CD145 R1958CP
User Manual: CD145
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CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 1958 Date: April 28, 2010 Change Request 6916 NOTE: This instruction was inadvertently transmitted in the policy section of the business requirement with incorrect final rules for FY of 2011. The correct FY is 2010. The business requirement has been revised. The transmittal number, date issued and all other information remain the same. SUBJECT: Skilled Nursing Facility (SNF) Health Insurance Prospective Payment System (HIPPS) Coding Updates Effective October 1, 2010 I. SUMMARY OF CHANGES: This instruction contains new HIPPS codes resulting from the conversion to the new RUG-IV coding system EFFECTIVE DATE: *October 1, 2010 IMPLEMENTATION DATE: October 4, 2010 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE R 6/30/Billing SNF PPS Services R 6/30.1/Health Insurance Prospective Payment System (HIPPS) Rate Code R 6/30.6.2/SNF PPS Rate Components R 6/30.6.3/Decision Logic Used by the Pricer on Claims III. FUNDING: For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers: No additional funding will be provided by CMS; Contractor activities are to be carried out within their operating budgets. For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. IV. ATTACHMENTS: Business Requirements Manual Instruction *Unless otherwise specified, the effective date is the date of service. Attachment - Business Requirements Pub. 100-04 Transmittal: 1958 Date: April 28, 2010 Change Request: 6916 NOTE: This instruction was inadvertently transmitted in the policy section of the business requirement with incorrect final rules for FY of 2011. The correct FY is 2010. The business requirement has been revised. The transmittal number, date issued and all other information remain the same. SUBJECT: Skilled Nursing Facility (SNF) Health Insurance Prospective Payment System (HIPPS) Coding Updates Effective October 1, 2010 Effective Date: October 1, 2010 Implementation Date: October 4, 2010 I. GENERAL INFORMATION A. Background: Effective October 1, 2010, the CMS is revising the SNF PPS case-mix system. The revised system will include 66 resource utilization groups (RUGs). This revised system is called the RUG-IV coding system. This instruction contains new HIPPS codes resulting from the conversion to the new RUG-IV coding system. The attached file contains the list of the newly added HIPPS codes. The 5-digit HIPPS code includes two components: the 3-digit classification code assigned to each RUG group, and newly defined 2-digit assessment indicators that specify the type of assessment used to support billing. B. Policy: Annual updates to the PPS rates for SNFs are required by section 1888(e) of the Social Security Act (the Act), as added by section 4432 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105–33, enacted on August 5, 1997), and amended by the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106–113, enacted on November 29, 1999), the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106–554, enacted on December 21, 2000), and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108–173, enacted on December 8, 2003). Our most recent annual update occurred in a final rule (74 FR 40289, August 11, 2009) that set forth updates to the SNF PPS payment rates for FY 2010. Under the BBA, each update of the SNF PPS payment rates must include the case-mix classification methodology applicable for the coming Federal FY. The FY 2011 payment rates reflect the use of the RUG-IV system (66 groups) that was discussed in detail in the proposed and final rules for FY 2010. II. BUSINESS REQUIREMENTS TABLE Use“Shall" to denote a mandatory requirement Number Requirement Responsibility (place an “X” in each applicable column) A D F C R SharedOTH / M I A H System ER B E R H Maintainers 6916.1 III. Medicare contractors shall add the attached list of new HIPPS codes to their claims processing systems effective for claims with dates of service on or after October 1, 2010. F M V C I C M W S S S F S X COB C PROVIDER EDUCATION TABLE Number Requirement 6916.2 A provider education article related to this instruction will be available at http://www.cms.hhs.gov/MLNMattersArticles/ shortly after the CR is released. You will receive notification of the article release via the established "MLN Matters" listserv. Contractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. In addition, the provider education article shall be included in your next regularly scheduled bulletin. Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in billing and administering the Medicare program correctly. IV. R I M M I A A E C C R X X Responsibility (place an “X” in each applicable column) A D F C R SharedOTH / M I A H System ER B E R H Maintainers R I F M V C M M I I C M W A A E S S S F C C R S X X SUPPORTING INFORMATION Section a: for any recommendations and supporting information associated with listed requirements, use the box below: N/A Use "Should" to denote a recommendation. X-Ref Recommendations or other supporting information: Requireme nt Number Section B: For all other recommendations and supporting information, use this space: N/A V. CONTACTS Pre-Implementation Contact(s): Jason Kerr, Jason.Kerr@cms.hhs.gov (for SNF claims processing), Julie Stankivic, Julie.Stankivic@cms.hhs.gov (for SNF PPS policy) Post-Implementation Contact(s): Appropriate Regional Office. http://www.cms.hhs.gov/MyHealthMyMedicare/Downloads/regionalmap.pdf or Medicare Administrative Contractor Project Officer VI. FUNDING Section A: For Fiscal Intermediaries (FIs), Carriers, and Regional Home Health Intermedicaries (RHHIs) use only one of the following statements: No additional funding will be provided by CMS; contractor activities are to be carried out within their operating budgets. Section B: For Medicare Administrative Contractors (MACs), use the following statement: The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. ATTACHMENT The following codes are added effective 10/01/10: CD101 RUX06 CD104 RUX10 CD105 RUX12 CD106 RUX13 CD110 RUX14 CD111 RUX15 CD112 RUX16 CD113 RUX20 CD114 RUX21 CD115 RUX22 CD116 RUX23 CD117 RUX24 CD120 RUX25 CD121 RUX26 CD124 RUX36 CD125 RUX46 CD126 RUX50 CD130 RUX51 CD131 RUX52 CD134 RUX53 CD135 RUX55 CD136 RUX56 CD140 RUX60 CD141 RUL06 CD144 RUL10 CD145 RUL12 CD146 RUL13 CD150 RUL14 CD151 RUL15 CD154 RUL16 CD155 RUL20 CD156 RUL21 CD160 RUL22 CD201 RUL23 CD204 RUL24 CD205 RUL25 CD206 RUL26 CD210 RUL36 CD211 RUL46 CD212 RUL50 CD213 RUL51 CD214 RUL52 CD215 RUL53 CD216 RUL55 CD217 RUL56 CD220 RUL60 CD221 CD224 CD225 CD226 CD230 CD231 CD234 CD235 CD236 CD240 CD241 CD244 CD245 CD246 CD250 CD251 CD254 CD255 CD256 CD260 CE101 CE104 CE105 CE106 CE110 CE111 CE112 CE113 CE114 CE115 CE116 CE117 CE120 CE121 CE124 CE125 CE126 CE130 CE131 CE134 CE135 CE136 CE140 CE141 CE144 CE145 CE146 RVX06 RVX10 RVX12 RVX13 RVX14 RVX15 RVX16 RVX20 RVX21 RVX22 RVX23 RVX24 RVX25 RVX26 RVX36 RVX46 RVX50 RVX51 RVX52 RVX53 RVX55 RVX56 RVX60 RVL06 RVL10 RVL12 RVL13 RVL14 RVL15 RVL16 RVL20 RVL21 RVL22 RVL23 RVL24 RVL25 RVL26 RVL36 RVL46 RVL50 RVL51 RVL52 RVL53 RVL55 RVL56 RVL60 RHX06 CE150 CE151 CE154 CE155 CE156 CE160 CE201 CE204 CE205 CE206 CE210 CE211 CE212 CE213 CE214 CE215 CE216 CE217 CE220 CE221 CE224 CE225 CE226 CE230 CE231 CE234 CE235 CE236 CE240 CE241 CE244 CE245 CE246 CE250 CE251 CE254 CE255 CE256 CE260 ES101 ES104 ES105 ES106 ES110 ES111 ES112 ES113 RHX10 RHX12 RHX13 RHX14 RHX15 RHX16 RHX20 RHX21 RHX22 RHX23 RHX24 RHX25 RHX26 RHX36 RHX46 RHX50 RHX51 RHX52 RHX53 RHX55 RHX56 RHX60 RHL06 RHL10 RHL12 RHL13 RHL14 RHL15 RHL16 RHL20 RHL21 RHL22 RHL23 RHL24 RHL25 RHL26 RHL36 RHL46 RHL50 RHL51 RHL52 RHL53 RHL55 RHL56 RHL60 RMX06 RMX10 ES114 ES115 ES116 ES117 ES120 ES121 ES124 ES125 ES126 ES130 ES131 ES134 ES135 ES136 ES140 ES141 ES144 ES145 ES146 ES150 ES151 ES154 ES155 ES156 ES160 ES201 ES204 ES205 ES206 ES210 ES211 ES212 ES213 ES214 ES215 ES216 ES217 ES220 ES221 ES224 ES225 ES226 ES230 ES231 ES234 ES235 ES236 RMX12 RMX13 RMX14 RMX15 RMX16 RMX20 RMX21 RMX22 RMX23 RMX24 RMX25 RMX26 RMX36 RMX46 RMX50 RMX51 RMX52 RMX53 RMX55 RMX56 RMX60 RML06 RML10 RML12 RML13 RML14 RML15 RML16 RML20 RML21 RML22 RML23 RML24 RML25 RML26 RML36 RML46 RML50 RML51 RML52 RML53 RML55 RML56 RML60 RLX06 RLX10 RLX12 ES240 ES241 ES244 ES245 ES246 ES250 ES251 ES254 ES255 ES256 ES260 ES301 ES304 ES305 ES306 ES310 ES311 ES312 ES313 ES314 ES315 ES316 ES317 ES320 ES321 ES324 ES325 ES326 ES330 ES331 ES334 ES335 ES336 ES340 ES341 ES344 ES345 ES346 ES350 ES351 ES354 ES355 ES356 ES360 HB101 HB104 HB105 RLX13 RLX14 RLX15 RLX16 RLX20 RLX21 RLX22 RLX23 RLX24 RLX25 RLX26 RLX36 RLX46 RLX50 RLX51 RLX52 RLX53 RLX55 RLX56 RLX60 RUC06 RUC10 RUC12 RUC13 RUC14 RUC15 RUC16 RUC20 RUC21 RUC22 RUC23 RUC24 RUC25 RUC26 RUC36 RUC46 RUC50 RUC51 RUC52 RUC53 RUC55 RUC56 RUC60 RUB06 RUB10 RUB12 RUB13 HB106 HB110 HB111 HB112 HB113 HB114 HB115 HB116 HB117 HB120 HB121 HB124 HB125 HB126 HB130 HB131 HB134 HB135 HB136 HB140 HB141 HB144 HB145 HB146 HB150 HB151 HB154 HB155 HB156 HB160 HB201 HB204 HB205 HB206 HB210 HB211 HB212 HB213 HB214 HB215 HB216 HB217 HB220 HB221 HB224 HB225 HB226 RUB14 RUB15 RUB16 RUB20 RUB21 RUB22 RUB23 RUB24 RUB25 RUB26 RUB36 RUB46 RUB50 RUB51 RUB52 RUB53 RUB55 RUB56 RUB60 RUA06 RUA10 RUA12 RUA13 RUA14 RUA15 RUA16 RUA20 RUA21 RUA22 RUA23 RUA24 RUA25 RUA26 RUA36 RUA46 RUA50 RUA51 RUA52 RUA53 RUA55 RUA56 RUA60 RVC06 RVC10 RVC12 RVC13 RVC14 HB230 HB231 HB234 HB235 HB236 HB240 HB241 HB244 HB245 HB246 HB250 HB251 HB254 HB255 HB256 HB260 HC101 HC104 HC105 HC106 HC110 HC111 HC112 HC113 HC114 HC115 HC116 HC117 HC120 HC121 HC124 HC125 HC126 HC130 HC131 HC134 HC135 HC136 HC140 HC141 HC144 HC145 HC146 HC150 HC151 HC154 HC155 RVC15 RVC16 RVC20 RVC21 RVC22 RVC23 RVC24 RVC25 RVC26 RVC36 RVC46 RVC50 RVC51 RVC52 RVC53 RVC55 RVC56 RVC60 RVB06 RVB10 RVB12 RVB13 RVB14 RVB15 RVB16 RVB20 RVB21 RVB22 RVB23 RVB24 RVB25 RVB26 RVB36 RVB46 RVB50 RVB51 RVB52 RVB53 RVB55 RVB56 RVB60 RVA06 RVA10 RVA12 RVA13 RVA14 RVA15 HC156 HC160 HC201 HC204 HC205 HC206 HC210 HC211 HC212 HC213 HC214 HC215 HC216 HC217 HC220 HC221 HC224 HC225 HC226 HC230 HC231 HC234 HC235 HC236 HC240 HC241 HC244 HC245 HC246 HC250 HC251 HC254 HC255 HC256 HC260 HD101 HD104 HD105 HD106 HD110 HD111 HD112 HD113 HD114 HD115 HD116 HD117 RVA16 RVA20 RVA21 RVA22 RVA23 RVA24 RVA25 RVA26 RVA36 RVA46 RVA50 RVA51 RVA52 RVA53 RVA55 RVA56 RVA60 RHC06 RHC10 RHC12 RHC13 RHC14 RHC15 RHC16 RHC20 RHC21 RHC22 RHC23 RHC24 RHC25 RHC26 RHC36 RHC46 RHC50 RHC51 RHC52 RHC53 RHC55 RHC56 RHC60 RHB06 RHB10 RHB12 RHB13 RHB14 RHB15 RHB16 HD120 HD121 HD124 HD125 HD126 HD130 HD131 HD134 HD135 HD136 HD140 HD143 HD144 HD145 HD146 HD150 HD151 HD154 HD155 HD156 HD160 HD201 HD204 HD205 HD206 HD210 HD211 HD212 HD213 HD214 HD215 HD216 HD217 HD220 HD221 HD224 HD225 HD226 HD230 HD231 HD234 HD235 HD236 HD240 HD241 HD244 HD245 RHB20 RHB21 RHB22 RHB23 RHB24 RHB25 RHB26 RHB36 RHB46 RHB50 RHB51 RHB52 RHB53 RHB55 RHB56 RHB60 RHA06 RHA10 RHA12 RHA13 RHA14 RHA15 RHA16 RHA20 RHA21 RHA22 RHA23 RHA24 RHA25 RHA26 RHA36 RHA46 RHA50 RHA51 RHA52 RHA53 RHA55 RHA56 RHA60 RMC06 RMC10 RMC12 RMC13 RMC14 RMC15 RMC16 RMC20 HD246 HD250 HD251 HD254 HD255 HD256 HD260 HE101 HE104 HE105 HE106 HE110 HE111 HE112 HE113 HE114 HE115 HE116 HE117 HE120 HE121 HE124 HE125 HE126 HE130 HE131 HE134 HE135 HE136 HE140 HE141 HE144 HE145 HE146 HE150 HE151 HE154 HE155 HE156 HE160 HE201 HE204 HE205 HE206 HE210 HE211 HE212 RMC21 RMC22 RMC23 RMC24 RMC25 RMC26 RMC36 RMC46 RMC50 RMC51 RMC52 RMC53 RMC55 RMC56 RMC60 RMB06 RMB10 RMB12 RMB13 RMB14 RMB15 RMB16 RMB20 RMB21 RMB22 RMB23 RMB24 RMB25 RMB26 RMB36 RMB46 RMB50 RMB51 RMB52 RMB53 RMB55 RMB56 RMB60 RMA06 RMA10 RMA12 RMA13 RMA14 RMA15 RMA16 RMA20 RMA21 HE213 HE214 HE215 HE216 HE217 HE220 HE221 HE224 HE225 HE226 HE230 HE231 HE234 HE235 HE236 HE240 HE241 HE244 HE245 HE246 HE250 HE251 HE254 HE255 HE256 HE260 LB101 LB104 LB105 LB106 LB110 LB111 LB112 LB113 LB114 LB115 LB116 LB117 LB120 LB121 LB124 LB125 LB126 LB130 LB131 LB134 LB135 RMA22 RMA23 RMA24 RMA25 RMA26 RMA36 RMA46 RMA50 RMA51 RMA52 RMA53 RMA55 RMA56 RMA60 RLB06 RLB10 RLB12 RLB13 RLB14 RLB15 RLB16 RLB20 RLB21 RLB22 RLB23 RLB24 RLB25 RLB26 RLB36 RLB46 RLB50 RLB51 RLB52 RLB53 RLB55 RLB56 RLB60 RLA06 RLA10 RLA12 RLA13 RLA14 RLA15 RLA16 RLA20 RLA21 RLA22 LB136 LB140 LB141 LB144 LB145 LB146 LB150 LB151 LB154 LB155 LB156 LB160 LB201 LB204 LB205 LB206 LB210 LB211 LB212 LB213 LB214 LB215 LB216 LB217 LB220 LB221 LB224 LB225 LB226 LB230 LB231 LB234 LB235 LB236 LB240 LB241 LB244 LB245 LB246 LB250 LB251 LB254 LB255 LB256 LB260 LC101 LC104 RLA23 RLA24 RLA25 RLA26 RLA36 RLA46 RLA50 RLA51 RLA52 RLA53 RLA55 RLA56 RLA60 CC201 CC204 CC205 CC206 CC210 CC211 CC212 CC213 CC214 CC215 CC216 CC217 CC220 CC221 CC224 CC225 CC226 CC230 CC231 CC234 CC235 CC236 CC240 CC241 CC244 CC245 CC246 CC250 CC251 CC254 CC255 CC256 CC260 CC101 LC105 LC106 LC110 LC111 LC112 LC113 LC114 LC115 LC116 LC117 LC120 LC121 LC124 LC125 LC126 LC130 LC131 LC134 LC135 LC136 LC140 LC141 LC144 LC145 LC146 LC150 LC151 LC154 LC155 LC156 LC160 LC201 LC204 LC205 LC206 LC210 LC211 LC212 LC213 LC214 LC215 LC216 LC217 LC220 LC221 LC224 LC225 CC104 CC105 CC106 CC110 CC111 CC112 CC113 CC114 CC115 CC116 CC117 CC120 CC121 CC124 CC125 CC126 CC130 CC131 CC134 CC135 CC136 CC140 CC141 CC144 CC145 CC146 CC150 CC151 CC154 CC155 CC156 CC160 CB201 CB204 CB205 CB206 CB210 CB211 CB212 CB213 CB214 CB215 CB216 CB217 CB220 CB221 CB224 LC226 LC230 LC231 LC234 LC235 LC236 LC240 LC241 LC244 LC245 LC246 LC250 LC251 LC254 LC255 LC256 LC260 LD101 LD104 LD105 LD106 LD110 LD111 LD112 LD113 LD114 LD115 LD116 LD117 LD120 LD121 LD124 LD125 LD126 LD130 LD131 LD134 LD135 LD136 LD140 LD141 LD144 LD145 LD146 LD150 LD151 LD154 CB225 CB226 CB230 CB231 CB234 CB235 CB236 CB240 CB241 CB244 CB245 CB246 CB250 CB251 CB254 CB255 CB256 CB260 CB101 CB104 CB105 CB106 CB110 CB111 CB112 CB113 CB114 CB115 CB116 CB117 CB120 CB121 CB124 CB125 CB126 CB130 CB131 CB134 CB135 CB136 CB140 CB141 CB144 CB145 CB146 CB150 CB151 LD155 LD156 LD160 LD201 LD204 LD205 LD206 LD210 LD211 LD212 LD213 LD214 LD215 LD216 LD217 LD220 LD221 LD224 LD225 LD226 LD230 LD231 LD234 LD235 LD236 LD240 LD241 LD244 LD245 LD246 LD250 LD251 LD254 LD255 LD256 LD260 LE101 LE104 LE105 LE106 LE110 LE111 LE112 LE113 LE114 LE115 LE116 CB154 CB155 CB156 CB160 CA201 CA204 CA205 CA206 CA210 CA211 CA212 CA213 CA214 CA215 CA216 CA217 CA220 CA221 CA224 CA225 CA226 CA230 CA231 CA234 CA235 CA236 CA240 CA241 CA244 CA245 CA246 CA250 CA251 CA254 CA255 CA256 CA260 CA101 CA104 CA105 CA106 CA110 CA111 CA112 CA113 CA114 CA115 LE117 LE120 LE121 LE124 LE125 LE126 LE130 LE131 LE134 LE135 LE136 LE140 LE141 LE144 LE145 LE146 LE150 LE151 LE154 LE155 LE156 LE160 LE201 LE204 LE205 LE206 LE210 LE211 LE212 LE213 LE214 LE215 LE216 LE217 LE220 LE221 LE224 LE225 LE226 LE230 LE231 LE234 LE235 LE236 LE240 LE241 LE244 CA116 CA117 CA120 CA121 CA124 CA125 CA126 CA130 CA131 CA134 CA135 CA136 CA140 CA141 CA144 CA145 CA146 CA150 CA151 CA154 CA155 CA156 CA160 BB201 BB204 BB205 BB206 BB210 BB211 BB212 BB213 BB214 BB215 BB216 BB217 BB220 BB221 BB224 BB225 BB226 BB230 BB231 BB234 BB235 BB236 BB240 BB241 LE245 LE246 LE250 LE251 LE254 LE255 LE256 LE260 PE201 PE204 PE205 PE206 PE210 PE211 PE212 PE213 PE214 PE215 PE216 PE217 PE220 PE221 PE224 PE225 PE226 PE230 PE231 PE234 PE235 PE236 PE240 PE241 PE244 PE245 PE246 PE250 PE251 PE254 PE255 PE256 PE260 PE101 PE104 PE105 PE106 PE110 PE111 BB244 BB245 BB246 BB250 BB251 BB254 BB255 BB256 BB260 BB101 BB104 BB105 BB106 BB110 BB111 BB112 BB113 BB114 BB115 BB116 BB117 BB120 BB121 BB124 BB125 BB126 BB130 BB131 BB134 BB135 BB136 BB140 BB141 BB144 BB145 BB146 BB150 BB151 BB154 BB155 BB156 BB160 BA201 BA204 BA205 BA206 BA210 PE112 PE113 PE114 PE115 PE116 PE117 PE120 PE121 PE124 PE125 PE126 PE130 PE131 PE134 PE135 PE136 PE140 PE141 PE144 PE145 PE146 PE150 PE151 PE154 PE155 PE156 PE160 PD201 PD204 PD205 PD206 PD210 PD211 PD212 PD213 PD214 PD215 PD216 PD217 PD220 PD221 PD224 PD225 PD226 PD230 PD231 PD234 BA211 BA212 BA213 BA214 BA215 BA216 BA217 BA220 BA221 BA224 BA225 BA226 BA230 BA231 BA234 BA235 BA236 BA240 BA241 BA244 BA245 BA246 BA250 BA251 BA254 BA255 BA256 BA260 BA101 BA104 BA105 BA106 BA110 BA111 BA112 BA113 BA114 BA115 BA116 BA117 BA120 BA121 BA124 BA125 BA126 BA130 BA131 PD235 PD236 PD240 PD241 PD244 PD245 PD246 PD250 PD251 PD254 PD255 PD256 PD260 PD101 PD104 PD105 PD106 PD110 PD111 PD112 PD113 PD114 PD115 PD116 PD117 PD120 PD121 PD124 PD125 PD126 PD130 PD131 PD134 PD135 PD136 PD140 PD141 PD144 PD145 PD146 PD150 PD151 PD154 PD155 PD156 PD160 PC201 BA134 BA135 BA136 BA140 BA141 BA144 BA145 BA146 BA150 BA151 BA154 BA155 BA156 BA160 AAA00 AAA01 AAA02 AAA03 AAA04 AAA05 AAA06 AAA07 AAA10 AAA11 AAA12 AAA13 AAA14 AAA15 AAA16 AAA17 AAA20 AAA21 AAA22 AAA23 AAA24 AAA25 AAA26 AAA30 AAA31 AAA32 AAA33 AAA34 AAA35 AAA36 AAA40 AAA41 AAA42 PC204 PC205 PC206 PC210 PC211 PC212 PC213 PC214 PC215 PC216 PC217 PC220 PC221 PC224 PC225 PC226 PC230 PC231 PC234 PC235 PC236 PC240 PC241 PC244 PC245 PC246 PC250 PC251 PC254 PC255 PC256 PC260 PC101 PC104 PC105 PC106 PC110 PC111 PC112 PC113 PC114 PC115 PC116 PC117 PC120 PC121 PC124 AAA43 AAA44 AAA45 AAA46 AAA50 AAA51 AAA52 AAA53 AAA54 AAA55 AAA56 AAA60 PC125 PC126 PC130 PC131 PC134 PC135 PC136 PC140 PC141 PC144 PC145 PC146 PC150 PC151 PC154 PC155 PC156 PC160 PB201 PB204 PB205 PB206 PB210 PB211 PB212 PB213 PB214 PB215 PB216 PB217 PB220 PB221 PB224 PB225 PB226 PB230 PB231 PB234 PB235 PB236 PB240 PB241 PB244 PB245 PB246 PB250 PB251 PB254 PB255 PB256 PB260 PB101 PB104 PB105 PB106 PB110 PB111 PB112 PB113 PB114 PB115 PB116 PB117 PB120 PB121 PB124 PB125 PB126 PB130 PB131 PB134 PB135 PB136 PB140 PB141 PB144 PB145 PB146 PB150 PB151 PB154 PB155 PB156 PB160 PA201 PA204 PA205 PA206 PA210 PA211 PA212 PA213 PA214 PA215 PA216 PA217 PA220 PA221 PA224 PA225 PA226 PA230 PA231 PA234 PA235 PA236 PA240 PA241 PA244 PA245 PA246 PA250 PA251 PA254 PA255 PA256 PA260 PA101 PA104 PA105 PA106 PA110 PA111 PA112 PA113 PA114 PA115 PA116 PA117 PA120 PA121 PA124 PA125 PA126 PA130 PA131 PA134 PA135 PA136 PA140 PA141 PA144 PA145 PA146 PA150 PA151 PA154 PA155 PA156 PA160 30 - Billing SNF PPS Services (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing data as follows. Refer to the Medicare Claims Processing Manual, Chapter 25, “Completing and Processing the UB-04 (CMS-1450) Data Set,” for further information about billing, as it contains UB-04 data elements and the corresponding fields in the electronic record: • In addition to the required fields identified in the Medicare Claims Processing Manual, Chapter 25, “Completing and Processing the UB-04 (CMS-1450) Data Set,” SNFs must also report occurrence span code “70” to indicate the dates of a qualifying hospital stay of at least three consecutive days which qualifies the beneficiary for SNF services. • Separate bills are required for each Federal fiscal year for admissions that span the annual update effective date (October 1.) • Use Type of Bill 21X for SNF inpatient services or 18X for hospital swing bed services. • Revenue Code 0022. This code indicates that this claim is being paid under the SNF PPS. This revenue code can appear on a claim as often as necessary to indicate different HIPPS Rate Code(s) and assessment periods. • There must be a line item on the claim for each assessment period represented on the claim with revenue code 0022. This code indicates that this claim is being paid under SNF PPS. This revenue code can appear on a claim as often as necessary to indicate different HIPPS rate code(s) and assessment periods. • The line item date of service date must contain an assessment reference date (ARD) when revenue code 0022 is present unless the HIPPS rate code is AAA00. • HCPCS/Rates field must contain a 5-digit “HIPPS Code”. The first three positions of the code contain the RUG group and the last two positions of the code contain a 2-digit assessment indicator (AI) code. See Tables 1 and 2 below for valid RUG codes and AI codes. • Service Units must contain the number of covered days for each HIPPS rate code. NOTE: Fiscal Intermediary Shared System (FISS) requirement: The sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days field less the number of days reported in an OSC 77. (Note: The covered units field is utilized in FISS and has no mapping to the 837 or paper claim). • Total Charges should be zero for revenue code 0022. • When a HIPPS rate code of RUAxx, RUBxx , RUCxx, RULxx and/or RUXxx is present, a minimum of two rehabilitation therapy ancillary codes are required (revenue code 042x and/or, 043x and/or, 044x). When a HIPPS rate code of RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RVBxx, RVCxx, RVLxx, and/or RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue code is required (revenue code 042x, 043x, or 044x. Bills that are missing required rehabilitation therapy ancillary revenue codes are to be returned to the SNF for resubmission. • The accommodation revenue code 018x, leave of absence is reported when the beneficiary is on a leave of absence and is not present at the midnight census taking time. • Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal diagnosis in the appropriate form locator. The code must be reported according to Official ICD-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-CM diagnosis code, including all five digits where applicable. • Other Diagnosis Codes Required – The SNF enters the full ICD-CM codes for up to eight additional conditions in the appropriate form locator. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines. NOTE: Information regarding the form locator numbers that correspond to these data element names and a table to crosswalk UB-04 form locators to the 837 transaction is found in Chapter 25. 30.1 - Health Insurance Prospective Payment System (HIPPS) Rate Code (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) The HIPPS rate code consists of the three-character resource utilization group (RUG) code that is obtained from the “Grouper” software program followed by a 2-digit assessment indicator (AI) that specifies the type of assessment associated with the RUG code obtained from the Grouper. SNFs must use the version of the Grouper software program identified by CMS for national PPS as described in the Federal Register for that year. The Grouper translates the data in the Long Term Care Resident Instrument into a case-mix group and assigns the correct RUG code. Effective for dates of service on or after October 1, 2010, the Grouper will automatically assign the 2-digit AI. Providers may access the following link for HIPPS code information: http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/02_HIPPSCodes.asp#TopOfPage The above link includes documents that contain the complete list of RUG codes and AIs billed for Part A SNF stays. Definitions and usage of each code are included. In addition, a master file of all valid/termed HIPPS codes is provided. The HIPPS rate code that appears on the claim must match the assessment that has been transmitted and accepted by the State in which the facility operates. The SNF may bill the program only after: • An assessment has been completed and submitted to the State RAI Database; • A Final Validation Report indicating that the assessment has been accepted by the state; and • The covered day has actually been used. SNFs that submit claims that have not completed this process will not be paid. It is important to remember that the record will be accepted into the State RAI database, even if the calculated RUG code differs from the submitted values. The error will be flagged on the final validation report by issuing a warning message and listing the correct RUG code. When such discrepancies occur, the RUG code reported on the Final Validation Report shall be used for billing purposes. 30.6.2 – SNF PPS Rate Components (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) The SNF PPS rate for each RUG group consists of 3 components: a nursing component, a therapy component and a non-case-mix adjusted component. The following describes the rate components used for SNF PPS: --The nursing per diem amount is a standard amount which includes direct nursing care and the cost of non-therapy ancillary services required by Medicare beneficiaries. --The nursing index is based on the amount of staff time, weighted by salary levels, associated with each RUG group. This index represents the amount of nursing time associated with caring for beneficiaries who qualify for the group. The nursing per diem amount is case-mix adjusted by applying the nursing index. The result is the nursing component for that RUG group. --The therapy per diem amount is a standard amount which includes physical, occupational, and speech-language therapy services provided to beneficiaries in a Part A stay. Payment varies based on the actual therapy resource minutes received by the beneficiary and reported on the MDS; --The therapy index is based on the amount of staff time, weighted by salary levels, associated with each RUG group. This index represents the amount of rehabilitation treatment time associated with caring for beneficiaries who qualify for the group. If the RUG group is in the Rehabilitation plus Extensive Services or Rehabilitation category, the therapy per diem amount is case-mix adjusted by applying the therapy index. The result is the therapy component for that Rehabilitation RUG group. --The non-case-mix therapy component is a standard amount to cover the cost of therapy assessments of beneficiaries who were determined not to need continued therapy services. If the RUG group is not in the Rehabilitation plus Extensive Services or Rehabilitation category, this payment is added to the rate as therapy component for that RUG group. --The non-case-mix component is also a standard amount added to the rate for each RUG group to cover administrative and capital-related costs. This standard amount is added to all RUG groups. 30.6.3 - Decision Logic Used by the Pricer on Claims (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) The SNF Pricer shall calculate the rate for each line item with revenue code 0022 on a SNF claim. The SNF Pricer shall determine the rate using the following information: - “HIPPS-CODE” on line item 0022; -“CBSA” - Per diem amounts defined within the Pricers as types of rate based on the statement covers “THRU-DATE”: Inpatient rate = Nursing case mix component General service rate = Non-case-mix component Therapy rate = Therapy non-case mix component Rehabilitation rate = Therapy case-mix component - Labor and non labor percentages based on the statement covers “THRU-DATE”; - Wage index, “SNF-FED BLEND” year, and “SNF-FACILITY RATE” based on the statement covers “THRU_DATE” - Rate adjustments applicable to the specific RUG code; - Nursing index based on the RUG code; - Therapy index based on the rehabilitation RUG code; On input records with TOB 21x (that is, all provider submitted claims and provider or FI initiated adjustments), Pricer will perform the following calculations in numbered order for each RUG code: (1) Multiply the applicable urban or rural inpatient rate depending on CBSA by the nursing index; (2) Multiply the applicable urban or rural rehab rate by the therapy index, add to (1); (3) For the top 23 RUG categories, add the general service rate to the sum of (1) and (2) for the (non-wage-adjusted) total PPS rate and proceed to step (4); OR for the lower 43 RUG categories, add the general service rate to the therapy rate to the sum of (1) and (2) for the (non-wage- adjusted) total PPS rate and proceed to step (4); (4) Multiply the sum of (3) by the labor percentage then multiply the product by the applicable wage index; (5) Multiply the sum of (3) by the non- labor percentage; (6) Add the product of (5) to the non-labor product in (4) for the (wage-adjusted) total PPS rate. Conditional Steps completed if applicable after (6): (6a) If diagnosis code 042 is present, multiply (6) by 2.28 and proceed to (7)– Effective October 1, 2004, for the FY 2005 Pricer, this represents the 128% AIDS adjustment implemented with Section 511 of the MMA.
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