MDS Alert

Published on Tue May 10, 2005 PDF

Keep your balance in the black with this essential information.

No one can be right all the time, but SNFs that rely on the MDS to select HIPPS codes will be wrong often enough to ring up some Medicare payment issues.

"Many billing offices assume the assessment indicator or last two positions of the Health Insurance PPS (HIPPS) code comes from MDS Section AA8a and b (reasons for assessment)," says Diane Atchinson, RN, MSN, principal of DPA Associates Inc. in Kansas City, MO. "But that's true only about 95 percent of the time," she cautions.

The problem: Misbilling the assessment indicator sets a SNF up for potential payment recoupments - or undercuts RUG revenues, which can add up over time.

Get hip to the HIPPS basics: The Centers for Medicare & Medicaid Services' five-position HIPPS code includes the three-letter RUG category and the two-digit assessment indicator. The latter tells the FI which Medicare or OBRA-required assessment generated the RUG category. "The HIPPS code thus tells the fiscal intermediary both the RUG level to pay and the benefit cycle that generated this RUG category," says Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

In most cases, the coding in AA8a and AA8b does jibe with the assessment indicator or last two digits of the HIPPS. For example, the assessment indicator for a 60-day Medicare assessment would be "03." And the coding in AA8a and b is "0" and "3," respectively.

"The '03' at the end of the RUG score tells the FI to pay that RUG rate from day 31 to 60 or day 31 through the date of discharge, if it comes before day 60," explains Christine Twombly, RNC, chief clinical consultant with Reingruber & Company in St. Petersburg, FL.

Cut Through Coding Confusion

Keep your eye out for these tricky coding scenarios where the coding in AA8 doesn't match the assessment indicator:

1. A Significant Change in Status Assessment that's not combined with another assessment will be coded differently on the MDS than the assessment modifier used by billers as part of the HIPPS code on the UB-92, cautions Jan Zacny, RN, a consultant with BKD Southern Missouri in Springfield, MO. "Nursing would code an SCSA as a 3 in Section AA8a and an 8 in Section AA8b (38) on the MDS, but the assessment modifier would be 30 (off cycle significant change outside the assessment window)," she says.

Watch out: When doing an SCSA outside the window, don't leave Section AA8b blank. Instead, code an "8" for other Medicare required assessment.

2. Combined assessments. Say the MDS coordinator does an OMRA that replaces a 30-day or 60-day MDS (when the assessment reference date or ARD of the OMRA falls within the assessment window for a regularly scheduled MDS), postulates Andrea Platt, RN, with Thomas Healthcare Consulting, PC, in Indianapolis. Facilities do OMRA assessments when the patient stops all rehabilitation therapy services and still requires skilled nursing services. You'd code the aforementioned assessment as a "0" in AA8a and an "8" in AA8b.

But if the MDS coordinator doesn't tell the billing office that the MDS is an OMRA replacing a 30-day or 60-day MDS, etc., the billing office will have no way of knowing that by simply looking at the MDS coding. That's because the coding options offer no way to convey this information to a biller.

In this case, "billing would identify this assessment, via the HIPPS modifier, as an OMRA assessment only," says Platt. (The assessment indicators for OMRAs replacing a 30-day, 60-day and 90-day assessment would be 28, 38 and 48, respectively.)

Thus, the MDS must give billing a heads-up that the OMRA is replacing a 30- or 60-day assessment - or the SNF could end up with a situation where it doesn't bill some days of the resident's stay, cautions Mines.

Remember: If you do a regularly scheduled assessment (say a 30- or 60-day) that's combined with an OMRA, the payment changes on the ARD of that combined assessment. If you use grace days, the payment would change on the day it would have changed for the regularly scheduled assessment.

Thus, if the ARD for the OMRA combined with a 30-day assessment were on day 23, the payment rate (new RUG) would change on that day, explains Twombly.

"But if the ARD for that combined assessment were on day 34, which is the last possible grace day, then the payment rate changes on day 31, just as it would with a normal 30-day assessment," Twombly says.