AHCA has issued a member update on PDPM claims processing. The update covers the latest information on the Medicare Administrative Contractors (MACs) ability to process claims with multiple Health Insurance Prospective Payment System (HIPPS) codes.

AHCA Weekly PDPM Update – Claims Processing Issues (October 31, 2019)

We know you all have been working very hard to implement the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) Patient-Driven Payment Model (PDPM) – and that it has been a bumpy ride. When PDPM went live on October 1, many members discovered problems with the PDPM Grouper software. AHCA informed the Centers for Medicare and Medicaid Services (CMS) about this issue, and the agency responded by updating software or providing workaround procedures of which you have been updated. CMS is making progress, but more work remains, as new problems have been identified in its claims processing systems. 

Initially, PDPM-related claims submitted in October were either being placed on hold or, if processed, were not recording accurate payments. Many of these issues were resolved by October 24 as you have been previously notified. Since then, AHCA has learned that while some Medicare Administrative Contractors (MACs) have been able to process claims with a single Health Insurance Prospective Payment System (HIPPS) code, none of the MACs are able to process claims with multiple HIPPS codes. CMS has assured AHCA that all MACs should be able to process and accurately pay all claims containing only one HIPPS code in the coming days.

Why Would a Claim Have More Than One HIPPS Code?

PDPM claims would have multiple HIPPS codes if an Interim Payment Assessment (IPA) was conducted. It is important to note that Transitional IPAs conducted in October as part of the transition from RUGs to PDPM would not be impacted by this claims software challenge. 

Scenarios in which an IPA might be conducted and result in multiple HIPPS codes include:

• A change in a patient’s needs while in the SNF, resulting in completion of an optional IPA without an interruption in the stay; or  
• The patient is readmitted to or resumes covered care in the same SNF in less than three days under the interrupted stay policy, and an optional IPA is completed. 

The number of October claims with multiple HIPPS codes is likely to be low. CMS estimates the percentage of claim potentially impacted will be 15 to 20 percent on average. However, this can vary by individual SNF. CMS’ projected date for a fix to properly pay for claims with multiple PDPM HIPPS codes is early December. 

You can learn more about PDPM HIPPS coding on page seven of CMS’ PDPM Frequently Asked Questions . Page three of this CMS document provides a longer overview of PDPM HIPPS coding for your background.

How You Can Help

AHCA needs your help in understanding the projected percentage of claims with multiple HIPPS codes that fall within CMS’ projection, as well as any MAC-specific issues. This will greatly assist our advocacy efforts in working with CMS to expedite a resolution.

Please complete this form by November 8 to share the following results from your October SNF PPS claims:

• The total number of October claims submitted and what percent had multiple PDPM HIPPS; 
• The total amount billed for using claims with multiple PDPM HIPPS codes; and 
• Your MAC’s narrative claim status reason code if placed on hold, not paid accurately, or otherwise producing an unexpected result.

AHCA remains in contact with CMS on a regular basis and will provide ongoing updates as we move towards the December fix. Please email pdpm@ahca.org with any questions, suggestions, or concerns