The Q4FY22 release of the Skilled Nursing Facility (SNF) Program for Evaluating Payment Patterns Electronic Report (PEPPER) with statistics through September 2022 is now available for download. Follow these steps to access your PEPPER and analyze any outlier billing patterns that may signal Medicare overpayment medical review risk for your facility.
About PEPPER
PEPPER is an educational tool that summarizes provider-specific data statistics for Medicare services that may be at risk for improper payments. Reports indicate how a providers data compares to peers in the jurisdiction, state and nation. High or low outlier trends are shared to guide providers in identifying areas of potential risk and need for compliance auditing and monitoring activities.
Visit the SNF “Training and Resources” page to access updated resources for using PEPPER, including recorded web-based training sessions, a sample SNF PEPPER, and the current SNF PEPPER User’s Guide (PDF, 11th Edition). PEPPER is developed under contract with the Centers for Medicare & Medicaid Services (CMS) by RELI Group, along with its partners TMF® Health Quality Institute and CGS.
| Target Areas Q4FY22 PEPPER | Target Area Definition | Outlier Indications per PEPPER contractor |
| High PT and OT Case Mix (new as of the Q4FY21 release) | Numerator: count of SNF claims where the first character of the HIPPS code, representing the PT and OT component, is one of the following: C, D, F, G, J, K, N, or O Denominator: count of all SNF claims | High or Low Outliers may indicate issues with MDS coding of the functional score, specifically section GG items used for the PT/OT component
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| High Speech Language Pathology Case Mix (new as of the Q4FY21 release) | Numerator: count of SNF claims where the second character of the HIPPS code, representing the SLP component, is one of the following: C, F, I, or L Denominator: count of all SNF claims | High or Low Outliers may indicate issues with MDS coding of the 5 patient characteristics included in the SLP component: acute neurological condition, SLP related comorbidity, cognitive impairment, swallowing disorder, or mechanically altered diet. Medical record documentation should clearly support coding in these areas. |
| High Nursing Case Mix (new as of Q4FY22 release) | Numerator: count of SNSF claims where the 3rd character of the HIPPS code, representing the nursing payment group, is one of the following: A, B, C, D, H, or L Denominator: count of all SNF claims | High or Low Outliers may indicate issues with coding and documentation related to the nursing component, including [but not limited to] the items indicating signs and symptoms of depression (i.e. D0300 or D0600) are coded on the MDS and substantiated in the medical record |
| 20 Day Episodes of Care | Numerator: count of episodes of care ending in the report period with a length of stay (LOS) of [exactly] 20 days Denominator: count of episodes of care ending in the report period | This could indicate that the SNF is continuing treatment beyond the point where skilled services are necessary |
| 90+ Days | Numerator: count of episodes of care ending in the report period with a LOS of 90+ days Denominator: count of all episodes of care ending in the report period | This could indicate that the SNF is continuing treatment beyond the point where skilled services are necessary |
| 3-5 Day Readmissions | Numerator: count of readmissions within 3-5 calendar days (4-6 consecutive days) to the same SNF for the same beneficiary (identified using the Health Insurance Claim number) during an episode that ends during the report period Denominator: count of all claims associated with SNF episodes ending during the report period, excluding patient discharge status code 20 (expired); (See Appendix 1 of SNF PEPPER User’s Guide) | This could indicate that patients are being discharged prematurely or that patients are being readmitted after the interrupted stay threshold, thereby resetting the variable per diem adjustment. |
Source: SNF PEPPER Users Guide Edition 11
Obtain your SNF PEPPER
To access your SNF PEPPER, the Chief Executive Officer, President, Administrator, Compliance Officer, Quality Assurance/Performance Improvement Officer, or other authorized user within your organization (selecting a job title closest to their title) should:
- Review the instructions and obtain the information required to authenticate access. Note: A new validation code will be required. This will be either a patient control number (found at form locator 03a on the UB-04 claim form) or a medical record number (found at form locator 03b on the UB-04 claim form) for a traditional Medicare Part A Fee-for-Service patient who received services from July 1, 2022, through Sept. 30, 2022 (“from” or “through” dates on a paid claim). Additionally, as a second option, a contact from the Provider Enrollment, Chain, and Ownership System (PECOS) will be sent an email and provided with a validation code to use to access the PEPPER from the PEPPER Portal. The validation code may be shared with others in the facility as deemed appropriate. SNFs that are swing-bed units of short-term acute care hospitals will use validation codes provided to Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) Security Administrators to access their PEPPER from the PEPPER Portal.
- Visit the PEPPER Resources Portal.
- Complete all the fields.
- Download your PEPPER.
The SNF PEPPER will be available to download for approximately two years.
Go to the SNF “Training and Resources” page to view resources for the Q4FY22 SNF PEPPER and to register for a live webinar on April 11 at 3 p.m. ET.
Concerned about outliers on your SNF PEPPER? Contact Proactive for a facility-specific PEPPER compliance analysis and QA review of Medicare claim coding and supportive documentation or for support in managing Medicare ADRs and Appeals.
Written By: Proactive LTC Consulting
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