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Cheatography

MDS HIPPS Modifiers Cheat Sheet (DRAFT) by [deleted]

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Introd­uction Health Insurance PPS (HIPPS) Codes

Each Medicare PPS assessment is used to support Medicare Part A payment for a maximum number of days. The HIPPS code must be entered on each claim, and must accurately reflect which assessment is being used to bill the RUG-III group for Medicare reimbu­rse­ment.

The CMS HIPPS codes contain a three position code to represent the RUG-III of the SNF resident, plus a 2-position assessment indicator to indicate which assessment was HIPPS modifier codes have been establ­ished for each type of assessment used to support Medicare payment. For example, the Medicare reason for assessment on a Medicare 5-Day assessment is “1”, and the HIPPS code is “01”.

Situations Requiring Dual Assess­ments

Under the SNF PPS, there are situations when two assess­ments may be needed to fulfill Medicare requir­ements. Rather than requiring such duplic­ation of effort, providers have the ability to combine assess­ments.

For example, if an OMRA is required during the assessment window for a Medicare 30-Day assessment (i.e., days 21-34), the SNF is required to perform only one assess­ment. There is no way to code two Medicare Reasons for Assess­ment. The combined OMRA/3­0-Day Medicare assessment is coded on the MDS as an OMRA and identified on the Part A billing by using a HIPPS modifier code of “28”. The combined assessment can then be used when billing the Medicare claim.

Similarly, if an assessment is a combined 30-Day and an SCSA, the SCSA is coded as the Primary Reason for assess­ment. The 30-Day is shown as the Medicare Reason for Assess­ment, and the HIPPS modifier code used for
billing is “32”.

Modifiers & Descri­ptions

Modi­fier
Asse­ssm­ents
11
Adission Assessment - Medicare 5 Day (or Readmi­ssi­on/­Return) assessment (Compr­ehe­nsive)
01
Medicare 5 Day Assessment (Full)
05
Read­mis­sio­n/R­eturn Medicare (Full)
07
Medicare 14 Day Assessment (Full)
17
Admi­ssion Assessment - Medicare 24 Day Assessment (Compr­ehe­nsi­ve))
02
Medicare 30 Day Assessment (Full)
03
Medicare 60 Day Assessment (Full)
04
Medicare 90 Day Assessment (Full)
54
Quarterly Review­-Me­dicae 90 day Assessment (Full)
30
Signif­icant Change in Status Assessment (SCSA) - not replacing
08
Other Medicare Require Assessment (OMRA) - Not replacing
Modi­fier
Signif­icant Correction of Prior Full Assess­ments**
40
Sig. Correction of a Prior Full Assess­ment- Previous Assess. Not replacing
41
Signif­icant Correction of Prior Full Assessment - Medicare 5 days-R­ead­mis­ion­/Return Medicare
45
Signif­icant Correction of Prior Full Assessment - Medicare 5 days
47
Signif­icant Correction of Prior Full Assessment - Medicare 14 day
42
Signif­icant Correction of Prior Full Assessment - Medicare 30 day
43
Signif­icant Correction of Prior Full Assessment - Medicare 60 day
44
Signif­icant Correction of Prior Full Assessment - Medicare 90 day
Modi­fier
Other Medicare Required Assessment (OMRA) - Replac­ing
18
OMRA replacing Medicare 5 Day Assess­ment- Medicare 14 days
78
OMRA replacing Medicare 14 Full Assessment - Medicare 14 days
28
OMRA replacing Medicare 14 Full Assessment - Medicare 30 days
38
OMRA replacing Medicare 14 Full Assessment - Medicare 60 days
48
OMRA replacing Medicare 14 Full Assessment - Medicare 90 days
Modi­fer
Signif­icant Change in Status Assessment (SCSA) - replac­ing**
31
SCSA replacing Medicare 5 Day Assessment
35
SCSA replacing Readmi­ssi­on/­Return Medicare Assessment Assessment
37
SCSA replacing Medicare 14 Day Assessment
32
SCSA replacing Medicare 30 Day Assessment
33
SCSA replacing Medicare 60 Day Assessment
34
SCSA replacing Medicare 90 Day Assessment
00
No Assessment Completed (Defau­lt)