Default or Provider Liable? I mistakenly thought a resident qualified for the interrupted stay when in actuality they readmitted beyond the 3-day interruption window (on day 4). I failed to schedule a new PPS 5-day assessment within the required timeframe. Can I still complete the PPS 5-day for billing?



Per RAI pg. 2-52, if the SNF fails to set the ARD within the defined ARD window for a 5-Day assessment, and the resident is still on Part A, the SNF must complete a late assessment. The ARD can be no earlier than the day the error was identified. The SNF will bill the default rate for the number of days that the assessment is out of compliance. This is equal to the number of days between the day following the last day of the available ARD window and the late ARD (including the late ARD). The SNF would then bill the HIPPS code established by the late assessment for the remainder of the SNF stay, unless the SNF chooses to complete an IPA. For example, a 5-Day assessment with an ARD of Day 11 is out of compliance for 3 days and therefore would be paid at the default rate (HIPPS: ZZZZZ) for days 1 through 3 of the Part A stay and the HIPPS code from the late 5-Day assessment for the remainder of the Part A stay, unless an IPA is completed.

If the SNF fails to set the ARD of a 5-Day assessment prior to the end of the last day of the ARD window, and the resident was already discharged from Medicare Part A when this error is discovered, the provider cannot complete an assessment for SNF PPS purposes and the days cannot be billed to Part A (i.e., provider liable).


Blog by Eleisha Wilkes, RN, GERO-BC, RAC-CTA, RAC-CT, DNS-CT, Proactive Medical Review

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