Skilled Nursing Facility Minimum Data Set Corrections

The Centers for Medicare & Medicaid Services (CMS) expects that most Health Insurance Prospective Payment System Code (HIPPS) corrections will be made during the beneficiary’s Medicare Part A stay. Therefore, providers that routinely submit corrections after the beneficiary’s Part A stay has ended may be subject to focused medical review.

Adjustment requests to change a HIPPS code may not be submitted for any claim that has already been medically reviewed; such claims are identified in the Fiscal Intermediary Shared System (FISS) system by an indicator on the claim record. This applies whether the medical review was performed either pre- or post-payment. All adjustment requests submitted are subject to medical review.

Adjustment requests based on corrected assessments must be submitted within 120 days of the service 'through' date. The 'through' date will be used to calculate the period during which adjustment requests may be submitted based on corrected Resident Assessment Instrument (RAI) assessments. The 'through' date indicates the last day of the billing period for which the HIPPS code is billed. Adjustment requests based on corrected assessments must be submitted within 120 days of the 'through' date on the bill. For HIPPS changes resulting from an Minimum Data Set (MDS) correction, providers must append a condition code D2 on their adjustment claim. An edit is in place to limit the time for submitting this type of adjustment request to 120 days from the service 'through' date. 

Medicare Review contractors will deny claims if the date of the MDS is after the claim entry date and the modified assessment results in changes to the HIPPS code. Providers will need to submit an appeal to request a corrected claim.

Resources

• CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual Chapter 6, Section 30.3 (PDF)