Managed Medicare and HIPPS code

Experts,

I have a resident with Aetna Managed Medicare, what assessments do I need to open. Biller needs a HIPPS code as she said AETNA adopted the PDPM rule.

Thank again for all the help from these confusion ?

[Talino]

Although the HIPPS code is required, most Medicare Advantage plans pay by levels or a pre-contracted rate. If this is the case,

Copy the Adm MDS and code it as a 5-Day. Set the ARD the same as the Adm but no later than day 8. Complete all items not included in the Adm item set. Dash-fill Section GG or select not assessed, whichever your software requires.

If there is no recent MDS to copy or a resident goes out to the hospital and returns under the MA plan, create a standalone 5-Day or even IPA. Both assm’ts will yield the HIPPS. Again dash-fill Section GG.

If the MA plan does pay according to the HIPPS code (I don’t know of one that really pays the full HIPPS rate) then you will have to complete Section GG.

As usual, do not submit these MDSs.

[MDSRN15]

Follow-up on this Ms. Talino:

1. Received a letter from United MCR plans that they will use PDPM rules for billing.

2. Rehab follows PDPM and sets more minutes. Rehab then bills on a higher rate.

3. Submitted an admission assessment to CMS and created a 5Day that's just in my system.

4. Admission and 5Day assessments created with two different HIPPS because of Section GG.

Question:

a. Which one do I give the biller? The one I submitted to CMS or the 5D in my system?

b. Which one should rehab follow, my HIPPS admission or my 5 day?

[Talino]

You should only use the HIPPS from a stand alone 5-Day.

A standalone Adm MDS does not yield the HIPPS code. Did you combine an Adm and 5D and submit or you just created a duplicate that's not submitted?

[MDSRN15]

I can calculate it automatically in my system.

Did not combine assessment.

So, when I create a standalone 5D as you stated I should dash-out GG, but rehab factors it out to create their HIPPS.

[MDSRN15]

rehab expects both of us to have the same HIPPS.

[Talino]

As I stated in my initial response, most MA plans pay a pre-contracted rate or by levels. In which case, regardless the intensity of therapy a resident receives, the pay is a standard rate (720 mins or 150 mins / week = one same preset rate). Even with traditional Medicare, Rehab therapy intensity does not drive the maximum reimbursement with PDPM.

If the plan does pay based on the HIPPS code then you must complete GG. Albeit I will verify with BOM if that's what the plan really pays. Otherwise you will be wasting time completing GGs.

[MDSRN15]

Since our United plans pay using PDPM, then I have to create an admission then a stand alone 5D with GG filled out, please confirm.

Wouldn't it be fraud since I'm submitting a different information to CMS and I'm billing a different one?

[amoLucia]

Boy! You 2 are like speaking a foreign language. It's awful when you (me) only knows a few words of that language. (Hehehe).

[Talino]

33 minutes ago, MDSRN15 said:

Since our United plans pay using PDPM, then I have to create an admission then a stand alone 5D with GG filled out, please confirm.

Wouldn't it be fraud since I'm submitting a different information to CMS and I'm billing a different one?

The stand alone Admission MDS does not have Section GG and will not yield the HIPPS code. Only the 5-Day or IPA have section GG which generate the HIPPS.

If you are seeing the HIPPS code in the Admission MDS, it is because a 5-Day is combined. If you have a standalone Adm MDS w/ ARD 10/1/19 or after, look at Section Z0100A. It is blank.

12 minutes ago, amoLucia said:

Boy! You 2 are like speaking a foreign language. It's awful when you (me) only knows a few words of that language. (Hehehe).

Lol, we're in a world of conundrum CMS created!

Edited Jan 8, 2020 by Talino

[MDSRN15]

I wish I can paste an image, but I did created an admission assessment and I have an icon that can calculate a PDPM and RUG at the same time on this assessment.

So, I can create a 5D with a HIPPS, submit to biller and its ok to have an admission submitted to CMS.

Its same rule when we had RUGs.

? Its already January and this is still giving nightmares. Im just glad that I have this forum to go to and have Ms.Talino's expertise. Thank you.

[amoLucia]

Talino - You are so very well-versed in the MDS CMS process. Do you teach it? (compliment ?)

I got stuck at MDS 2.0 when I was Unit Managering. I LIVED with my books and even then I struggled. I envied the MDS RNACs but I couldn't fathom all the intricacies back then.