A0600 Medicare Number and A030B PPS assessment Fatal Error

Below is guidance provided today (10/20/14)by CMS, from the Virginia & North Carolina RAI Managers. This question has been asked frequently since the October 1^st software update, and CMS has responded to industry questions about the requirement for a Medicare number on PPS MDS assessments.

Question:

 A third-party, private insurance company requires that facilities complete and submit an assessment to them for reimbursement.  Since the beneficiary does not have a Health Insurance Claim Number (HICN) to enter into Item A0600B, the new edit for this item is causing a problem with our software in that the facility cannot “lock” the assessment in order to generate a RUG.  What can a vendor do to assist the facility in order to generate a RUG to send to the third-party insurance company? 

The answer is:

Answer:

 Edit (-3571) for Item A0600B states: “If this is a PPS assessment (A0310B= [01,02,03,04,05,06,07]), then the Medicare or comparable railroad insurance number (A0600B) must be present (not [^]).  Thus, the submission will be rejected if this is a PPS assessment and A0600B is equal to [^].”  In effect, if an assessment is coded as a PPS assessment, it will fail edit -3571 if the HICN or comparable Railroad Insurance number is not present (left blank) in Item A0600B.

Rationale:

Assessments that are being completed for third party billing must NOT be submitted to the QIES ASAP system.  Marking assessments as a PPS assessment when it is not for a Medicare part A Stay does not follow RAI coding instructions.  Submitting assessments marked as PPS to CMS when a facility is not seeking payment for a Medicare part A stay, is a violation of HIPAA’s minimum necessary standard. 

Vendors should work with their providers to meet their needs.  How these needs are met are between the provider and the vendor, i.e., a business arrangement.  A vendor is permitted (and encouraged) to add additional functionality that the free, CMS provided software, jRAVEN, does not provide. 

An example of a possible vendor solution to the question above: The vendor may choose to not enforce this edit until the RUG has been generated since the assessment is for third-party insurance purposes and would not be submitted to CMS.