payor source on discharge

Posted
by 410rn 410rn (New) New

Hi, anyone here complete Section S for New York? I have a question specifically about Section S8055. Primary Payor:

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Item Rationale:
To determine the primary payment source as of the MDS Assessment Reference
Date (A2300).
Steps for Assessment:
Check with the billing office to review current payment source(s). Do not rely
exclusively on information recorded in the resident's clinical record.
Definitions and Coding Instructions:
Enter the Code of the one source of coverage that has primary responsibility for and pays for most of the resident’s current nursing home stay on the Assessment Reference Date (A2300).
Code 1. Medicare – Medicare Part A (traditional) or Medicare Part C (Medicare
Choice/HMO) is the primary payor. Medicaid may pay for the Medicare co-insurance
and/or deductibles.
Code 2. Medicaid* – Medicaid fee-for-service is the primary payor. Residents with
Medicaid coverage supplemented by Medicare Part B should be recorded as
Medicaid payor.
Code 3. Medicaid Pending* - There is no other primary third-party coverage being
used for the resident's present stay, and the facility has sought, or intends to seek,
establishment of Medicaid eligibility for coverage as of the Assessment Reference
Date (A2300).
Code 4. Medicaid Managed Care* - A Medicaid managed care program is the
primary payor. Medicaid Managed Care (“Mainstream” managed care) covers acute,
primary, specialty, long term care and behavioral health through managed care
organizations (MCOs) for residents who are not Medicare eligible. 

Example:

Patient's Medicare last covered day is 11/22/21, discharged home on 11/23/21. The patient is private pay after Medicare ends.

Discharge RNA/End of PPS ARD = 11/23/21.

What should I code as primary payor in S8055?

410rn

410rn

9 Posts

I can't seem to edit my post. Forgot to add this:

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Code 5. Managed Long-Term Care* - A Medicaid Managed Long Term Care (MLTC) plan is the primary payor. MLTC assists chronically ill or disabled individuals who require health and long-term care services. Full Medicaid eligibility and most often but not always Medicare eligible. MLTC plan types include FIDA, Partial
Capitation Plans, Program of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus and Medicaid Advantage.
Code 9. None of the Above - The primary third-party payor is not Medicare Part A or Medicaid, and Medicaid is not pending. A resident who pays privately, or has long-term care insurance or Veteran’s Administration benefits, or one who receives charity care. 

 

Talino

Talino

Specializes in ER CCU MICU SICU LTC/SNF. 1,010 Posts

Quote

Definitions and Coding Instructions:
Enter the Code of the one source of coverage that has primary responsibility for and pays for most of the resident’s current nursing home stay on the Assessment Reference Date (A2300)

If Medicare was the primary prior and Medicaid would have been on day of discharge, select Medicare. The day of discharge is a non-billable day, hence, no payer is evidently responsible. For tracking purposes, NY requires it to gather info of payer sources during the period/s of residency.