Guidance on PPS MDS Assessments Provided

Cil Bullard, RN, CPC, Virginia RAI/OASIS Coordinator has provided guidance to facilities after receiving information from the Centers for Medicare and Medicaid Services (CMS).  She noted that the question requiring clarification has been asked frequently since the October 1 software update, and CMS has responded about the requirement for a Medicare number on PPS MDS assessments.

Question:

A third-party, private insurance company requires that facilities complete and submit an assessment to them for reimbursement.  Since the beneficiary does not have a Health Insurance Claim Number (HICN) to enter into Item A0600B, the new edit for this item is causing a problem with our software in that the facility cannot “lock” the assessment in order to generate a RUG.  What can a vendor do to assist the facility in order to generate a RUG to send to the third-party insurance company?  

The answer is:

Edit (-3571) for Item A0600B states: “If this is a PPS assessment (A0310B= [01,02,03,04,05,06,07]), then the Medicare or comparable railroad insurance number (A0600B) must be present (not [^]).  Thus, the submission will be rejected if this is a PPS assessment and A0600B is equal to [^].”  In effect, if an assessment is coded as a PPS assessment, it will fail edit -3571 if the HICN or comparable Railroad Insurance number is not present (left blank) in Item A0600B.

Rationale:

Assessments that are being completed for third party billing must NOT be submitted to the QIES ASAP system.  Marking assessments as a PPS assessment when it is not for a Medicare part A Stay does not follow RAI coding instructions.  Submitting assessments marked as PPS to CMS when a facility is not seeking payment for a Medicare part A stay, is a violation of HIPAA’s minimum necessary standard.  

Vendors should work with their providers to meet their needs.  How these needs are met are between the provider and the vendor, i.e., a business arrangement.  A vendor is permitted (and encouraged) to add additional functionality that the free, CMS provided software, jRAVEN, does not provide.  

An example of a possible vendor solution to the question above: The vendor may choose to not enforce this edit until the RUG has been generated since the assessment is for third-party insurance purposes and would not be submitted to CMS.  

Additional questions about the clarification should be directed to Cil Bullard at priscilla.bullard@vdh.virginia.gov or by phone at 804.367.2141.