CMS Manual System Department of Health & Human Services (DHHS)

Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS)

Transmittal 1958 Date: April 28, 2010

Change Request 6916

NOTE: This instruction was inadvertently transmitted in the policy section of the business requirement with incorrect final rules for FY of 2011. The correct FY is 2010. The business requirement has been revised. The transmittal number, date issued and all other information remain the same.

SUBJECT: Skilled Nursing Facility (SNF) Health Insurance Prospective Payment System (HIPPS) Coding Updates Effective October 1, 2010 I. SUMMARY OF CHANGES: This instruction contains new HIPPS codes resulting from the conversion to the new RUG-IV coding system EFFECTIVE DATE: *October 1, 2010 IMPLEMENTATION DATE: October 4, 2010 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D CHAPTER / SECTION / SUBSECTION / TITLE

R 6/30/Billing SNF PPS Services

R 6/30.1/Health Insurance Prospective Payment System (HIPPS) Rate Code

R 6/30.6.2/SNF PPS Rate Components

R 6/30.6.3/Decision Logic Used by the Pricer on Claims

III. FUNDING: For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers: No additional funding will be provided by CMS; Contractor activities are to be carried out within their operating budgets. For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined

in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. IV. ATTACHMENTS: Business Requirements Manual Instruction *Unless otherwise specified, the effective date is the date of service.

Attachment - Business Requirements Pub. 100-04 Transmittal: 1958 Date: April 28, 2010 Change Request: 6916 NOTE: This instruction was inadvertently transmitted in the policy section of the business requirement with incorrect final rules for FY of 2011. The correct FY is 2010. The business requirement has been revised. The transmittal number, date issued and all other information remain the same. SUBJECT: Skilled Nursing Facility (SNF) Health Insurance Prospective Payment System (HIPPS) Coding Updates Effective October 1, 2010 Effective Date: October 1, 2010 Implementation Date: October 4, 2010 I. GENERAL INFORMATION A. Background: Effective October 1, 2010, the CMS is revising the SNF PPS case-mix system. The revised system will include 66 resource utilization groups (RUGs). This revised system is called the RUG-IV coding system. This instruction contains new HIPPS codes resulting from the conversion to the new RUG-IV coding system. The attached file contains the list of the newly added HIPPS codes. The 5-digit HIPPS code includes two components: the 3-digit classification code assigned to each RUG group, and newly defined 2-digit assessment indicators that specify the type of assessment used to support billing. B. Policy: Annual updates to the PPS rates for SNFs are required by section 1888(e) of the Social Security Act (the Act), as added by section 4432 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105–33, enacted on August 5, 1997), and amended by the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106–113, enacted on November 29, 1999), the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106–554, enacted on December 21, 2000), and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108–173, enacted on December 8, 2003). Our most recent annual update occurred in a final rule (74 FR 40289, August 11, 2009) that set forth updates to the SNF PPS payment rates for FY 2010. Under the BBA, each update of the SNF PPS payment rates must include the case-mix classification methodology applicable for the coming Federal FY. The FY 2011 payment rates reflect the use of the RUG-IV system (66 groups) that was discussed in detail in the proposed and final rules for FY 2010. II. BUSINESS REQUIREMENTS TABLE Use“Shall" to denote a mandatory requirement Number Requirement Responsibility (place an “X” in each

applicable column) A

/B

DME

FI

CAR

RHH

Shared-System

Maintainers

OTHER

MAC

MAC

RIER

I FISS

MCS

VMS

CWF

6916.1 Medicare contractors shall add the attached list of new HIPPS codes to their claims processing systems effective for claims with dates of service on or after October 1, 2010.

X X X COBC

III. PROVIDER EDUCATION TABLE Number Requirement Responsibility (place an “X” in each

applicable column) A

/B MAC

DME

MAC

FI

CARRIER

RHHI

Shared-System

Maintainers

OTHER

FISS

MCS

VMS

CWF

6916.2 A provider education article related to this instruction will be available at http://www.cms.hhs.gov/MLNMattersArticles/ shortly after the CR is released. You will receive notification of the article release via the established "MLN Matters" listserv. Contractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. In addition, the provider education article shall be included in your next regularly scheduled bulletin. Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in billing and administering the Medicare program correctly.

X X

IV. SUPPORTING INFORMATION Section a: for any recommendations and supporting information associated with listed requirements, use the box below: N/A Use "Should" to denote a recommendation. X-Ref Requirement Number

Recommendations or other supporting information:

Section B: For all other recommendations and supporting information, use this space: N/A V. CONTACTS Pre-Implementation Contact(s): Jason Kerr, Jason.Kerr@cms.hhs.gov (for SNF claims processing), Julie Stankivic, Julie.Stankivic@cms.hhs.gov (for SNF PPS policy) Post-Implementation Contact(s): Appropriate Regional Office. http://www.cms.hhs.gov/MyHealthMyMedicare/Downloads/regionalmap.pdf or Medicare Administrative Contractor Project Officer VI. FUNDING Section A: For Fiscal Intermediaries (FIs), Carriers, and Regional Home Health Intermedicaries (RHHIs) use only one of the following statements: No additional funding will be provided by CMS; contractor activities are to be carried out within their operating budgets. Section B: For Medicare Administrative Contractors (MACs), use the following statement: The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. ATTACHMENT

The following codes are added effective 10/01/10:CD101 RUX06CD104 RUX10CD105 RUX12CD106 RUX13CD110 RUX14CD111 RUX15CD112 RUX16CD113 RUX20CD114 RUX21CD115 RUX22CD116 RUX23CD117 RUX24CD120 RUX25CD121 RUX26CD124 RUX36CD125 RUX46CD126 RUX50CD130 RUX51CD131 RUX52CD134 RUX53CD135 RUX55CD136 RUX56CD140 RUX60CD141 RUL06CD144 RUL10CD145 RUL12CD146 RUL13CD150 RUL14CD151 RUL15CD154 RUL16CD155 RUL20CD156 RUL21CD160 RUL22CD201 RUL23CD204 RUL24CD205 RUL25CD206 RUL26CD210 RUL36CD211 RUL46CD212 RUL50CD213 RUL51CD214 RUL52CD215 RUL53CD216 RUL55CD217 RUL56CD220 RUL60

CD221 RVX06CD224 RVX10CD225 RVX12CD226 RVX13CD230 RVX14CD231 RVX15CD234 RVX16CD235 RVX20CD236 RVX21CD240 RVX22CD241 RVX23CD244 RVX24CD245 RVX25CD246 RVX26CD250 RVX36CD251 RVX46CD254 RVX50CD255 RVX51CD256 RVX52CD260 RVX53CE101 RVX55CE104 RVX56CE105 RVX60CE106 RVL06CE110 RVL10CE111 RVL12CE112 RVL13CE113 RVL14CE114 RVL15CE115 RVL16CE116 RVL20CE117 RVL21CE120 RVL22CE121 RVL23CE124 RVL24CE125 RVL25CE126 RVL26CE130 RVL36CE131 RVL46CE134 RVL50CE135 RVL51CE136 RVL52CE140 RVL53CE141 RVL55CE144 RVL56CE145 RVL60CE146 RHX06

CE150 RHX10CE151 RHX12CE154 RHX13CE155 RHX14CE156 RHX15CE160 RHX16CE201 RHX20CE204 RHX21CE205 RHX22CE206 RHX23CE210 RHX24CE211 RHX25CE212 RHX26CE213 RHX36CE214 RHX46CE215 RHX50CE216 RHX51CE217 RHX52CE220 RHX53CE221 RHX55CE224 RHX56CE225 RHX60CE226 RHL06CE230 RHL10CE231 RHL12CE234 RHL13CE235 RHL14CE236 RHL15CE240 RHL16CE241 RHL20CE244 RHL21CE245 RHL22CE246 RHL23CE250 RHL24CE251 RHL25CE254 RHL26CE255 RHL36CE256 RHL46CE260 RHL50ES101 RHL51ES104 RHL52ES105 RHL53ES106 RHL55ES110 RHL56ES111 RHL60ES112 RMX06ES113 RMX10

ES114 RMX12ES115 RMX13ES116 RMX14ES117 RMX15ES120 RMX16ES121 RMX20ES124 RMX21ES125 RMX22ES126 RMX23ES130 RMX24ES131 RMX25ES134 RMX26ES135 RMX36ES136 RMX46ES140 RMX50ES141 RMX51ES144 RMX52ES145 RMX53ES146 RMX55ES150 RMX56ES151 RMX60ES154 RML06ES155 RML10ES156 RML12ES160 RML13ES201 RML14ES204 RML15ES205 RML16ES206 RML20ES210 RML21ES211 RML22ES212 RML23ES213 RML24ES214 RML25ES215 RML26ES216 RML36ES217 RML46ES220 RML50ES221 RML51ES224 RML52ES225 RML53ES226 RML55ES230 RML56ES231 RML60ES234 RLX06ES235 RLX10ES236 RLX12

ES240 RLX13ES241 RLX14ES244 RLX15ES245 RLX16ES246 RLX20ES250 RLX21ES251 RLX22ES254 RLX23ES255 RLX24ES256 RLX25ES260 RLX26ES301 RLX36ES304 RLX46ES305 RLX50ES306 RLX51ES310 RLX52ES311 RLX53ES312 RLX55ES313 RLX56ES314 RLX60ES315 RUC06ES316 RUC10ES317 RUC12ES320 RUC13ES321 RUC14ES324 RUC15ES325 RUC16ES326 RUC20ES330 RUC21ES331 RUC22ES334 RUC23ES335 RUC24ES336 RUC25ES340 RUC26ES341 RUC36ES344 RUC46ES345 RUC50ES346 RUC51ES350 RUC52ES351 RUC53ES354 RUC55ES355 RUC56ES356 RUC60ES360 RUB06HB101 RUB10HB104 RUB12HB105 RUB13

HB106 RUB14HB110 RUB15HB111 RUB16HB112 RUB20HB113 RUB21HB114 RUB22HB115 RUB23HB116 RUB24HB117 RUB25HB120 RUB26HB121 RUB36HB124 RUB46HB125 RUB50HB126 RUB51HB130 RUB52HB131 RUB53HB134 RUB55HB135 RUB56HB136 RUB60HB140 RUA06HB141 RUA10HB144 RUA12HB145 RUA13HB146 RUA14HB150 RUA15HB151 RUA16HB154 RUA20HB155 RUA21HB156 RUA22HB160 RUA23HB201 RUA24HB204 RUA25HB205 RUA26HB206 RUA36HB210 RUA46HB211 RUA50HB212 RUA51HB213 RUA52HB214 RUA53HB215 RUA55HB216 RUA56HB217 RUA60HB220 RVC06HB221 RVC10HB224 RVC12HB225 RVC13HB226 RVC14

HB230 RVC15HB231 RVC16HB234 RVC20HB235 RVC21HB236 RVC22HB240 RVC23HB241 RVC24HB244 RVC25HB245 RVC26HB246 RVC36HB250 RVC46HB251 RVC50HB254 RVC51HB255 RVC52HB256 RVC53HB260 RVC55HC101 RVC56HC104 RVC60HC105 RVB06HC106 RVB10HC110 RVB12HC111 RVB13HC112 RVB14HC113 RVB15HC114 RVB16HC115 RVB20HC116 RVB21HC117 RVB22HC120 RVB23HC121 RVB24HC124 RVB25HC125 RVB26HC126 RVB36HC130 RVB46HC131 RVB50HC134 RVB51HC135 RVB52HC136 RVB53HC140 RVB55HC141 RVB56HC144 RVB60HC145 RVA06HC146 RVA10HC150 RVA12HC151 RVA13HC154 RVA14HC155 RVA15

HC156 RVA16HC160 RVA20HC201 RVA21HC204 RVA22HC205 RVA23HC206 RVA24HC210 RVA25HC211 RVA26HC212 RVA36HC213 RVA46HC214 RVA50HC215 RVA51HC216 RVA52HC217 RVA53HC220 RVA55HC221 RVA56HC224 RVA60HC225 RHC06HC226 RHC10HC230 RHC12HC231 RHC13HC234 RHC14HC235 RHC15HC236 RHC16HC240 RHC20HC241 RHC21HC244 RHC22HC245 RHC23HC246 RHC24HC250 RHC25HC251 RHC26HC254 RHC36HC255 RHC46HC256 RHC50HC260 RHC51HD101 RHC52HD104 RHC53HD105 RHC55HD106 RHC56HD110 RHC60HD111 RHB06HD112 RHB10HD113 RHB12HD114 RHB13HD115 RHB14HD116 RHB15HD117 RHB16

HD120 RHB20HD121 RHB21HD124 RHB22HD125 RHB23HD126 RHB24HD130 RHB25HD131 RHB26HD134 RHB36HD135 RHB46HD136 RHB50HD140 RHB51HD143 RHB52HD144 RHB53HD145 RHB55HD146 RHB56HD150 RHB60HD151 RHA06HD154 RHA10HD155 RHA12HD156 RHA13HD160 RHA14HD201 RHA15HD204 RHA16HD205 RHA20HD206 RHA21HD210 RHA22HD211 RHA23HD212 RHA24HD213 RHA25HD214 RHA26HD215 RHA36HD216 RHA46HD217 RHA50HD220 RHA51HD221 RHA52HD224 RHA53HD225 RHA55HD226 RHA56HD230 RHA60HD231 RMC06HD234 RMC10HD235 RMC12HD236 RMC13HD240 RMC14HD241 RMC15HD244 RMC16HD245 RMC20

HD246 RMC21HD250 RMC22HD251 RMC23HD254 RMC24HD255 RMC25HD256 RMC26HD260 RMC36HE101 RMC46HE104 RMC50HE105 RMC51HE106 RMC52HE110 RMC53HE111 RMC55HE112 RMC56HE113 RMC60HE114 RMB06HE115 RMB10HE116 RMB12HE117 RMB13HE120 RMB14HE121 RMB15HE124 RMB16HE125 RMB20HE126 RMB21HE130 RMB22HE131 RMB23HE134 RMB24HE135 RMB25HE136 RMB26HE140 RMB36HE141 RMB46HE144 RMB50HE145 RMB51HE146 RMB52HE150 RMB53HE151 RMB55HE154 RMB56HE155 RMB60HE156 RMA06HE160 RMA10HE201 RMA12HE204 RMA13HE205 RMA14HE206 RMA15HE210 RMA16HE211 RMA20HE212 RMA21

HE213 RMA22HE214 RMA23HE215 RMA24HE216 RMA25HE217 RMA26HE220 RMA36HE221 RMA46HE224 RMA50HE225 RMA51HE226 RMA52HE230 RMA53HE231 RMA55HE234 RMA56HE235 RMA60HE236 RLB06HE240 RLB10HE241 RLB12HE244 RLB13HE245 RLB14HE246 RLB15HE250 RLB16HE251 RLB20HE254 RLB21HE255 RLB22HE256 RLB23HE260 RLB24LB101 RLB25LB104 RLB26LB105 RLB36LB106 RLB46LB110 RLB50LB111 RLB51LB112 RLB52LB113 RLB53LB114 RLB55LB115 RLB56LB116 RLB60LB117 RLA06LB120 RLA10LB121 RLA12LB124 RLA13LB125 RLA14LB126 RLA15LB130 RLA16LB131 RLA20LB134 RLA21LB135 RLA22

LB136 RLA23LB140 RLA24LB141 RLA25LB144 RLA26LB145 RLA36LB146 RLA46LB150 RLA50LB151 RLA51LB154 RLA52LB155 RLA53LB156 RLA55LB160 RLA56LB201 RLA60LB204 CC201LB205 CC204LB206 CC205LB210 CC206LB211 CC210LB212 CC211LB213 CC212LB214 CC213LB215 CC214LB216 CC215LB217 CC216LB220 CC217LB221 CC220LB224 CC221LB225 CC224LB226 CC225LB230 CC226LB231 CC230LB234 CC231LB235 CC234LB236 CC235LB240 CC236LB241 CC240LB244 CC241LB245 CC244LB246 CC245LB250 CC246LB251 CC250LB254 CC251LB255 CC254LB256 CC255LB260 CC256LC101 CC260LC104 CC101

LC105 CC104LC106 CC105LC110 CC106LC111 CC110LC112 CC111LC113 CC112LC114 CC113LC115 CC114LC116 CC115LC117 CC116LC120 CC117LC121 CC120LC124 CC121LC125 CC124LC126 CC125LC130 CC126LC131 CC130LC134 CC131LC135 CC134LC136 CC135LC140 CC136LC141 CC140LC144 CC141LC145 CC144LC146 CC145LC150 CC146LC151 CC150LC154 CC151LC155 CC154LC156 CC155LC160 CC156LC201 CC160LC204 CB201LC205 CB204LC206 CB205LC210 CB206LC211 CB210LC212 CB211LC213 CB212LC214 CB213LC215 CB214LC216 CB215LC217 CB216LC220 CB217LC221 CB220LC224 CB221LC225 CB224

LC226 CB225LC230 CB226LC231 CB230LC234 CB231LC235 CB234LC236 CB235LC240 CB236LC241 CB240LC244 CB241LC245 CB244LC246 CB245LC250 CB246LC251 CB250LC254 CB251LC255 CB254LC256 CB255LC260 CB256LD101 CB260LD104 CB101LD105 CB104LD106 CB105LD110 CB106LD111 CB110LD112 CB111LD113 CB112LD114 CB113LD115 CB114LD116 CB115LD117 CB116LD120 CB117LD121 CB120LD124 CB121LD125 CB124LD126 CB125LD130 CB126LD131 CB130LD134 CB131LD135 CB134LD136 CB135LD140 CB136LD141 CB140LD144 CB141LD145 CB144LD146 CB145LD150 CB146LD151 CB150LD154 CB151

LD155 CB154LD156 CB155LD160 CB156LD201 CB160LD204 CA201LD205 CA204LD206 CA205LD210 CA206LD211 CA210LD212 CA211LD213 CA212LD214 CA213LD215 CA214LD216 CA215LD217 CA216LD220 CA217LD221 CA220LD224 CA221LD225 CA224LD226 CA225LD230 CA226LD231 CA230LD234 CA231LD235 CA234LD236 CA235LD240 CA236LD241 CA240LD244 CA241LD245 CA244LD246 CA245LD250 CA246LD251 CA250LD254 CA251LD255 CA254LD256 CA255LD260 CA256LE101 CA260LE104 CA101LE105 CA104LE106 CA105LE110 CA106LE111 CA110LE112 CA111LE113 CA112LE114 CA113LE115 CA114LE116 CA115

LE117 CA116LE120 CA117LE121 CA120LE124 CA121LE125 CA124LE126 CA125LE130 CA126LE131 CA130LE134 CA131LE135 CA134LE136 CA135LE140 CA136LE141 CA140LE144 CA141LE145 CA144LE146 CA145LE150 CA146LE151 CA150LE154 CA151LE155 CA154LE156 CA155LE160 CA156LE201 CA160LE204 BB201LE205 BB204LE206 BB205LE210 BB206LE211 BB210LE212 BB211LE213 BB212LE214 BB213LE215 BB214LE216 BB215LE217 BB216LE220 BB217LE221 BB220LE224 BB221LE225 BB224LE226 BB225LE230 BB226LE231 BB230LE234 BB231LE235 BB234LE236 BB235LE240 BB236LE241 BB240LE244 BB241

LE245 BB244LE246 BB245LE250 BB246LE251 BB250LE254 BB251LE255 BB254LE256 BB255LE260 BB256PE201 BB260PE204 BB101PE205 BB104PE206 BB105PE210 BB106PE211 BB110PE212 BB111PE213 BB112PE214 BB113PE215 BB114PE216 BB115PE217 BB116PE220 BB117PE221 BB120PE224 BB121PE225 BB124PE226 BB125PE230 BB126PE231 BB130PE234 BB131PE235 BB134PE236 BB135PE240 BB136PE241 BB140PE244 BB141PE245 BB144PE246 BB145PE250 BB146PE251 BB150PE254 BB151PE255 BB154PE256 BB155PE260 BB156PE101 BB160PE104 BA201PE105 BA204PE106 BA205PE110 BA206PE111 BA210

PE112 BA211PE113 BA212PE114 BA213PE115 BA214PE116 BA215PE117 BA216PE120 BA217PE121 BA220PE124 BA221PE125 BA224PE126 BA225PE130 BA226PE131 BA230PE134 BA231PE135 BA234PE136 BA235PE140 BA236PE141 BA240PE144 BA241PE145 BA244PE146 BA245PE150 BA246PE151 BA250PE154 BA251PE155 BA254PE156 BA255PE160 BA256PD201 BA260PD204 BA101PD205 BA104PD206 BA105PD210 BA106PD211 BA110PD212 BA111PD213 BA112PD214 BA113PD215 BA114PD216 BA115PD217 BA116PD220 BA117PD221 BA120PD224 BA121PD225 BA124PD226 BA125PD230 BA126PD231 BA130PD234 BA131

PD235 BA134PD236 BA135PD240 BA136PD241 BA140PD244 BA141PD245 BA144PD246 BA145PD250 BA146PD251 BA150PD254 BA151PD255 BA154PD256 BA155PD260 BA156PD101 BA160PD104 AAA00PD105 AAA01PD106 AAA02PD110 AAA03PD111 AAA04PD112 AAA05PD113 AAA06PD114 AAA07PD115 AAA10PD116 AAA11PD117 AAA12PD120 AAA13PD121 AAA14PD124 AAA15PD125 AAA16PD126 AAA17PD130 AAA20PD131 AAA21PD134 AAA22PD135 AAA23PD136 AAA24PD140 AAA25PD141 AAA26PD144 AAA30PD145 AAA31PD146 AAA32PD150 AAA33PD151 AAA34PD154 AAA35PD155 AAA36PD156 AAA40PD160 AAA41PC201 AAA42

PC204 AAA43PC205 AAA44PC206 AAA45PC210 AAA46PC211 AAA50PC212 AAA51PC213 AAA52PC214 AAA53PC215 AAA54PC216 AAA55PC217 AAA56PC220 AAA60PC221PC224PC225PC226PC230PC231PC234PC235PC236PC240PC241PC244PC245PC246PC250PC251PC254PC255PC256PC260PC101PC104PC105PC106PC110PC111PC112PC113PC114PC115PC116PC117PC120PC121PC124

PC125PC126PC130PC131PC134PC135PC136PC140PC141PC144PC145PC146PC150PC151PC154PC155PC156PC160PB201PB204PB205PB206PB210PB211PB212PB213PB214PB215PB216PB217PB220PB221PB224PB225PB226PB230PB231PB234PB235PB236PB240PB241PB244PB245PB246PB250PB251

PB254PB255PB256PB260PB101PB104PB105PB106PB110PB111PB112PB113PB114PB115PB116PB117PB120PB121PB124PB125PB126PB130PB131PB134PB135PB136PB140PB141PB144PB145PB146PB150PB151PB154PB155PB156PB160PA201PA204PA205PA206PA210PA211PA212PA213PA214PA215

PA216PA217PA220PA221PA224PA225PA226PA230PA231PA234PA235PA236PA240PA241PA244PA245PA246PA250PA251PA254PA255PA256PA260PA101PA104PA105PA106PA110PA111PA112PA113PA114PA115PA116PA117PA120PA121PA124PA125PA126PA130PA131PA134PA135PA136PA140PA141

PA144PA145PA146PA150PA151PA154PA155PA156PA160

30 - Billing SNF PPS Services (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing data as follows. Refer to the Medicare Claims Processing Manual, Chapter 25, “Completing and Processing the UB-04 (CMS-1450) Data Set,” for further information about billing, as it contains UB-04 data elements and the corresponding fields in the electronic record:

• In addition to the required fields identified in the Medicare Claims Processing Manual, Chapter 25, “Completing and Processing the UB-04 (CMS-1450) Data Set,” SNFs must also report occurrence span code “70” to indicate the dates of a qualifying hospital stay of at least three consecutive days which qualifies the beneficiary for SNF services.

• Separate bills are required for each Federal fiscal year for admissions that span the annual

update effective date (October 1.)

• Use Type of Bill 21X for SNF inpatient services or 18X for hospital swing bed services.

• Revenue Code 0022. This code indicates that this claim is being paid under the SNF PPS. This revenue code can appear on a claim as often as necessary to indicate different HIPPS Rate Code(s) and assessment periods.

• There must be a line item on the claim for each assessment period represented on the

claim with revenue code 0022. This code indicates that this claim is being paid under SNF PPS. This revenue code can appear on a claim as often as necessary to indicate different HIPPS rate code(s) and assessment periods.

• The line item date of service date must contain an assessment reference date (ARD) when

revenue code 0022 is present unless the HIPPS rate code is AAA00.

• HCPCS/Rates field must contain a 5-digit “HIPPS Code”. The first three positions of the code contain the RUG group and the last two positions of the code contain a 2-digit assessment indicator (AI) code. See Tables 1 and 2 below for valid RUG codes and AI codes.

• Service Units must contain the number of covered days for each HIPPS rate code.

NOTE: Fiscal Intermediary Shared System (FISS) requirement:

The sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days field less the number of days reported in an OSC 77. (Note: The covered units field is utilized in FISS and has no mapping to the 837 or paper claim).

• Total Charges should be zero for revenue code 0022.

• When a HIPPS rate code of RUAxx, RUBxx , RUCxx, RULxx and/or RUXxx is present, a minimum of two rehabilitation therapy ancillary codes are required (revenue code 042x and/or, 043x and/or, 044x). When a HIPPS rate code of RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RVBxx, RVCxx, RVLxx, and/or RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue code is required (revenue code 042x, 043x, or 044x. Bills that are missing required rehabilitation therapy ancillary revenue codes are to be returned to the SNF for resubmission.

• The accommodation revenue code 018x, leave of absence is reported when the

beneficiary is on a leave of absence and is not present at the midnight census taking time.

• Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal diagnosis in the appropriate form locator. The code must be reported according to Official ICD-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-CM diagnosis code, including all five digits where applicable.

• Other Diagnosis Codes Required – The SNF enters the full ICD-CM codes for up to eight

additional conditions in the appropriate form locator. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines.

NOTE: Information regarding the form locator numbers that correspond to these data element names and a table to crosswalk UB-04 form locators to the 837 transaction is found in Chapter 25. 30.1 - Health Insurance Prospective Payment System (HIPPS) Rate Code (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) The HIPPS rate code consists of the three-character resource utilization group (RUG) code that is obtained from the “Grouper” software program followed by a 2-digit assessment indicator (AI) 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. 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. 30.6.2 – SNF PPS Rate Components (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) 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. --The nursing index is based on the amount of staff time, weighted by salary levels, associated with each RUG group. This index represents the amount of nursing time associated with caring for beneficiaries who qualify for the group.

The nursing per diem amount is case-mix adjusted by applying the nursing index. The result is the nursing component for that RUG group.

--The therapy per diem amount is a standard amount which includes physical, occupational, and speech-language therapy services provided to beneficiaries in a Part A stay. Payment varies based on the actual therapy resource minutes received by the beneficiary and reported on the MDS; --The therapy index is based on the amount of staff time, weighted by salary levels, associated with each RUG group. This index represents the amount of rehabilitation treatment time associated with caring for beneficiaries who qualify for the group.

If the RUG group is in the Rehabilitation plus Extensive Services or Rehabilitation category, the therapy per diem amount is case-mix adjusted by applying the therapy index. The result is the therapy component for that Rehabilitation RUG group.

--The non-case-mix therapy component is a standard amount to cover the cost of therapy assessments of beneficiaries who were determined not to need continued therapy services.

If the RUG group is not in the Rehabilitation plus Extensive Services or Rehabilitation category, this payment is added to the rate as therapy component for that RUG group.

--The non-case-mix component is also a standard amount added to the rate for each RUG group to cover administrative and capital-related costs.

This standard amount is added to all RUG groups.

30.6.3 - Decision Logic Used by the Pricer on Claims (Rev., 1958; Issued: 04-28-10; Effective Date: 10-01-10; Implementation Date: 10-04-10) The SNF Pricer shall calculate the rate for each line item with revenue code 0022 on a SNF claim. The SNF Pricer shall determine the rate using the following information:

- “HIPPS-CODE” on line item 0022; -“CBSA” - Per diem amounts defined within the Pricers as types of rate based on the statement covers “THRU-DATE”:

Inpatient rate = Nursing case mix component General service rate = Non-case-mix component Therapy rate = Therapy non-case mix component Rehabilitation rate = Therapy case-mix component

- Labor and non labor percentages based on the statement covers “THRU-DATE”; - Wage index, “SNF-FED BLEND” year, and “SNF-FACILITY RATE” based on the statement covers “THRU_DATE” - Rate adjustments applicable to the specific RUG code; - Nursing index based on the RUG code; - Therapy index based on the rehabilitation RUG code;

On input records with TOB 21x (that is, all provider submitted claims and provider or FI initiated adjustments), Pricer will perform the following calculations in numbered order for each RUG code: (1) Multiply the applicable urban or rural inpatient rate depending on CBSA by the nursing

index;

(2) Multiply the applicable urban or rural rehab rate by the therapy index, add to (1); (3) For the top 23 RUG categories, add the general service rate to the sum of (1) and (2) for the

(non-wage-adjusted) total PPS rate and proceed to step (4); OR for the lower 43 RUG categories, add the general service rate to the therapy rate to the sum of (1) and (2) for the (non-wage- adjusted) total PPS rate and proceed to step (4);

(4) Multiply the sum of (3) by the labor percentage then multiply the product by the applicable

wage index; (5) Multiply the sum of (3) by the non- labor percentage; (6) Add the product of (5) to the non-labor product in (4) for the (wage-adjusted) total PPS

rate. Conditional Steps completed if applicable after (6): (6a) If diagnosis code 042 is present, multiply (6) by 2.28 and proceed to (7)– Effective October 1, 2004, for the FY 2005 Pricer, this represents the 128% AIDS adjustment implemented with Section 511 of the MMA.