Managing Medicare Advantage HIPPS Codes: Skilled Nsg. Facil.

Medicare Advantage Organization (MC) HIPPS Codes Update for SNF Encounters When No Admission Assessment Was Completed:

On December 4, 2014, CMS released a memo regarding additional guidance regarding Submission of Health Insurance Prospective Payment System (HIPPS) Codes to the Encounter Data System to all MAO providers clarifying the requirements. When billing for all Medicare Advantage Organizations (MAO), PACE Organizations, Cost Plans, and certain Demonstrations providers were originally told by CMS that they must provide Health Insurance Prospective Payment System (HIPPS) Codes for Skilled Nursing Facility (SNF) claims submitted effective July 1, 2014. 

This updated CMS memo regarding Submission of Health Insurance Prospective Payment System (HIPPS) Codes to the Encounter Data System to all MAO providers was to provide further guidance about this requirement for SNF encounters when no Admission Assessment was completed during the Medicare Advantage Organization (MAO) covered stay. The guidance in the May 23, 2014 memo and this updated memo are extended through the 2015 dates of services. The CMS memo continues to note that the MAO’s shall submit the HIPPS codes during the MAO- covered SNF stay.  MAOs receive the HIPPS codes through the facility billing process.

Skilled nursing facilities should review the following clarifications on the requirements of the recent CMS memo as it applies to facility billing process for MAOs:

• Stays of more than 14 days:  If the Admission assessment for a stay in the facility was completed prior to the MAO-covered portion of the stay, MAOs must submit to CMS a HIPPS code by following the guidance in the order they are listed below.
  • Bill the HIPPS code from another assessment completed during the MAO-covered portion of the stay 
    If the OBRA Admission assessment was completed for the current stay prior to the MAO-covered portion of the stay, and another assessment (e.g., Quarterly Assessment or any PPS assessment required by the MAO) was completed during the MAO-covered portion of the stay, the MAO shall submit the HIPPS code generated from Quarterly or PPS assessment.
  • Bill the HIPPS code from the most recent assessment that was completed prior to the MAO-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).
• 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.
  • Bill 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 codes. This may be another assessment (e.g., Quarterly Assessment or any PPS assessment)
  • Bill a default HIPPS code of ‘AAA00’  Bill a default HIPPS code for SNF encounter submissions to CMS only if all of the following criteria are met:
    • The SNF stay was less than 14 days within a spell of illness
    • Discharge occurred prior to the completion of the initial OBRA Admission assessment
    • No other assessment was completed during the stay.
      To bill a default HIPPS code to the Encounter Data System, MAOs should use the default Resource Utilization Group (RUG) code of “AAA” and Assessment Indicator “00” on encounter data submissions starting with “from” dates of service July 1, 2014. 

Due to the ever-evolving nature of changing insurance coverage, facilities should follow the traditional Medicare PPS schedule unless otherwise notified in writing by the Managed Care Organization. In addition, facility's should develop a system for review of current managed care contracts to ensure they meet the contract specific requirements for coverage and compliance with billing requirements (e.g. need for MDS) to ensure that the facility is accurately reimbursed for the services rendered to each of the MCO's beneficiaries.  Contract review should occur on an annual basis and with any changes to the contract.

If you need help with understanding or interpreting these updates, please contact Kris B Harmony or call (617) 595-6032.