CMS Pub. 100-04, ch. 1, § 140.2

Assessments

(Rev. 3001, Issued: 08-01-14, Effective: 10-01-12, Implementation: 01-05-15)

The case-mix groups used to determine payments under several Medicare prospective

payment systems (PPS) are based on clinical assessments of the beneficiary. Each

payment system uses a different patient assessment tool:

Payment System Assessment Used

Skilled Nursing Facility – SNF PPS Minimum Data Set

Home Health – HH PPS Outcomes and Assessment Information

Set

Inpatient Rehabilitation Facility – IRF PPS IRF Patient Assessment Instrument

In all three payment systems, the assessments are entered into software at the provider

site that encodes the data into a standard transmission format and transmits the

assessments to quality improvement systems. In addition, the software runs the data from

the assessments through grouping software that generates a case-mix group to be used on

Medicare PPS claims. These case mix groups are reported on claims using a Health

Insurance PPS (HIPPS) code.

CMS provides free grouping software to perform this function, but many providers create

their own software due to their need to integrate these data entry and grouping functions

with their own administrative systems. In some cases, this results in HIPPS codes

reported on claims that differ from the HIPPS code calculated by the assessment system.

In the interest of payment accuracy, Medicare claims processing systems may

temporarily hold Medicare PPS claims paid under these payment systems (Medicare

Advantage claims are excluded), in order to validate the claim information against the

assessment record. If the information found in the assessment system differs from the

claim information, the assessment information will be used to pay the claim. This

process will occur within the payment floor period.

This process may be used for various purposes, including:

• Validating the provider-submitted HIPPS code

• Ensuring timely assessment submission requirements are met

• Ensuring conditions of payment are met.