Our facility is seeing an influx of Medicare Advantage Medical Review. Unfortunately, there have been a few denials based on the PDPM HIPPS code billed versus the HIPPS code generated from the MDS assessment. For example, the MA plan predetermined a score without comorbidity conditions COPD and Pulmonary Fibrosis. Now they have denied at the medical review because our MDS HIPPS code (KAPD1) did not match the plan’s approved HIPPS code (KAPF1). We billed as was approved, not what was MDS generated. Is there any way to overturn these decisions? We haven’t had luck so far.



Yes. Appeal the initial findings. Reviewers aren’t always the experts. As providers, we must follow guidelines set forth in the RAI User’s Manual and the MDS must always be coded accurately. In general, there may be up to three levels of appeal, and in some cases, it may require going to the administrative law judge (ALJ) to advocate and overturn the initial decision. But SNFs should stand behind what they know and defend the medically necessary services provided. I’d suggest including a cover letter with the appeal noting the discrepancy and explaining the RAI coding guidelines with look-back periods. In the future, you may want work with the MA case manager to negotiate and educate on the legal requirements of the MDS on the front end.

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Blog by Stacy Baker, OTR/L, RAC-CT, CHC, Proactive Medical Review

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