(Medicare Claims Processing Manual)

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.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).   30.2  Coding PPS Bills for Ancillary Services  (Rev. 3230, Issued: 04- 03-15, Effective: 06-15-15, Implementation: 06-15-15)  When coding PPS bills for ancillary services associated with a Part A inpatient stay, the traditional revenue codes will continue to be shown, e.g., 0250 - Pharmacy, 042x - Physical Therapy, in conjunction with the appropriate entries in Service Units and Total Charges.    SNFs are required to report the number of units based on the procedure or service.    For therapy services, that is revenue codes 042x, 043x, and 044x, units represent the number of calendar days of therapy provided.  For example, if the beneficiary received physical therapy, occupational therapy or speech -language pathology on May 1, that would be considered one calendar day and would be billed as one unit.   SNFs are required to report the actual charge for each line item, in Total Charges.   30.3  Adjustment Requests  (Rev. 3230, Issued: 04- 03-15, Effective: 06 -15-15, Implementation: 06- 15-15)  Adjustment requests based on corrected assessments must be submitted within 120 days of the service through date.  The through date will be used to calculate the period during which adjustment requests may be submitted based on corrected RAI assessment s.  The through date indicates the last day of the billing period for which the HIPPS code is billed.  Adjustment requests based on corrected assessments must be submitted within 120 days of the through date on the bill.  For HIPPS changes resulting fr om an MDS correction, providers must append a condition code D2 on their adjustment claim.  An edit is in place to limit the time for submitting this type of adjustment request to 120 days from the service through date.   The CMS expects that most HIPPS code corrections will be made during the course of the beneficiarys Medicare Part A stay.  Therefore, providers that routinely submit corrections after the beneficiarys Part A stay has ended may be subject to focused medical review.   Adjustment requests to change a HIPPS code may not be submitted for any claim that has already been medically reviewed, such claims are identified in the FISS system by an indicator on the claim record.  This applies whether or not the medical review was performed either pre-  or post -payment.  All adjustment requests submitted are subject to medical review.  Information regarding medical review is located in the Medicare Program Integrity Manual.  30.4 - SNF PPS Pricer Software  (Rev. 3230, Issued: 04- 03-15, Effective: 06 -15-15, Implementation: 06- 15-15)  The Balanced Budget Act (BBA) of 1997 (Public Law 105- 33) mandated the implementation of a per diem prospective payment system (PPS) for skilled nursing facilities (SNFs), covering all costs (routine, ancillary, and capital) of covered SNF services furnish ed to beneficiaries under Part A of the Medicare program.   Effective for cost reporting periods beginning on or after July 1, 1998, all skilled nursing services billed on TOB 21x will be paid based on calculations made by the SNF Pricer. The SNF Pricer operates as a module within CMS claims processing systems.  T he SNF Pricer makes all payment calculations applicable under SNF PPS.  Medicare claims processing systems must send an input record for each HIPPS code reported on the claim to Pricer and Pricer will return an output record to the shared systems.  The Pri cer is available electronically to the shared systems and is updated at least annually. A PC version of the SNF Pricer Program can be found at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service- Payment/PCPricer/SNF.html  The following describes the elements of SNF PPS claims that are used in the SNF PPS Pricer and the logic that is used to make payment determinations.  No part of the Pricer logic is required to be incorporated into a SNFs billing system in order to bill M edicare. The following is presented for A/B MACs (A)  and as information for the SNFs, in order to help SNFs understand their SNF PPS payments and how they are determined.  30.4.1 - Input/Output Record Layout                                                       (Rev. 11109, Issued: 11-04- 21 Effective:10 -01-22, Implementation:01-03-22)  The SNF Pricer input/output file will be 300 bytes in length.  The required data and format are shown below.  File Position  Format  Title  Description  1-4 X(4)  MSA  Input item: The metropolitan statistical area (MSA) code.  Medicare claims processing systems pull this code from field 13 of the provider specific file.  5-9 X(5)  CBSA  Input item: Core -Based Statistical Area  10 X SPEC -WI-IND Input item (if applicable) :Special Wage Index Indicator  Valid Values: Y  (yes) or N (no) 11-16 X(6)  SPEC -WI Input item (if applicable): Special Wage Index  17-21 X(5)  HIPPS- CODE  Input Item: Health Insurance Prospective Payment System Code  Medicare claims processing systems must copy the HIPPS code reported File Position  Format  Title  Description  by the provider on each 0022 revenue code line  22-29 9(8) FROM -DATE  Input item: The statement covers period from date, copied from the claim form. Date format must be CCYYMMDD.  30-37 9(8) THRU- DATE  Input item: The statement covers period through date, copied from the claim form.  Date format must be CCYYMMDD.  38 X QRP -IND Input Item -Effective January 1, 2022 field renamed QRP -IND from FED -PPS- BLEND.  Input Item: Effective October 1, 2017, MACs shall populate the FED PPS BLEND IND field in the PSF with a "1" to indicate the SNF did not meet the quality reporting requirements.-  39-45 9(05)V9(02)  SNF-FACILITY RATE  Input item: Rate based on each SNFs historical costs (from (from A/B MAC (A) audited cost reports) including exception payments. NOTE :  All facilities have been paid at the full federal rate since FY 2002.  46-52 X(7)  SNF-PRIN -DIAG -CODE  Input item: The principle diagnosis code, copied from the claim form.  Must be three to seven positions left justified with no decimal points.  53-59 X(7)  SNF-OTHER -DIAG -CODE2  Input item: Additional Diagnosis Code, copied from the claim form, if present, must be three to seven positions left justified with no decimal points.  60-220 Defined above  Additional Diagnosis data  Input item: Up to twenty -three additional diagnosis codes accepted from claim. Copied from the claim form.  Must be three to seven File Position  Format  Title  Description  positions left justified with no decimal points.  221-228 9(06)V9(02)  SNF-PAYMENT RATE  Output Item: The Calculated TOTAL amount received by the SNF based on the days received.  Effective FY 2018, this amount reflects VBP adjustment.  NOTE: Effective October 1, 2019, the previously calculated RUG per diem rate is replaced by the PDPM Calculated TOTAL amount received by the SNF.    229-230 9(2) SNF-RTC  Output item: A return code set by Pricer to define the payment circumstances of the claim or an error in input data. Payment return code:  00 HIPPS rate returned  Error return codes:  20 INVALID RATE COMPONENT  30 Bad CBSA code  40 Thru date < July 1, 1998 or Invalid  50 Invalid federal blend for that Year -NO LONGER IN USE  60 Invalid federal blend- NO LONGER IN USE  61 Federal blend = 0 and SNF  Thru date < January 1, 2000- NO LONGER IN USE   70     Invalid VBP Multiplier -        80     SNF -PDPM -UNITS =       ZERO         90      INVALID HIPPS CODE         01     CURRENT -DAYS > 100  File Position  Format  Title  Description  231-242 S9V9(11)  VBP -MULTIPLIER  Input item: Medicare systems move this information from field 52 of the provider specific file.  243-250 S9(06)V9(02)  VBP -PAY- DIFF  Output item: The total SNF VBP adjustment amount, determined by subtracting the SNF VBP adjustment total payment from the SNF PPS payment that would otherwise apply to the line. Added to the claim as a value code QV amount.  NOTE: Effective October 1, 2019, the previously calculated VBP difference per day is replaced by the TOTAL VBP difference amount.  251-252  9(02)  SNF-PDPM -UNITS  Input item: The number of service units reported by the SNF on the revenue code 0022 line that is being priced.  253-255  9(03)  SNF-PDPM -PRIOR -DAYS  Input item: When pricing the first revenue code 0022 line on a claim, this is the number of prior SNF days identified by FISS from claims history. On later dated revenue code 0022 lines, this is the days from claims history plus any units from any earlier dated.  256-300  X(45)  FILLER  Blank   Input records on claims must include all input items. Output records will contain all input and output items. The Medicare claims processing systems will move the following Pricer output items to the claim record. The return code will be placed in the claim header. The SNF -PAYMENT -RATE amount for each HIPPS code will be placed in the rate field of the appropriate revenue code 0022 line.  The Medicare claims processing systems will multiply the rate on each 0022 line by the number of units that correspond to each line.  The system will sum all 0022 lines and place this amount in the Provider Reimbursement field minus any coinsurance due from the patient.  For claims with dates of service on or after July 1, 2002, Pricer will compute payment only where the SNF -RTC is 00.   30.4.2  SNF PPS Rate Components (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  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.