The sound of spring is in the air and irritants abound.

The sniffling, sneezing and coughing is always a telltale sign of a change in seasons. 

April also brings to us the release of the Program for Evaluating Payment Patterns Electronic Report (PEPPER).

Fun fact, on why pepper makes us sneeze: It contains a volatile compound called piperine which is released when pepper is crushed. When this compound reaches the nose, it irritates certain receptors in the nose and causes us to sneeze respond to get rid of the irritant.

ACHOO!

PEPPER reports, on the other hand, shouldn’t be viewed as an additional nuisance and should provide useful data for the entire interdisciplinary team to review to assess trending and develop strategies for supplemental review of documentation. 

What Is PEPPER? 

PEPPER is a report that uses National SNF claims data to identify areas within the SNF prospective payment system (PPS) that could be at risk for improper Medicare payment. These areas are referred to as “target areas.” 

PEPPER is a data report that contains a single SNF’s Medicare claims data statistics (obtained from the UB-04 claims submitted to the Medicare Administrative Contractor [MAC]) for these target areas. All SNFs that have sufficient data to generate a report receive a PEPPER, which contains statistics for these target areas. 

The SNF PEPPER allows SNFs to compare their billing statistics with national, jurisdiction and state percentile values for each target area with reportable data for the most recent three fiscal years (Oct. 1 through Sept. 30) included in PEPPER.

What areas are compared in PEPPER?

PEPPER reports show how a SNF’s data compares to aggregate jurisdiction, state and national statistics. Statistics in PEPPER are presented in tabular form and in graphs that depict the SNF’s target area percentages over time. All of the data tables, graphs and reports in PEPPER were designed to assist SNFs with the identification of potentially improper payments. PEPPER is developed and distributed by the RELI Group, along with its partners TMF® Health Quality Institute and CGS, under contract with the Centers for Medicare & Medicaid Services (CMS).

Also, of key importance when teams are reviewing data the following should be considered:

PEPPER does not identify the presence of improper payments, but it can be used as a guide for auditing and monitoring efforts. A SNF can use PEPPER to compare its claims data over time to identify areas of potential concern and to identify changes in billing practices.

Great! So, what are this year’s target areas?

To begin, the target areas are constructed as ratios and expressed as percentages; the numerator represents episodes of care that may be identified as problematic, and the denominator represents episodes of care of a larger comparison group. 

This year’s target areas are as follows:

High Physical Therapy and Occupational Therapy Case Mix (new as of the fourth-quarter fiscal 2021 release)

Definition: The High Physical Therapy and Occupational Therapy Case Mix target area assesses the use of the physical therapy (PT) and occupational therapy (OT) case mix groups with the highest PT or OT case mix index. N: count of SNF claims where the first character of the Health Insurance Prospective Payment System (HIPPS) code, representing the physical and occupational therapy component, is one of the following: C, D, F, G, J, K, N, or O D: count of all SNF claims

High Speech Language Pathology Case Mix (new as of the Q4FY21 release)

Definition: The High Speech Language Pathology Case Mix target area assesses the frequency of four of the SLP case mix groups with the highest case mix index. N: 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 D: count of all SNF claims

High Nursing Case Mix (new as of the Q4FY22 release)

Definition: The High Nursing Case Mix target area assesses the use of six of the highest paying categories of the nursing payment groups. N: count of SNF claims where the third character of the HIPPS code, representing the nursing payment group, is one of the following: A, B, C, D, H, or L D. count of all SNF claim

20-Day Episodes of Care

Definition: N: count of episodes of care ending in the report period with a LOS of 20 days D: count of all episodes of care ending in the report period

90+ Day Episodes of Care

Definition: N: count of episodes of care ending in the report period with a LOS of 90+ days D: count of all episodes of care ending in the report period

3- to 5-Day Readmission

Definition: N: count of readmissions within three to five calendar days (four to six 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 D: count of all claims associated with SNF episodes ending during the report period, excluding patient discharge status code 20 (expired).

Now let’s move on to considerations on how teams should review and use this data.

First, we need to remember that PEPPER target areas were identified by CMS as being potentially at risk for improper Medicare payments. 

A high target area percent does not necessarily indicate the presence of improper payment or that the provider is doing anything wrong; however, under these circumstances, providers may wish to review their medical record documentation to ensure that the services their beneficiaries receive are appropriate and necessary, as well as to ensure that the documentation in the medical record supports the level of care and services for which they have received Medicare reimbursement.

The updated user guide also provides suggested interventions for teams to use when their trends are at/above the 80th percentile or at/below the 20th percentile. 

For example, a High Physical Therapy and Occupational Therapy Case Mix at/above the 80th percentile could indicate issues with the MDS coding of patients’ functional score. The SNF should review nursing and therapy documentation in the medical record to ensure the appropriateness of MDS coding, specifically as it relates to the ten items in Section GG, which is used for the PT and OT component.

Whereas a High Physical Therapy and Occupational Therapy Case Mix at/below the 20th percentile could indicate issues with insufficient medical record documentation, which is needed to accurately reflect patients’ functional scores. The SNF should review the accuracy or completeness of the medical record with members of the nursing and therapy staff, specifically as it relates to the ten items in Section GG, which is used for the PT and OT component.

Likewise, a High Speech Language Pathology Case Mix at/above the 80th percentile could indicate issues with the MDS coding of any of the five patient characteristics included in the SLP component: acute neurologic condition, SLP-related comorbidity, cognitive impairment, swallowing disorder, or mechanically altered diet. The SNF should review documentation to ensure that all SLP-component patient characteristics coded on the MDS are substantiated in the medical record.

High Speech Language Pathology Case Mix at/below the 20th percentile could indicate issues with insufficient medical record documentation, which is needed to accurately reflect any of the five patient characteristics included in the SLP component: acute neurologic condition, SLP-related comorbidity, cognitive impairment, swallowing disorder, or mechanically altered diet. 

The SNF should review the accuracy or completeness of the medical record documentation with members of nursing, therapy, and other staff to ensure that all patient characteristics associated with SLP components are adequately captured on the MDS.

Ready to download your reports?

The SNF PEPPER is available to the SNF’s CEO, administrator, president, Quality Assurance and Performance Improvement officer, or compliance officer through a secure portal at PEPPER.CBRPEPPER.org 

Spring is in the air, so it’s definitely time to dust off the old and take a fresh look at trends and methods for improving data reporting and care provision. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected].

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.