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As previously communicated, the Centers for Medicare & Medicaid Services
(CMS) requires that all Medicare Advantage Organizations (MAO) submit Health
Insurance Prospective Payment System (HIPPS) codes on all Skilled Nursing
Facility (SNF) and Home Health Agency (HHA) claims/encounters with a "from"
date on or after July 1, 2014. The original communication from CMS indicated
that the HIPPS codes should come from the initial Omnibus Budget Reconciliation
Act
(OBRA)-required comprehensive assessment (Admission assessment) and Outcome and
Assessment Information Set (Start of Care assessment), respectively.
SNF claims/encounters
Recently, Independence received further guidance from CMS regarding this
requirement for SNF encounters when no Admission assessment was completed
during the Medicare Advantage (MA)-covered stay. The requirements previously
communicated, as well as
this new guidance from CMS, extended to 2015 dates
of service. The following rules apply if there was no Admission assessment
completed during the MA-covered part of the stay:
- Stays of more than 14 days. If the Admission assessment for a stay
in the facility was completed prior to the MA-covered portion of the stay, MAOs
must submit to CMS a HIPPS code by following the guidance in the order they are
listed below:
- –Submit the HIPPS code from another assessment completed
during the MA-covered portion of the stay. If the OBRA Admission assessment
was completed for the current stay prior to the MA-covered portion of the stay,
and another assessment (e.g., Quarterly Assessment or any Prospective Payment
System assessment required by the MAO) was completed during the MA-covered
portion of the stay, the MAO shall submit the HIPPS code generated from that
other assessment on their encounter submissions to CMS.1
- –Submit the HIPPS code from the most recent assessment
that was completed prior to the MA-covered portion of the stay. If no
assessment was completed during the MA-covered portion of the stay from which a
HIPPS code could be generated, the MAO shall submit to CMS the HIPPS code from
the most recent OBRA or other assessment that was completed prior to the
MA-covered portion of the stay (which may be the Admission
assessment).1
- Stays of 14 days or less. If there was no Admission
assessment completed before discharge for a stay of less than 14 days, MAOs
must submit to CMS
a HIPPS code by following the guidance in the order they are listed below:
- –Submit the HIPPS code from another assessment from the
stay. If no OBRA Admission assessment was completed for a SNF stay of less
than 14 days, the MAO shall submit to CMS the HIPPS code from any other
assessment that was completed during the stay that produces a HIPPS
code.1
- –Submit a default HIPPS code of "AAA00." MAOs may
submit a default HIPPS code for SNF encounter submissions to CMS only if: 1)
the SNF stay was less than 14 days within a spell of illness, 2) the
beneficiary has been discharged prior to the completion of the initial OBRA
Admission assessment, and 3) no other assessment was completed during the
stay.2 To submit a default HIPPS code to the Encounter Data System,
MAOs should use the default Resource Utilization Group code of "AAA" and
Assessment Indicator "00" on encounter data submissions starting with "from"
dates of service July 1, 2014.
MAOs may not use this default code in other situations, such as to
avoid collecting the proper HIPPS code, or when the MAO's systems are not
prepared to submit the HIPPS code to CMS.
As a reminder, all SNF and HHA claims/encounters must be submitted on the
837-Institutional format.
If you have any questions about these requirements, please contact your
Network Coordinator.
1 CMS understands that some MAOs require
providers to conduct assessments similar to those used under traditional
Medicare Part A Prospective Payment System (PPS) rules. Providers may submit to
MAOs, and MAOs can submit to the Encounter Data System, HIPPS codes derived
from the same item set and data specifications as those used under the SNF PPS.
We note that, in such cases, providers must not submit these assessments
through the traditional PPS assessment system.
2 Per the Assessment Management Requirements and Tips for
Comprehensive Assessments (RAI Manual, pg. 2-17): "If a resident is discharged
prior to the completion deadline for the assessment, completion of the
assessment is not required." Federal statute and regulations require that SNFs
and Nursing Facilities promptly assess residents upon admission but no later
than the 14th calendar day of the resident's admission (admission date + 13
calendar days).
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