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
/
B
D
M
E
F
I
C
A
R
R
H
H
Shared-
System
Maintainers
OTH
ER
M
A
C
M
A
C
R
I
E
R
I
F
I
S
S
M
C
S
V
M
S
C
W
F
6916.1
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.
X
X
X
COB
C
III. PROVIDER EDUCATION TABLE
Number
Requirement
Responsibility (place an “X” in each
applicable column)
A
/
B
M
A
C
D
M
E
M
A
C
F
I
C
A
R
R
I
E
R
R
H
H
I
Shared-
System
Maintainers
OTH
ER
F
I
S
S
M
C
S
V
M
S
C
W
F
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.
X
X
IV. 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
Requireme
nt
Number
Recommendations or other supporting information:
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 RVX06
CD224 RVX10
CD225 RVX12
CD226 RVX13
CD230 RVX14
CD231 RVX15
CD234 RVX16
CD235 RVX20
CD236 RVX21
CD240 RVX22
CD241 RVX23
CD244 RVX24
CD245 RVX25
CD246 RVX26
CD250 RVX36
CD251 RVX46
CD254 RVX50
CD255 RVX51
CD256 RVX52
CD260 RVX53
CE101 RVX55
CE104 RVX56
CE105 RVX60
CE106 RVL06
CE110 RVL10
CE111 RVL12
CE112 RVL13
CE113 RVL14
CE114 RVL15
CE115 RVL16
CE116 RVL20
CE117 RVL21
CE120 RVL22
CE121 RVL23
CE124 RVL24
CE125 RVL25
CE126 RVL26
CE130 RVL36
CE131 RVL46
CE134 RVL50
CE135 RVL51
CE136 RVL52
CE140 RVL53
CE141 RVL55
CE144 RVL56
CE145 RVL60
CE146 RHX06
CE150 RHX10
CE151 RHX12
CE154 RHX13
CE155 RHX14
CE156 RHX15
CE160 RHX16
CE201 RHX20
CE204 RHX21
CE205 RHX22
CE206 RHX23
CE210 RHX24
CE211 RHX25
CE212 RHX26
CE213 RHX36
CE214 RHX46
CE215 RHX50
CE216 RHX51
CE217 RHX52
CE220 RHX53
CE221 RHX55
CE224 RHX56
CE225 RHX60
CE226 RHL06
CE230 RHL10
CE231 RHL12
CE234 RHL13
CE235 RHL14
CE236 RHL15
CE240 RHL16
CE241 RHL20
CE244 RHL21
CE245 RHL22
CE246 RHL23
CE250 RHL24
CE251 RHL25
CE254 RHL26
CE255 RHL36
CE256 RHL46
CE260 RHL50
ES101 RHL51
ES104 RHL52
ES105 RHL53
ES106 RHL55
ES110 RHL56
ES111 RHL60
ES112 RMX06
ES113 RMX10
ES114 RMX12
ES115 RMX13
ES116 RMX14
ES117 RMX15
ES120 RMX16
ES121 RMX20
ES124 RMX21
ES125 RMX22
ES126 RMX23
ES130 RMX24
ES131 RMX25
ES134 RMX26
ES135 RMX36
ES136 RMX46
ES140 RMX50
ES141 RMX51
ES144 RMX52
ES145 RMX53
ES146 RMX55
ES150 RMX56
ES151 RMX60
ES154 RML06
ES155 RML10
ES156 RML12
ES160 RML13
ES201 RML14
ES204 RML15
ES205 RML16
ES206 RML20
ES210 RML21
ES211 RML22
ES212 RML23
ES213 RML24
ES214 RML25
ES215 RML26
ES216 RML36
ES217 RML46
ES220 RML50
ES221 RML51
ES224 RML52
ES225 RML53
ES226 RML55
ES230 RML56
ES231 RML60
ES234 RLX06
ES235 RLX10
ES236 RLX12
ES240 RLX13
ES241 RLX14
ES244 RLX15
ES245 RLX16
ES246 RLX20
ES250 RLX21
ES251 RLX22
ES254 RLX23
ES255 RLX24
ES256 RLX25
ES260 RLX26
ES301 RLX36
ES304 RLX46
ES305 RLX50
ES306 RLX51
ES310 RLX52
ES311 RLX53
ES312 RLX55
ES313 RLX56
ES314 RLX60
ES315 RUC06
ES316 RUC10
ES317 RUC12
ES320 RUC13
ES321 RUC14
ES324 RUC15
ES325 RUC16
ES326 RUC20
ES330 RUC21
ES331 RUC22
ES334 RUC23
ES335 RUC24
ES336 RUC25
ES340 RUC26
ES341 RUC36
ES344 RUC46
ES345 RUC50
ES346 RUC51
ES350 RUC52
ES351 RUC53
ES354 RUC55
ES355 RUC56
ES356 RUC60
ES360 RUB06
HB101 RUB10
HB104 RUB12
HB105 RUB13
HB106 RUB14
HB110 RUB15
HB111 RUB16
HB112 RUB20
HB113 RUB21
HB114 RUB22
HB115 RUB23
HB116 RUB24
HB117 RUB25
HB120 RUB26
HB121 RUB36
HB124 RUB46
HB125 RUB50
HB126 RUB51
HB130 RUB52
HB131 RUB53
HB134 RUB55
HB135 RUB56
HB136 RUB60
HB140 RUA06
HB141 RUA10
HB144 RUA12
HB145 RUA13
HB146 RUA14
HB150 RUA15
HB151 RUA16
HB154 RUA20
HB155 RUA21
HB156 RUA22
HB160 RUA23
HB201 RUA24
HB204 RUA25
HB205 RUA26
HB206 RUA36
HB210 RUA46
HB211 RUA50
HB212 RUA51
HB213 RUA52
HB214 RUA53
HB215 RUA55
HB216 RUA56
HB217 RUA60
HB220 RVC06
HB221 RVC10
HB224 RVC12
HB225 RVC13
HB226 RVC14
HB230 RVC15
HB231 RVC16
HB234 RVC20
HB235 RVC21
HB236 RVC22
HB240 RVC23
HB241 RVC24
HB244 RVC25
HB245 RVC26
HB246 RVC36
HB250 RVC46
HB251 RVC50
HB254 RVC51
HB255 RVC52
HB256 RVC53
HB260 RVC55
HC101 RVC56
HC104 RVC60
HC105 RVB06
HC106 RVB10
HC110 RVB12
HC111 RVB13
HC112 RVB14
HC113 RVB15
HC114 RVB16
HC115 RVB20
HC116 RVB21
HC117 RVB22
HC120 RVB23
HC121 RVB24
HC124 RVB25
HC125 RVB26
HC126 RVB36
HC130 RVB46
HC131 RVB50
HC134 RVB51
HC135 RVB52
HC136 RVB53
HC140 RVB55
HC141 RVB56
HC144 RVB60
HC145 RVA06
HC146 RVA10
HC150 RVA12
HC151 RVA13
HC154 RVA14
HC155 RVA15
HC156 RVA16
HC160 RVA20
HC201 RVA21
HC204 RVA22
HC205 RVA23
HC206 RVA24
HC210 RVA25
HC211 RVA26
HC212 RVA36
HC213 RVA46
HC214 RVA50
HC215 RVA51
HC216 RVA52
HC217 RVA53
HC220 RVA55
HC221 RVA56
HC224 RVA60
HC225 RHC06
HC226 RHC10
HC230 RHC12
HC231 RHC13
HC234 RHC14
HC235 RHC15
HC236 RHC16
HC240 RHC20
HC241 RHC21
HC244 RHC22
HC245 RHC23
HC246 RHC24
HC250 RHC25
HC251 RHC26
HC254 RHC36
HC255 RHC46
HC256 RHC50
HC260 RHC51
HD101 RHC52
HD104 RHC53
HD105 RHC55
HD106 RHC56
HD110 RHC60
HD111 RHB06
HD112 RHB10
HD113 RHB12
HD114 RHB13
HD115 RHB14
HD116 RHB15
HD117 RHB16
HD120 RHB20
HD121 RHB21
HD124 RHB22
HD125 RHB23
HD126 RHB24
HD130 RHB25
HD131 RHB26
HD134 RHB36
HD135 RHB46
HD136 RHB50
HD140 RHB51
HD143 RHB52
HD144 RHB53
HD145 RHB55
HD146 RHB56
HD150 RHB60
HD151 RHA06
HD154 RHA10
HD155 RHA12
HD156 RHA13
HD160 RHA14
HD201 RHA15
HD204 RHA16
HD205 RHA20
HD206 RHA21
HD210 RHA22
HD211 RHA23
HD212 RHA24
HD213 RHA25
HD214 RHA26
HD215 RHA36
HD216 RHA46
HD217 RHA50
HD220 RHA51
HD221 RHA52
HD224 RHA53
HD225 RHA55
HD226 RHA56
HD230 RHA60
HD231 RMC06
HD234 RMC10
HD235 RMC12
HD236 RMC13
HD240 RMC14
HD241 RMC15
HD244 RMC16
HD245 RMC20
HD246 RMC21
HD250 RMC22
HD251 RMC23
HD254 RMC24
HD255 RMC25
HD256 RMC26
HD260 RMC36
HE101 RMC46
HE104 RMC50
HE105 RMC51
HE106 RMC52
HE110 RMC53
HE111 RMC55
HE112 RMC56
HE113 RMC60
HE114 RMB06
HE115 RMB10
HE116 RMB12
HE117 RMB13
HE120 RMB14
HE121 RMB15
HE124 RMB16
HE125 RMB20
HE126 RMB21
HE130 RMB22
HE131 RMB23
HE134 RMB24
HE135 RMB25
HE136 RMB26
HE140 RMB36
HE141 RMB46
HE144 RMB50
HE145 RMB51
HE146 RMB52
HE150 RMB53
HE151 RMB55
HE154 RMB56
HE155 RMB60
HE156 RMA06
HE160 RMA10
HE201 RMA12
HE204 RMA13
HE205 RMA14
HE206 RMA15
HE210 RMA16
HE211 RMA20
HE212 RMA21
HE213 RMA22
HE214 RMA23
HE215 RMA24
HE216 RMA25
HE217 RMA26
HE220 RMA36
HE221 RMA46
HE224 RMA50
HE225 RMA51
HE226 RMA52
HE230 RMA53
HE231 RMA55
HE234 RMA56
HE235 RMA60
HE236 RLB06
HE240 RLB10
HE241 RLB12
HE244 RLB13
HE245 RLB14
HE246 RLB15
HE250 RLB16
HE251 RLB20
HE254 RLB21
HE255 RLB22
HE256 RLB23
HE260 RLB24
LB101 RLB25
LB104 RLB26
LB105 RLB36
LB106 RLB46
LB110 RLB50
LB111 RLB51
LB112 RLB52
LB113 RLB53
LB114 RLB55
LB115 RLB56
LB116 RLB60
LB117 RLA06
LB120 RLA10
LB121 RLA12
LB124 RLA13
LB125 RLA14
LB126 RLA15
LB130 RLA16
LB131 RLA20
LB134 RLA21
LB135 RLA22
LB136 RLA23
LB140 RLA24
LB141 RLA25
LB144 RLA26
LB145 RLA36
LB146 RLA46
LB150 RLA50
LB151 RLA51
LB154 RLA52
LB155 RLA53
LB156 RLA55
LB160 RLA56
LB201 RLA60
LB204 CC201
LB205 CC204
LB206 CC205
LB210 CC206
LB211 CC210
LB212 CC211
LB213 CC212
LB214 CC213
LB215 CC214
LB216 CC215
LB217 CC216
LB220 CC217
LB221 CC220
LB224 CC221
LB225 CC224
LB226 CC225
LB230 CC226
LB231 CC230
LB234 CC231
LB235 CC234
LB236 CC235
LB240 CC236
LB241 CC240
LB244 CC241
LB245 CC244
LB246 CC245
LB250 CC246
LB251 CC250
LB254 CC251
LB255 CC254
LB256 CC255
LB260 CC256
LC101 CC260
LC104 CC101
LC105 CC104
LC106 CC105
LC110 CC106
LC111 CC110
LC112 CC111
LC113 CC112
LC114 CC113
LC115 CC114
LC116 CC115
LC117 CC116
LC120 CC117
LC121 CC120
LC124 CC121
LC125 CC124
LC126 CC125
LC130 CC126
LC131 CC130
LC134 CC131
LC135 CC134
LC136 CC135
LC140 CC136
LC141 CC140
LC144 CC141
LC145 CC144
LC146 CC145
LC150 CC146
LC151 CC150
LC154 CC151
LC155 CC154
LC156 CC155
LC160 CC156
LC201 CC160
LC204 CB201
LC205 CB204
LC206 CB205
LC210 CB206
LC211 CB210
LC212 CB211
LC213 CB212
LC214 CB213
LC215 CB214
LC216 CB215
LC217 CB216
LC220 CB217
LC221 CB220
LC224 CB221
LC225 CB224
LC226 CB225
LC230 CB226
LC231 CB230
LC234 CB231
LC235 CB234
LC236 CB235
LC240 CB236
LC241 CB240
LC244 CB241
LC245 CB244
LC246 CB245
LC250 CB246
LC251 CB250
LC254 CB251
LC255 CB254
LC256 CB255
LC260 CB256
LD101 CB260
LD104 CB101
LD105 CB104
LD106 CB105
LD110 CB106
LD111 CB110
LD112 CB111
LD113 CB112
LD114 CB113
LD115 CB114
LD116 CB115
LD117 CB116
LD120 CB117
LD121 CB120
LD124 CB121
LD125 CB124
LD126 CB125
LD130 CB126
LD131 CB130
LD134 CB131
LD135 CB134
LD136 CB135
LD140 CB136
LD141 CB140
LD144 CB141
LD145 CB144
LD146 CB145
LD150 CB146
LD151 CB150
LD154 CB151
LD155 CB154
LD156 CB155
LD160 CB156
LD201 CB160
LD204 CA201
LD205 CA204
LD206 CA205
LD210 CA206
LD211 CA210
LD212 CA211
LD213 CA212
LD214 CA213
LD215 CA214
LD216 CA215
LD217 CA216
LD220 CA217
LD221 CA220
LD224 CA221
LD225 CA224
LD226 CA225
LD230 CA226
LD231 CA230
LD234 CA231
LD235 CA234
LD236 CA235
LD240 CA236
LD241 CA240
LD244 CA241
LD245 CA244
LD246 CA245
LD250 CA246
LD251 CA250
LD254 CA251
LD255 CA254
LD256 CA255
LD260 CA256
LE101 CA260
LE104 CA101
LE105 CA104
LE106 CA105
LE110 CA106
LE111 CA110
LE112 CA111
LE113 CA112
LE114 CA113
LE115 CA114
LE116 CA115
LE117 CA116
LE120 CA117
LE121 CA120
LE124 CA121
LE125 CA124
LE126 CA125
LE130 CA126
LE131 CA130
LE134 CA131
LE135 CA134
LE136 CA135
LE140 CA136
LE141 CA140
LE144 CA141
LE145 CA144
LE146 CA145
LE150 CA146
LE151 CA150
LE154 CA151
LE155 CA154
LE156 CA155
LE160 CA156
LE201 CA160
LE204 BB201
LE205 BB204
LE206 BB205
LE210 BB206
LE211 BB210
LE212 BB211
LE213 BB212
LE214 BB213
LE215 BB214
LE216 BB215
LE217 BB216
LE220 BB217
LE221 BB220
LE224 BB221
LE225 BB224
LE226 BB225
LE230 BB226
LE231 BB230
LE234 BB231
LE235 BB234
LE236 BB235
LE240 BB236
LE241 BB240
LE244 BB241
LE245 BB244
LE246 BB245
LE250 BB246
LE251 BB250
LE254 BB251
LE255 BB254
LE256 BB255
LE260 BB256
PE201 BB260
PE204 BB101
PE205 BB104
PE206 BB105
PE210 BB106
PE211 BB110
PE212 BB111
PE213 BB112
PE214 BB113
PE215 BB114
PE216 BB115
PE217 BB116
PE220 BB117
PE221 BB120
PE224 BB121
PE225 BB124
PE226 BB125
PE230 BB126
PE231 BB130
PE234 BB131
PE235 BB134
PE236 BB135
PE240 BB136
PE241 BB140
PE244 BB141
PE245 BB144
PE246 BB145
PE250 BB146
PE251 BB150
PE254 BB151
PE255 BB154
PE256 BB155
PE260 BB156
PE101 BB160
PE104 BA201
PE105 BA204
PE106 BA205
PE110 BA206
PE111 BA210
PE112 BA211
PE113 BA212
PE114 BA213
PE115 BA214
PE116 BA215
PE117 BA216
PE120 BA217
PE121 BA220
PE124 BA221
PE125 BA224
PE126 BA225
PE130 BA226
PE131 BA230
PE134 BA231
PE135 BA234
PE136 BA235
PE140 BA236
PE141 BA240
PE144 BA241
PE145 BA244
PE146 BA245
PE150 BA246
PE151 BA250
PE154 BA251
PE155 BA254
PE156 BA255
PE160 BA256
PD201 BA260
PD204 BA101
PD205 BA104
PD206 BA105
PD210 BA106
PD211 BA110
PD212 BA111
PD213 BA112
PD214 BA113
PD215 BA114
PD216 BA115
PD217 BA116
PD220 BA117
PD221 BA120
PD224 BA121
PD225 BA124
PD226 BA125
PD230 BA126
PD231 BA130
PD234 BA131
PD235 BA134
PD236 BA135
PD240 BA136
PD241 BA140
PD244 BA141
PD245 BA144
PD246 BA145
PD250 BA146
PD251 BA150
PD254 BA151
PD255 BA154
PD256 BA155
PD260 BA156
PD101 BA160
PD104 AAA00
PD105 AAA01
PD106 AAA02
PD110 AAA03
PD111 AAA04
PD112 AAA05
PD113 AAA06
PD114 AAA07
PD115 AAA10
PD116 AAA11
PD117 AAA12
PD120 AAA13
PD121 AAA14
PD124 AAA15
PD125 AAA16
PD126 AAA17
PD130 AAA20
PD131 AAA21
PD134 AAA22
PD135 AAA23
PD136 AAA24
PD140 AAA25
PD141 AAA26
PD144 AAA30
PD145 AAA31
PD146 AAA32
PD150 AAA33
PD151 AAA34
PD154 AAA35
PD155 AAA36
PD156 AAA40
PD160 AAA41
PC201 AAA42
PC204 AAA43
PC205 AAA44
PC206 AAA45
PC210 AAA46
PC211 AAA50
PC212 AAA51
PC213 AAA52
PC214 AAA53
PC215 AAA54
PC216 AAA55
PC217 AAA56
PC220 AAA60
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
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.
