PDPM Claims Update

Carl J. Pucci in Finance & Reimbursement

AHCA has released a bulletin below which summarizes CMS response to PDPM claims adjustment issues:

We have heard from members that some claims submitted under PDPM to report information previously missed or that was entered incorrectly in the previous submission, have created problems. This may result in unexpected payment adjustments for the SNF PPS Part A claim, even when the initially submitted claim was paid correctly. This has also occurred in claims that were being submitted merely to report an additional item subject to consolidated billing requirements but that should not impact the PDPM payment rates.   

AHCA contacted the Centers for Medicare and Medicaid Services (CMS) about the issue and received the below response. They have identified the specific claims processing systems issue, but it will not be fixed until October. However, CMS is offering the following workarounds providers can follow to avoid receiving incorrect payment rates on initial claim submissions or receiving unexpected and incorrect payment adjustments when claim corrections are submitted later.  

When attempting to submit SNF PPS adjustment claims while CMS works to resolve the systems issues, follow the below steps:   

Full CMS Message on SNF PDPM Claims Issue 

Skilled Nursing Facility (SNF) PDPM initial claims that are processed out of sequence are not paying the correct Variable Per Diem (VPD)-adjusted rate.  

Also, all adjustment claims are not processing correctly.  

Claims need to process in date of service order for each stay for the VPD to calculate correctly.  

We [CMS] will correct this issue in October. In the interim:

  • Submit claims in sequence by waiting at least 2 weeks before billing subsequent claims 
  • To adjust claims, 
    1. Cancel the initial claim and all subsequent claims in the SNF stay then rebill in sequential order; or 
    2. Hold adjustments (when allowable) until October when they will process correctly

We [CMS] encourage you to submit a complete bill at the time of entry 

CMS has indicated that this above information is also being shared with all Medicare Administrative Contractor provider support personnel this week. 

We encourage you to share this information with your appropriate billing and finance staff. Contact pdpm@ahca.org if you have any questions.  

NYSHFA/NYSCAL CONTACT:

Carl J. Pucci
Chief Financial Officer
518-462-4800 x36