Compliance tip: The relationship between the assessment and the claim

Jun 07, 2018
The Bottom Line

The following post is an excerpt from HCPro’s title, Long-Term Care Billing A to Z, by Charlotte L. Kohler, RN, CPA, CRCE-I, CPC, ACS, CHBC.

Each scheduled SNF Medicare assessment is used to support Medicare PPS reimbursement. The scheduled assessment establishes a per diem payment rate for associated standard payment periods. Assessments are performed for days 5, 14, 30, 60, and 90, according to the length of the resident’s stay. Additional unscheduled assessments are performed due to:

  • Significant changes in status assessments

  • When there are significant corrections to a prior comprehensive assessment

  • At the start or end of a therapy assessment

  • When there is a change or resumption of therapy

The unscheduled assessment may impact the per diem payment rates for days within a standard payment period.

A Medicare unscheduled assessment that falls within a scheduled Medicare-required assessment window cannot be followed by the scheduled assessment later in that window. The MDS coordinator would combine the two assessments with an assessment reference date (ARD) appropriate to the unscheduled assessment. If the scheduled assessment was completed and an unscheduled assessment fell within that assessment window, the unscheduled assessment may supersede the scheduled assessment, and the payment may be modified until the next unscheduled or scheduled assessment. Payment for unscheduled assessments varies depending on the situation.

If an assessment has an ARD outside of the scheduled assessment window, Medicare will pay the default rate for the days the ARD is out of compliance. If an assessment is performed early where the ARD is not in the assessment window, Medicare will pay the default rate for the days the assessment was noncompliant. If an assessment is completed late where the ARD is prior to the end of the period during which the late assessment would have controlled the payment, Medicare will pay the default rate for the days the assessment is noncompliant. When no assessment exists in the QIES ASAP system due to a missed assessment, Medicare will not pay for those days.


Centers for Medicare & Medicaid Services, Version 1.13, October 2015

Department of Health and Human Services, Medicare-Required SNF PPS Assessments

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