Ask the Experts, MDS 3.0 Items, Payment/economy

Ask the expert: Changing of payers and PPS schedule

Q: I have always been instructed that if someone changes skilled payers, such as from a Medicare Advantage Plan to regular Medicare Part A, that the PPS schedule has to be restarted.  Someone asked me where to find the documentation for this, and I am having difficulty locating this. Can you please give me some direction and let me know where to find this information?

A: According to the MDS User’s Manual, the Medicare Part A PPS schedule applies only to a patient with traditional (fee-for-service) Medicare Part A. It also states, that the first day of Medicare Part A coverage for the current stay is considered day 1 for PPS assessment scheduling purposes.(Page 2-39 and 2-40)

You can also direct the person looking for documentation to check the definitions at MDS item A2400 Medicare Stay:

MOST RECENT MEDICARE STAY: This is a Medicare Part A covered stay that has started on or after the most recent admission/entry or reentry to the nursing facility.

MEDICARE-COVERED STAY: Skilled nursing facility stays billable to Medicare Part A. [Does not include stays billable to Medicare Advantage HMO plans]


READMISSION: Day 1 of Medicare Part A coverage after readmission following a discharge. Skilled nursing facilities (SNFs) must assess the clinical condition of beneficiaries by completing the MDS assessment for each Medicare resident receiving Part A SNF-level care for reimbursement under the SNF PPS.