Conducting Resident Assessments

50.4 - Conducting Resident Assessments (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21) The imposition of sanctions does not waive the SNF’s responsibility to perform assessments in accordance with the clinical schedule defined in the SOM. Comprehensive admission assessments are still due within 14 days of admission to the SNF. Facility staff must also maintain the schedule for quarterly and annual assessments, and perform SCSAs and SCPAs when clinically appropriate. Medicare-required assessments are also necessary for all beneficiaries in the SNF whose stays are not subject to the payment ban. If, during the sanction period, staff do not perform Medicare-required assessments for beneficiaries in covered Part A stays, no payment is made and the SNF must submit a claim using the HIPPS default rate code and an occurrence code 77 indicating provider liability, in order to ensure that the beneficiary’s spell of illness (benefit period) is updated. Part A benefits are NOT available for beneficiaries admitted after the effective date of the payment ban. Therefore, the facility is not required to perform Medicare PPS assessments. Medicare payments can begin no earlier than the date the sanction is lifted. For Medicare PPS assessment scheduling purposes, the date the sanction is lifted should be considered day 1. In this case, if the sanctions are lifted effective June 15, the assessment reference date for the Medicare 5-day assessment must be set between June 15 and June 22 (i.e., the eighth day of the covered stay). An SNF may choose to perform the Medicare-required assessments during the sanction period, but is not required to do so. Generally, a facility should continue to do the Medicare PPS assessments if SNF staff believe the sanction was in error and may be lifted retroactively. In this case, the SNF would be able to bill Medicare at the correct rate. When the SNF does not receive timely notification that a payment ban has been lifted, and staff is unaware of the need to start the Medicare-Required schedule (the beneficiary meets all applicable eligibility and coverage requirements), the SNF shall bill the Medicare 5-day and 14-day assessment using the HIPPS code generated by the 14-day OBRA required assessment. If the SNF did not perform any assessments with an assessment reference date during the assessment window for the Medicare-Required 5- day or 14-day assessment, the SNF shall bill the default rate for those covered days associated with the assessment. Where the SNF did not perform an assessment with an ARD that fell in the applicable Medicare-Required Assessment window for the 30, 60 and 90-day Medicare-Required Assessments it shall bill the default rate. If the SNF did perform an assessment, including a SCSA, where the ARD fell in the window of a 30, 60 or 90-day Medicare-Required Assessment (including grace days), the SNF shall bill using the HIPPS code generated from the assessment in accordance with the payment policies found in Chapter 28 of the Provider Reimbursement Manual. The date the sanction is lifted is Day 1 for purposes of the Medicare assessment schedule. NOTE: In order to bill with the default code the beneficiary must at least meet the requirements for SNF coverage. EXAMPLE 1: The SNF is notified on June 15th that its payment ban was lifted effective June 1. The beneficiary was admitted on June 1. The SNF did not perform any of the Medicare-Required Assessments. However, the SNF did perform the initial OBRA assessment. The initial OBRA assessment shall be used to bill the 5-day Medicare- Required Assessment for up to 14 days. Day 15 is day 1 for purposes of starting the Medicare-required assessment schedule and a 5-day Medicare required assessment shall be performed. EXAMPLE 2: The SNF is notified on August 15 that its payment ban was lifted on June 1. The beneficiary was admitted on June 1. The SNF did not perform any of the Medicare-Required Assessments. However, the SNF did perform the initial OBRA Assessment. The initial OBRA assessment shall be used to bill the 5-day Medicare required assessment and the 14-day Medicare required assessment. The 30-day assessment shall be billed through day 44 at the default rate. Day 45 is day 1 for purposes of starting the Medicare- required assessment schedule and a 5-day Medicare required assessment shall be performed. See §120.1 for the revised Medicare-required assessment schedule under the SNF PDPM effective October 1, 2019.