As Medicare shifts toward value-based care, Skilled Nursing Facilities (SNFs) are increasingly under pressure to not only provide quality care but also accurately document and report it. The Merit-based Incentive Payment System (MIPS) plays a key role in this transition, but for SNFs, navigating the reporting process is far from straightforward.

Whether you are a SNF administrator, manager, or CEO, the stakes are high. A poor MIPS score can lead to significant Medicare payment penalties, while a strong performance can boost your facility’s reputation and revenue.

Key MIPS Challenges Faced by SNFs

1. Complex Provider Attribution

MIPS performance is tracked at the individual clinician level (NPI/TIN), but in SNFs, providers often:

• Work across multiple facilities or locations
• Bill under different Tax Identification Numbers (TINs)
• Provide care in transient or shared settings

Attribution errors may lead to inaccurate scoring or exclusions, with clinicians being incorrectly evaluated or omitted entirely.

2. Incomplete or Fragmented Data Capture

SNFs often use a combination of:

• Electronic Health Records (EHRs)
• Paper-based documentation
• Third-party billing platforms

Disparate systems make it difficult to aggregate MIPS-required data points, such as quality measures, Promoting Interoperability data, and Improvement Activities.

3. Limited Technical Infrastructure

Many SNFs lack the IT support needed to:

• Integrate MIPS-specific registries
• Ensure data submission in QPP-compliant formats
• Automate performance monitoring

This leads to manual errors, missed deadlines, or non-reporting, which can trigger automatic penalties.

4. Confusion Around Measure Applicability

Clinicians in SNFs, especially specialists like geriatricians, NPs, and physiatrists, often struggle to find relevant quality measures or activities under MIPS that match the SNF care setting.

This results in:

• Underreporting or opting out of measures
• Lower performance scores due to non-applicability
• Missed bonus opportunities

5. Resource Constraints

SNFs typically operate under tight staffing and budget constraints. Without dedicated MIPS consultants or trained in-house staff, reporting becomes a reactive process rather than a strategic one.

Facilities miss out on incentives and risk compliance errors.

Key Quality Measures applicable for SNFs

The following measures are particularly relevant for SNF’s:

1. Measure #006: Coronary Artery Disease (CAD): Antiplatelet Therapy

• Type: Process
• Description: Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed aspirin or clopidogrel.
• Relevance: Addresses cardiovascular health, a common concern in SNF populations.

2. Measure #007: CAD: Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)

• Type: Process
• Description: Percentage of patients aged 18 years and older with CAD and a history of MI or LVEF ≤ 40% who were prescribed beta-blocker therapy.
• Relevance: Ensures appropriate management of patients with significant cardiac history.

3. Measure #008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

• Type: Process
• Description: Percentage of patients aged 18 years and older with HF and LVEF ≤ 40% who were prescribed beta-blocker therapy.
• Relevance: Targets effective management of heart failure, prevalent among SNF residents.

4. Measure #047: Advance Care Plan

• Type: Process
• High Priority: Yes
• Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision-maker documented, or documentation that an advance care plan was discussed but not established.
• Relevance: Promotes patient-centered care and aligns with SNF goals of respecting resident preferences.

5. Measure #130: Documentation of Current Medications in the Medical Record

• Type: Process
• High Priority: Yes
• Description: Percentage of visits for patients aged 18 years and older during which the clinician documented a list of current medications.
• Relevance: Critical for medication management and reducing adverse drug events in SNF settings.

6. Measure #154: Falls: Risk Assessment

• Type: Process
• High Priority: Yes
• Description: Percentage of patients aged 65 years and older who were screened for future fall risk during the measurement period.
• Relevance: Addresses fall prevention, a significant concern in SNFs.

Key QRP Measures applicable to SNF’s

The SNF Quality Reporting Program (QRP), established under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, mandates that SNFs report specific quality measures to the Centers for Medicare & Medicaid Services (CMS).

Categories of SNF QRP Measures

SNF QRP measures are categorized based on the data collection method:

• Assessment-Based Measures: Derived from the Minimum Data Set (MDS) assessments submitted by SNFs.
• Claims-Based Measures: Calculated using Medicare Fee-For-Service (FFS) claims data; no additional data submission is required from SNFs.

Key Assessment-Based Measures

These measures are collected through MDS assessments and focus on various aspects of patient care:

• Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
• Application of Percent of Residents Experiencing One or More Falls with Major Injury
• Drug Regimen Review Conducted with Follow-Up for Identified Issues
• Change in Self-Care Score for Medical Rehabilitation Patients
• Change in Mobility Score for Medical Rehabilitation Patients
• Discharge Self-Care Score for Medical Rehabilitation Patients
• Discharge Mobility Score for Medical Rehabilitation Patients
• Transfer of Health Information to the Provider—Post-Acute Care
• Transfer of Health Information to the Patient—Post-Acute Care
• COVID-19 Vaccination Coverage among Healthcare Personnel

Key Claims-Based Measures

These measures are calculated from Medicare FFS claims data and reflect outcomes such as hospital readmissions and emergency department visits:

• Discharge to Community – Post Acute Care (PAC) SNF QRP
• Medicare Spending Per Beneficiary (MSPB) – PAC SNF QRP
• Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP
• Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

Actionable Solutions for SNF MIPS Success

1. Perform a MIPS Readiness Assessment

Conduct a thorough review of:

• Clinician eligibility and attribution
• Available reporting methods (EHR, registry, QPP portal)
• Current participation status (individual, group, APM)

TriumpHealth can help SNFs build a tailored MIPS strategy based on your providers’ billing patterns and facility setup.

2. Leverage Group or Virtual Group Reporting

SNFs with multiple eligible clinicians may benefit from Group Reporting, which allows:

• Aggregate data submission for all clinicians under one TIN
• Uniform performance measurement
• Reduced administrative burden

Consider Virtual Group formation with aligned providers across facilities, which CMS permits under MIPS.

3. Align SNF Quality Metrics with MIPS Measures

Many MIPS Quality Measures align closely with SNF QRP and Care Compare standards, such as:

• Pressure ulcer prevention
• Medication reconciliation
• Fall risk assessment

Map existing QRP and Minimum Data Set (MDS) metrics to applicable MIPS measures to reduce redundancy.

4. Invest in a Qualified Registry or QCDR Partner

Registries can:

• Simplify data capture and submission
• Translate SNF workflows into MIPS-compliant reports
• Offer benchmark comparisons and feedback loops

 5. Train and Empower Your Team

MIPS success requires cross-functional participation. Equip your:

• Medical directors
• Compliance officers
• Billing teams
• Clinical staff

With tools and training to understand:

• Category requirements (Quality, PI, IA, Cost)
• Scoring thresholds
• Documentation protocols

6. Conduct an Annual MIPS Audit and Gap Analysis

Before submitting data:

• Review prior year scores
• Identify underperforming measures
• Flag missing documentation
• Explore improvement activities relevant to SNF workflows (e.g., care coordination, fall prevention programs)

Proactively resolve issues before submission deadlines and build long-term compliance strength.

How MIPS Impacts SNF Reimbursement and Reputation

• Positive Score (Above Threshold): Up to +9% adjustment
• Negative Score (Below Threshold): Up to -9% penalty
• Public Reporting: MIPS scores are published on CMS Care Compare, impacting referrals, partnerships, and patient trust

TriumpHealth: Your Partner in MIPS Reporting for SNFs

Our experienced consultants provide:

• Clinician attribution validation
• Custom measure selection and mapping
• End-to-end reporting support via QPP, EHR, or Registry
• Appeals and Targeted Review assistance
• MIPS training and documentation protocols

Conclusion: MIPS Reporting for SNFs is Challenging but Solvable

SNF leaders don’t need to navigate MIPS alone. With proactive planning, strategic data use, and the right MIPS partners, your facility can avoid costly penalties, maximize incentives, and reinforce your commitment to high-quality patient care. Ready to improve your SNF’s MIPS performance? Contact TriumpHealth at (888) 747-3836 x0 or [email protected] to Schedule a Free Consultation.