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 say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
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 isolation for active infectious disease should be coded only when the resident requires 
transmission-based precautions and single room isolation (alone in a separate room) because of active infection 
(i.e., symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or 
epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet 
transmission. Do not code this item if the resident only has a history of infectious disease (e.g., s/p MRSA or 
s/p C-Diff - no active symptoms). Do not code this item if the precautions are standard precautions, because these types of precautions apply to everyone. Standard precautions include hand hygiene compliance, glove 
use, and additionally may include masks, eye protection, and gowns. Examples of when the isolation criterion 
would not apply include urinary tract infections, encapsulated pneumonia, and wound infections. 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Section O: Special Treatments Procedures, and Programs. 
 
The rules say that you should code for "single room isolation" only when all of the following conditions are 
met: 
 
1.The resident has active infection with highly transmissible or epidemiologically significant pathogens that 
have been acquired by physical contact or airborne or droplet transmission. 
2.Precautions are over and above standard precautions. That is, transmission-based precautions (contact, 
droplet, and/or airborne) must be in effect. 
3.The resident is in a room alone because of active infection and cannot have a roommate. This means that the 
resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a 
similar active infection that requires isolation. 
4.The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. 
rehabilitation, activities, dining, etc.). 
 
You can find this rule in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment 
Instrument (RAI) Version 3.0 Manual, Section O: Special Treatments Procedures, and Programs. 
 
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.