Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This 
involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new 
Patient-Driven Payment Model (PDPM), which is effective for services provided on or after 10/1/2019, the 
HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under 
the revised model. The first position represents the Physical and Occupational Therapy case-mix group. The 
second position represents the Speech-Language Pathology (SLP) case-mix group. The third character 
represents the nursing case-mix group. The fourth character represents the Non-Therapy Ancillary (NTA) case-
mix group. The fifth character represents the assessment indicator code. You can find this information in the 
Centers for Medicare and Medicaid Service (CMS), Internet-Only Manual, Medicare Claims Processing 
Manual, Chapter 6, Sections 10, 30, and 120. 
 
The rules say that active diagnoses are intended to code diseases that have a direct relationship to the residents 
current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or 
risk of death. One of the important functions of the Minimum Data Set (MDS) assessment is to generate an 
updated, accurate picture of the residents current health status. You can find this rule in the Centers for 
Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 
3. 
 
The rules say that for parenteral/IV feeding (K05010A), the following fluids may be included when there is 
supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or 
hydration need. This supporting documentation should be noted in the residents medical record according to 
State and/or internal facility policy: 
 
1. IV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered continuously or 
intermittently 2. IV fluids running at KVO (Keep Vein Open) 
3. IV fluids contained in IV Piggybacks 
4. Hypodermoclysis and subcutaneous ports in hydration therapy 
5. IV fluids can be coded in K0510A if needed to prevent dehydration if the additional fluid intake is 
specifically needed for nutrition and hydration. Prevention of dehydration should be clinically indicated and 
supporting documentation should be provided in the medical record. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Chapter 3. 
 
The rules say that the following items are not to be coded in K0510A: 
 
1. IV Medications -Code these when appropriate in O0100H 
2. IV fluids used to reconstitute and/or   dilute medications for IV administration. 
3. IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay. 
4. IV fluids administered solely as flushes.Parenteral/IV fluids administered in conjunction with 
chemotherapy or dialysis. 
 
Enteral feeding formulas should not be coded as a mechanically altered diet. They should only be covered as 
K0510D - therapeutic diet - when the enteral formula is altered to manage problematic health conditions, e.g. 
enteral formulas specific to diabetics 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Chapter 3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.