During the December SNF Open Door Forum call, CMS announced their plan to release the MDS 1.19.1, which will be effective October 1, 2024. CMS has indicated the revisions will be minor and impact primarily the following 3 areas of the MDS:

  • Section GG: Self-care and Mobility
    • The removal for the discharge goal column from the 5- day Medicare MDS
  • Section O: Immunizations
    • Addition of items to collect information related to the resident’s COVID vaccination status
  • Section N; High Risk Medications and Indication for use
    • Addition of item to collect information related to the use of anticonvulsant medications

The first two changes relate to updates to the SNF QRP program finalized in the FY2024 SNF PPS Final Rule. As outlined in this rule, CMS has removed the SNF QRP Measure related to the Percent of Patients with and Admission and Discharge Functional Assessment and a Care Plan that Addresses Function for the program. This was one of the first SNF QRP measures when the program was introduced as mandated by the IMPACT Act, and the focus was on the completion of the admission assessment from self-care and mobility item in section GG and establishing at least one discharge goal that addresses function. In the final rule, CMS indicated that the performance of this measure among SNFs was so high that meaningful distinctions in improvement can no longer be made. In addition, CMS has indicated that there are now outcome measures available, such as the Discharge Function Measures that are more strongly associated with the desired resident outcomes. As a result of this change, the collection of data related to the establishment of discharge goals is no longer necessary and will be eliminated. Another change to SNF QRP finalized includes the addition of a new measure to identify the Percent of residents who are up to date with the COVID-19 vaccine in accordance to the CDC recommendations. New data elements will be added to section O of the MDS to enable data to be collected for this measure. The data collection will likely be in a format similar to the coding items for the pneumococcal vaccine coding.

The updates to the high-risk drug classification coding in section O is the result of CMS’ increased focus on the use of high-risk psychotropic medications and their agreement with a recent OIG study that found although CMS met a goal related to the reduction of antipsychotic medications in nursing homes, the overall use of psychotropic medications during this period increased. The study raised concerns that when antipsychotic medications were discontinued, other drug classifications were substituted without an appropriate indication for their use.

Anticonvulsant is a drug classification which also increased, leading to questions related to the appropriateness of its increased use. The collection of data related to this drug classification will enable CMS to focus additional efforts on the appropriate use of these medications. The MDS 1.19.1 will be available at the link below when it is released in early 2024:

Minimum Data Set (MDS) 3.0 Technical Information | CMS

The MDS has a ripple effect on facility reimbursement, quality measures and care quality. Make plans to join Proactive beginning February 7, 2024 for The Impact of the MDS webinar series. This 5-session series targets what facility leaders need to know about the MDS to oversee and drive reimbursement, quality measures/QRP, 5-Star success and care quality.

Proactive’s MDS experts will provide clarity on crucial performance areas impacted by the RAI process, avoiding common errors and driving outcomes through MDS accuracy in your facility. Learn more and register The Impact of the MDS – Proactive LTC Consulting (proactiveltcexperts.com)




Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant

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