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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 says that Section GG includes items about functional abilities and goals. It includes items focused on 
prior function, admission performance, discharge goals, and discharge performance. Functional status is 
assessed based on the need for assistance when performing self-care and mobility activities. The first step is to 
assess the residents self-care performance based on direct observation, incorporating resident self-reports and 
reports from qualified clinicians, care staff, or family documented in the residents medical record during the 
three-day assessment period. CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day assessment period. For Section GG, the assessment period is the 
first three days of the Part A stay, starting with the start of the most recent Medicare stay. You can find this rule 
in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 
Manual, Chapter 3, MDS Items (GG), page GG-1 and page GG-10. 
 
The rules also say that Section GG of the Minimal Data Set (MDS) reports the resident's self-care performance. 
The facility must assess the residents self-care performance based on direct observation, incorporating resident 
self-reports and reports from qualified clinicians, care staff, or family documented in the residents medical 
record during the three-day assessment period. It is anticipated that an interdisciplinary team of qualified 
clinicians is involved in assessing the resident during the three-day assessment period. 
 
When reviewing the medical record, interviewing staff, and observing the resident, be familiar with the 
definition for each activity (e.g., eating, oral hygiene). Documentation in the medical record is used to support 
assessment coding of Section GG. Data entered should be consistent with the clinical assessment 
documentation in the residents medical record. 
 
You can find this information in the You can find this information in the Long-Term Care Facility Resident 
Assessment Instrument 3.0 Users Manual, Chapter 4. Section GG. 
 
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.