As previously communicated, the Centers for Medicare & Medicaid Services (CMS) requires that all Medicare Advantage Organizations (MAO) submit Health Insurance Prospective Payment System (HIPPS) codes on all Skilled Nursing Facility (SNF) and Home Health Agency (HHA) claims/encounters with a "from" date on or after July 1, 2014. The original communication from CMS indicated that the HIPPS codes should come from the initial Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessment (Admission assessment) and Outcome and Assessment Information Set (Start of Care assessment), respectively.

SNF claims/encounters

Recently, AmeriHealth received further guidance from CMS regarding this requirement for SNF encounters when no Admission assessment was completed during the Medicare Advantage (MA)-covered stay. The requirements previously communicated, as well as this new guidance from CMS, extended through 2015 dates of service. The following rules apply if there was no Admission assessment completed during the MA-covered part of the stay:

• Stays of more than 14 days. If the Admission assessment for a stay in the facility was completed prior to the MA-covered portion of the stay, MAOs must submit to CMS a HIPPS code by following the guidance in the order they are listed below:
  • –Submit the HIPPS code from another assessment completed during the MA-covered portion of the stay. If the OBRA Admission assessment was completed for the current stay prior to the MA-covered portion of the stay, and another assessment (e.g., Quarterly Assessment or any Prospective Payment System assessment required by the MAO) was completed during the MA-covered portion of the stay, the MAO shall submit the HIPPS code generated from that other assessment on their encounter submissions to CMS.¹
  • –Submit the HIPPS code from the most recent assessment that was completed prior to the MA-covered portion of the stay. If no assessment was completed during the MA-covered portion of the stay from which a HIPPS code could be generated, the MAO shall submit to CMS the HIPPS code from the most recent OBRA or other assessment that was completed prior to the MA-covered portion of the stay (which may be the Admission assessment).¹
• Stays of 14 days or less. If there was no Admission assessment completed before discharge for a stay of less than 14 days, MAOs must submit to CMS a HIPPS code by following the guidance in the order they are listed below:
  • –Submit the HIPPS code from another assessment from the stay. If no OBRA Admission assessment was completed for a SNF stay of less than 14 days, the MAO shall submit to CMS the HIPPS code from any other assessment that was completed during the stay that produces a HIPPS code.¹
  • –Submit a default HIPPS code of "AAA00." MAOs may submit a default HIPPS code for SNF encounter submissions to CMS only if: 1) the SNF stay was less than 14 days within a spell of illness, 2) the beneficiary has been discharged prior to the completion of the initial OBRA Admission assessment, and 3) no other assessment was completed during the stay.² To submit a default HIPPS code to the Encounter Data System, MAOs should use the default Resource Utilization Group code of "AAA" and Assessment Indicator "00" on encounter data submissions starting with "from" dates of service July 1, 2014.
    MAOs may not use this default code in other situations, such as to avoid collecting the proper HIPPS code, or when the MAO's systems are not prepared to submit the HIPPS code to CMS.

If you have any questions about these requirements, please contact your Hospital/Ancillary Services Coordinator.

¹ CMS understands that some MAOs require providers to conduct assessments similar to those used under traditional Medicare Part A Prospective Payment System (PPS) rules. Providers may submit to MAOs, and MAOs can submit to the Encounter Data System, HIPPS codes derived from the same item set and data specifications as those used under the SNF PPS. We note that, in such cases, providers must not submit these assessments through the traditional PPS assessment system.

² Per the Assessment Management Requirements and Tips for Comprehensive Assessments (RAI Manual, pg. 2-17): "If a resident is discharged prior to the completion deadline for the assessment, completion of the assessment is not required." Federal statute and regulations require that SNFs and Nursing Facilities promptly assess residents upon admission but no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days).