Re: pps hierarchy vs. indexing and maximization of medicare

[Caralyn Davis]

FYI, From the Medicare Claims Processing Manual, chapter 6, snf inpatient part a billing, http://www.cms.gov/manuals/104_claims/clm104c06.pdf:     30.1 - Health Insurance Prospective Payment System (HIPPS) Rate Code (Rev. 1, 10-01-03) The HIPPS rate code consists of the three-character resource utilization group (RUG) code (see Table 1 below) that is obtained from the "Grouper" software program followed by a 2-digit AI (see Table 2 below) that specifies the type of assessment associated with the RUG code obtained from the Grouper. 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. The AIs were developed by CMS. The Grouper will not automatically assign the 2-digit AI, except in the case of a swing bed MDS that is will result in a special payment situation AI (see below). 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 cannot put a HIPPS rate code on the claim that does not match the assessment.       ----- Original Message ----- From: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Tuesday, December 09, 2003 2:31 PM Subject: Re: pps hierarchy vs. indexing and maximization of medicare In regard to this I have a question to ask the group. Is it appropriate to manually change the UB92 to an SE3 (higher reimbursement) for billing if the MDS scored a RHA (because of the hierarchal)? I understand that the FI may not being matching all Medicare MDS assessments to the UB92 at this date, but will any of the FI's allow the facilities to adjust the UB92 for higher reimbursement? If the therapy information was removed the MDS would rug out as a SE3, but therapy was provided and I believe should be listed on the MDS. Any thoughts? Comments? Thank you in advance for any and all responses. AND Happy Holidays TEAM.  Denise [EMAIL PROTECTED] Dear colleagues, Could someone please direct me to source documentation from CMS or a fiscal intermediary where it states that even though some lower hierarchal groups pay more than a higher group in the PPS payment hierarchy, (ex. an SE3 pays more than any high rehab category in my facility on an MC5 medicare assessment when put through the grouper) a facility must accept the lower payment for the first 14 days, even though this issue in the PPS system has been identified. I know my software is in compliance with CMS and state regulations. I recently attended  a medicare seminar where it was stated that manipulation of start dates or not projecting rehab in section T could be considered gaming the system, even though there is clinical justification for the higher paying category. Is it not the responsibility of the MDS coordinator to ensure "capture" of reimbursement and not only "care" patterns? I have spoken to several colleagues since attending the conference and have gotten conflicting interpretations of the rules. I am trusting that a response from AANAC  will clarify this issue. thank you!  A. Valiante  R.N.