May 1, 2008
SNF/CERT HIPPS Code Information – Adjusting Claims
Follow these instructions when billing HIPPS (Health Insurance Prospective Payment System) codes on Skilled Nursing Facility (SNF) Resource Utilization Group (RUG) adjustment claims.
Claims returned to the provider (RTP) with reason code 31258 cannot be adjusted through Direct Data Entry (DDE).
• Reason code 31258 = The HIPPS code on this SNF RUG adjustment claim (18x or 21x) has been changed; the adjustment was provider initiated (adjustment requestor ID equals ‘H’); and was not submitted within the 120-day time period.
Providers who use software other than DDE should submit adjustment claims using that software. The Fiscal Intermediary Shared System (FISS) will assign an RTP status to the adjusted claim; FCSO’s claims department will override the RTP and release the claim for processing.
Providers who do not have software other than DDE should resubmit adjustment claims via paper. Include the following statement in the remarks field, “We cannot resubmit the claim through DDE.” Note: It will take 29 days to finalize the adjustment when submitting paper claims.
Reminder – add the following information when adjusting your claims.
• Condition Code – D9 = Any other change
• Adjustment Reason Code – PI – Program Integrity
• Remarks – Adjustment due to SNF/CERT conference call held with FCSO on 11/19/07, incorrectly billed HIPPS code. (Date and your initials)
• Make the appropriate changes to the line items and resubmit.
PPS (Prospective Payment System) Minimum Data Set (MDS) Schedule
Medicare MDS Assessment Type |
Modifiers |
Applicable Payment Days |
|---|---|---|
5-day MDS |
1 |
Can bill up to 14 days |
14-day MDS |
7 |
Can bill up to 16 days |
30-day MDS |
2 |
Can bill up to 30 days |
60-day MDS |
3 |
Can bill up to 30 days |
90-day MDS |
4 |
Can bill up to 10 days |
Other Medicare Require Assessment (OMRA) |
8 |
Change of status |
Readmission |
5 |
Can bill 14 days |
Need More Information?
Refer to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Pub. 100-04, Chapter 6 
, sections 30.1 and 30.5.1, or call the Provider Contact Center at 1-888-664-4112.
, sections 30.1 and 30.5.1, or call the Provider Contact Center at 1-888-664-4112.