The Centers for Medicare & Medicaid Services (CMS) has released updated quality measure documentation for providers, including version 17.0 of the MDS 3.0 Quality Measures (QM) User’s Manual and version 7.0 of the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual. These updates, announced September 19, 2025, include materials that became effective January 1, 2025, as well as additional changes that will take effect on October 1, 2025.
The updated materials are available as a consolidated .zip file titled MDS 3.0 QM User’s Manual v17.0 Effective 1-1-2025 and Associated User Manual Files.zip, which includes six key documents:
- MDS 3.0 QM User’s Manual V17.0, which took effect January 1, 2025, outlines specifications for MDS-based quality measures and includes a summary of notable changes from version 16.0;
- A Risk Adjustment Appendix File for the MDS 3.0 QM Manual, which uses the same adjustment values as the previous version because the updates did not significantly change the calculations;
- Updated Claims-based Quality Measure Technical Specifications and related appendix for the Nursing Home Compare website;
- SNF QM User’s Manual V7.0, which details measure specifications for the SNF QRP effective October 1, 2025;
- A Risk Adjustment Appendix File for the SNF QM Manual;
- An Imputation Appendix File for the SNF QM Manual, which provides scoring details specifically for the Discharge Function Score measure when some data is missing.
These updates coincide with ongoing CMS efforts to improve access to publicly reported quality data through enhancements to the Medicare Compare websites and the new Provider Data Catalog (PDC), now available for download and public use.
The complete file package can be accessed here.
Compliance Perspective
Issue
CMS has released the updated MDS 3.0 Quality Measures User’s Manual v17.0 and SNF QRP Measure Calculations and Reporting User’s Manual v7.0, which include revised technical specifications, appendices, and risk adjustment files for both MDS-based and claims-based quality measures. These updates include materials that became effective January 1, 2025, as well as additional changes set to take effect on October 1, 2025. As facilities prepare for the remaining updates, it is important to evaluate current procedures, address staff training needs, and implement internal auditing processes to ensure compliance with the updated specifications.
Discussion Points
- Facilities should review and revise current quality monitoring and reporting procedures to align with both the January and October 2025 updates to the MDS 3.0 QM and SNF QRP manuals. This may include updating internal workflows related to data submission, validation, and correction processes. Facilities that routinely work with consultants for compliance reviews or mock surveys may wish to prioritize a focused review of their existing quality measure reporting systems to ensure they reflect the most current technical guidance.
- Educate appropriate staff on recent and upcoming updates to quality measure specifications. Training should help staff understand how the measures are calculated, including any updates related to data adjustments or how missing information is handled. Med-Net Academy offers the course Understanding and Using the Medicare Triple Check Process, which helps staff improve billing accuracy, avoid false claims, reduce denials, ensure residents receive entitled benefits, and better align clinical documentation with financial data. Additionally, Understanding the 5-Star Rating Program covers the rating system’s methodology, including the three performance domains, staffing measures, survey impacts (such as infection control and complaints), and factors affecting a facility’s rating.
- Conduct audits of quality measure data, particularly those related to risk-adjusted outcomes. Conduct audits to identify errors or documentation issues in quality measure calculations before the data is publicly reported. Some facilities may benefit from outside support to perform focused mock audits or reviews tied to their quality improvement programs, especially in areas where performance has changed or declined. Working with consultants during this process can provide a fresh perspective and help uncover opportunities to improve compliance.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*