MDS Alert

Published on Mon Oct 27, 2008 PDF

The Centers for Medicare & Medicaid Services allows these 5 scenarios.

You can bill Medicare the default rate without an MDS in these limited situations:

• When the stay is less than eight days within a spell of illness (that is, benefit period).

• The SNF is notified on an untimely basis or is unaware of a Medicare Secondary Payer denial;

• The SNF is notified on an untimely basis of the revocation of a payment ban;

• The beneficiary requests a demand bill; or,

• The SNF is notified on an untimely basis or is unaware of a beneficiary's disenrollment from a Medicare Advantage program.

Important point: You can use the OBRA-required admission assessment to replace a Medicare-required five-day and 14-day assessment in scenarios involving untimely notice of an MSP denial, revocation of a payment ban -- or a resident's disenrollment from a Medicare Advantage plan, according to the final SNF PPS rule. This would allow the SNF to bill the MDS-generated RUG score rather than the default rate. But in those same scenarios, a SNF would have to do the 30-, 60- or 90-day PPS assessment within the window in order to bill the MDS-generated RUG. "Otherwise, you'd bill the default rate," says Ron Orth, RN, NHA, CPC, RAC-CT, president of Clinical Reimburse- ment Solutions LLC in Milwaukee.

Also: Language in both the FY 2009 SNF PPS final rule and July 2008 RAI user's manual update says the SNF can bill the default rate if it doesn't do an MDS when a resident's Part A stay is less than eight days within a spell of illness (that is, benefit period). Orth doesn't think that language is an error on CMS' part. But it is "a big surprise," he says.

Consultant Marilyn Mines, RN, RAC-CT, BC concurs, noting that the requirement puts the onus on nursing more than on billing for tracking a resident's benefit period.

Stay tuned: Some industry experts say the language cited above about the stay being less than eight days within a benefit period is causing confusion and they plan to ask CMS to further clarify this instruction.