate the last potential day of billing based on the maximum benefit period for the condition and the day the acute change of condition (ACOC) was first noticed, the number of days between the onset of the ACOC and the practitioner visit, and a summary sheet that provides aggregate data on all episodes entered into the tool. Version 3.2 includes an additional resident eligibility field for facilities to use if they’d like to double-check that claims are submitted only for eligible residents (please note that facilities that use this version must enter eligibility in order for feedback to populate). Version 3.1 does not include the additional resident eligibility field.

If you have questions regarding the tool, please contact Faiza Haq, Senior Project Manager for Payment Reform, at or 212-506-5421.

Practitioner Payment Tools
Practitioner Payment Incentives

This model tests a new payment under the Medicare physician fee schedule that can be billed by a practitioner for an initial visit to evaluate an acute change in condition in the long term care (LTC) facility. Payment for the service would be based on the condition of the resident rather than whether the service is furnished in a hospital or LTC facility setting. In other words, when a practitioner sees a beneficiary in the LTC facility for an acute change in condition, the practitioner would be paid for the service at the equivalent of an acute hospital initial visit code (99223). The level of documentation needed is comprehensive; however, practitioners can follow the simplified documentation standards relating to “Removing Redundancy in E/M Visit Documentation” beginning January 1, 2019 and detailed here.

Of note, practitioners had an opportunity to bill a NFI-specific code for care conferences prior to January 1, 2019; however, this was discontinued and practitioners are advised to bill the other Advanced Care Planning (ACP) codes (99497-99498).

Nursing Documentation Tools
Nursing Documentation Education

Proper nursing documentation for the six conditions is essential for telling the story of the resident’s clinical progression and is required for an episode to be considered billable by CMS. To assist in the training and education of CNAs, LPNs, and RNs, NY–RAH has created in-service presentations and lesson plans highlighting the critical elements that must be documented by each.