SAM and Medicare PPS
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Understanding and Using Medicare Prospective
Payment System Functions in SAM.
Introduction
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This presentation will show you how to use SAM’s OASIS
and billing functionality to create, transmit, manage, and
adjust Requests for Anticipated Payments and Final
Claims according to specifications published by HCFA.
After this presentation you should be able to create RAPS,
final claim EOEs, and perform adjustments suggested by
SAM including Partial Episode Payments, Low Utilization
Payment Adjustments, Significant Change In Condition
and Outlier Adjustments.
SAM PPS Topics
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Entering Medicare Plan of Care
Entering OASIS Assessment
OASIS Summary
Creating Invoices for PPS
The new PPS RAP service item
The new PPS EOE service item
The RAP Invoice and Claim
The EOE Invoice and Claim
PPS Billing Log
Adjusting your RAPs and EOEs
Payments, Applying Cash and Adjustments
PPS and the OASIS Potential Problem Log
PPS and the Account Log
PPS and the Sales Report
PPS and the Medicare Episode Report
PPS and the Aging Report
PPS and the Utility Census Report
PPS and the General Ledger
Steps in PPS Billing
Entering Medicare Plan of Care
Medicare PPS Billing begins with a Medicare Plan of Care for the patient entered in SAM.
Without a Medicare Plan of Care, this patient will not be considered for PPS billing. The
Medicare Payer must be assigned a “Medicare” payer class.
Entering OASIS Assessment
In addition, a OASIS Assessment “associated with the Plan of Care” is required.
OASIS Summary
Once the OASIS Assessment is completed, pressing the Summary button will display the
PPS information. We have not yet created the RAP or EOE, this is reference information
only, however, it does show us that we have completed the information necessary on the
assessment for PPS billing.
Setting Client/Payer Requirements
You can set the client/payer relationship requirements to require “Signed Plan of Care
(and billable visit).” If this option is turned “On” for the client/payer relationship, the
RAP will not be created unless a billable visit exists for the certification period. In
addition, The EOE will not be created unless all Plan of Cares and Verbal Orders for
the certification period have a “Received Signed” date.
Creating PPS Invoices
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Before you generate PPS Invoices, make sure you have the following:
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A Medicare or Episodic Insurance payer.
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Branch ID entered for the office.
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Clients associated with the Medicare or Episodic Insurance payer.
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First skilled billable visit (on the cert begin for 60% RAPs)
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Plan of Care for the Medicare or Episodic Insurance payer (no
overlapping plans of care for same payer.)
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A Start of Care, Resumption of Care, Recert or follow-up OASIS
Assessment for the patient.
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The OASIS Assessment is associated with the appropriate Plan of Care.
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The OASIS Assessment has a status of “locked” or “exported.”
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You can click the “summary” button on the OASIS Assessment and get
the PPS Episode amount with no assessment errors reported.
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If the Medicare client is “Medicare Secondary Payer”, placing “MSP” in
the client's “Bill Notes” field will cause all RAP and EOE claims to be
created with occurrence code 1 = '05’, occurrence date 1 = RAP date,
and the remark will read "Services provided by our agency are not
associated with previous MSP."
Creating PPS Invoices
Once the Medicare Plan of Care and OASIS Assessment are complete we are ready
to create PPS invoices/claims. On the “Create Invoices” screen, click the “PPS”
Option, and Click the “Create Invoices” button. You may create PPS Invoices at any
time. You may also optionally select to create PPS invoices for one client.
The new PPS RAP Service Item
When a PPS RAP invoice is created, SAM creates a PPS RAP service item for either the
date of the first billable visit or the start of episode date if no billable visit is found. The
invoice description shows the percentage of payment requested, the HHRG and HIPPS
codes, as well as the wage index and case mix weight.
The new PPS EOE Service Item
When a PPS EOE invoice is created, SAM creates a PPS EOE service item for the End of
Episode date. The invoice description shows the percentage of payment previously
requested, the HHRG and HIPPS codes, as well as the wage index and case mix weight.
The RAP Invoice
The RAP Claim
Source of admission on the claim will be set to a ‘9’ meaning unavailable, unless the
information has been entered for the patient in Care Manager. The claim must be edited in
SAM with the true source of admission if it was not entered for the patient.
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B – Transfer from another HHA
C – Readmission to same HHA
1 – Physician referral
2 – Clinic referral
3 – HMO referral
4 – Transfer from a hospital facility
5 – Transfer from a SNF
6 – Transfer from another healthcare facility
7 – Emergency room
8 – Court/Law Enforcement
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9 – Information unavailable
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 SAM sets the RAP service item date (locator 46) equal to the first billable visit's
date. The first billable visit for an initial RAP (60%) is a skilled visit with a status of
"confirmed", "verified" or "closed." This is also the patient’s start of care date.
 The first billable visit for a subsequent RAP (50%) is a skilled or unskilled visit with a
status of "confirmed", "verified" or "closed" within the certification period. If no billable visit
is found, the date will be set to the certification begin date. On the UB92 claim, locator 6
(statement period covers dates) will be set equal to the RAP service item date. On
subsequent RAP claims, locator 6 dates will reflect the certification begin date.
The EOE Invoice
The EOE Claim
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On EOE claims, locator 6 dates will reflect the certification period.
The date in locator 6 on the EOE UB92 must match the date in locator 6 of the
RAP UB92. For this reason, it is important that the date of the first billable
visit be known at the time the RAP is created. If this is not the case, BOTH
the RAP and EOE claims must be edited and resubmitted. If you need to edit
the claims, check with your clinical staff to make sure that the OASIS
Assessment and scheduled visit information are correct. If not, they may need
to make adjustment to the assessment(s) or schedule before you recreate the
RAP/EOE claims. Source of admission on the claim will be set to a ‘9’
meaning unavailable, unless the information has been entered for the patient
in Care Manager. The claim must be edited in SAM with the true source of
admission if it was not entered for the patient.
Patient status will be a “30” if the cert end date is the end of episode.
Otherwise, the patient status will be set to a “06” to represent a discharge or
transfer before the cert end date. A transfer in SAM is a type of discharge. Do
not use the transfer patient status as this means “transfer within the
organization” and not to another agency.
This claim contains line items for visits and supplies closed at the time the
episode is detected to be over.
SAM will default to code 270 for Medicare Supplies. If those supplies are
wound care, the claim must be edited and the code for the wound care
supplies changed to 623.
EOE Claim
SAM PPS Billing Log
During the invoicing process, several situations will be detected and logged.
SAM PPS Billing Log Entry Types
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A billing log report will be displayed on the screen. This log will report any errors or warnings
regarding the creating of the PPS invoices. This report will sort entries based on the Plan of Care
certification begin date. The billing log is saved as N:\pps.log and is appended to each time the
Create PPS Invoices option is selected.
An additional billing log in Microsoft Excel format (n:\ppslog.xls) is also created which will contain all
of the information last appended to the billing log (n:\pps.log) (only current information.) This will
allow you to easily sort the file by name, messages, etc. Long messages such as “OUTLIERS” or
“SCICS” are truncated to 254 characters in the .xls file.
List below are just a few of the type of errors that SAM might report in the billing log.
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Although a PPS RAP was created, no billable visit exists.
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No OASIS record information found for the Plan Of Care.
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OASIS not found with assessment reason of Start of Care, Resumption of Care, Recert followup.
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Plan of Care for has no mailed date for cert begin.
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OASIS document is not locked or exported.
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Although the episode has ended, the week the episode ended within has not been closed so a
PPS EOE service item and final claim will not yet be created.
You can use this checklist to trouble shoot any problems reported on the billing log:
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What is the “payer set #” for the client/payer relationship to the Medicare payer?
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Are all of the Medicare visits on that payer set?
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Is the Plan of Care for that payer set?
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Is the OASIS Assessment associated with the correct plan of care?
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Are all of the OASIS Assessments associated with the correct plan of care?
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Do you have a first skilled billable visit:
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For a 60% RAP must be equal to the cert begin date
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For a 50% RAP must be within cert period
SAM PPS Billing Log Entry Types
RAP created for patient name on date falls within previous episode for patient. PEP coding is required.
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You do not need to adjust your claim. Medicare is aware of PEPs and will pay accordingly. You
will only be paid “short” if a LUPA occurs or if another agency picks up your patient within your
original cert period. After you receive your payment for the episode, you will need to adjust your
EOE service item to match the remittance.
Patient is qualified for OUTLIER payment.
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You do not need to adjust your claim. Medicare counts your visits on your EOE claim, and adjusts
your payment accordingly if you have reached the threshold amount for an outlier. After you
receive your payment for the episode, you will need to adjust your EOE service item to match the
remittance.
Patient’s original condition has changed (SCIC). The original HIPPS code is FIRST_HIPPS. As of SCIC_DATE,
the new HIPPS code is HIPPS with a Case Mix Weight of CMW. A SCIC adjustment may be appropriate.
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Only adjust the claim if the SCIC will cause the episode amount to increase.
Adjust the EOE claim before transmitting:
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Adjust the current EOE detail line (0023 line) to reflect the number of days (in the days/units field)
appropriate (from the pps log) for the original HIPPS code.
Add a new line as follows: description = “PPS EOE”, code = “0023”, HCPCS/rate = new HIPPS
code (from pps log), date of service = date of SCIC (from pps log), days/units = days for new
HIPPS code (from pps log).
Skilled billable visit for patient not found on or after date. RAP PPS bill was created BUT be sure a billable visit
was done.
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Adjust the claim to reflect the date of the skilled billable visit in locator 46 (serv date) to be equal to
locator 6 (statement period covers dates) from date before you transmit the RAP claim.
The episode patient for the date plan of care has only x visits and qualifies as a LUPA. The RAP payment for
this episode was $. The EOE payment for this episode is $. The total episode payment should be
REDUCED by $.
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Medicare will pay the episode at the LUPA rate.
Adjust the RAP as usual to reflect the “take back.”
Adjusting the PPS Service Items
If for any reason you need to make a adjustment to the RAP or EOE, you will want to
adjust the PPS Service Items. Find the PPS RAP and/or EOE service item by date, client,
and payer.
Adjusting the PPS Service Items
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Adjust the service items so that the final value of the two equals the correct total
episode amount and select the PPS Adjustment Type (this will be used for
reporting).
Payment, Applying Cash and
Adjustments
When you get a remittance, add that as a payment in SAM and record the “EFT #”, “Check
#” or “Remit #” as the payment number.
1. If there is a payment for a RAP, apply the cash to the RAP invoice.
2. If there is a recoup for a RAP, apply a negative cash application to the RAP invoice
AND adjust the RAP service item to 0.
3. If there is a payment for an EOE, (at this point it should be payment for the entire
episode) 1) apply the cash to the EOE invoice and then 2) adjust the EOE service item
to match the amount paid for the EOE.
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If you follow this process, you should be able to balance the SAM payment/cash app
report to your remittance advice.
When you are making the RAP / EOE service item adjustments be sure to categorize
them correctly (LUPA, SCIC, etc.), these adjustments are reported on the Medicare
Episode report.
The final claim (EOE) must be submitted 60 days after the paid date of the RAP or 120
from the SOC date (whichever is greater), or the RAP will be “auto cancelled” also
known as a “take back.” In this case, the “take back” will be shown on your remittance.
Apply a negative cash application to the RAP invoice; do not make any adjustment to
the RAP so it will stay on your Invoice Aging report. Resubmit the RAP claim, wait 3
days and then submit the EOE claim.
PPS and the OASIS Potential Problem Log
The OASIS Potential Problem Log report may be run to “flag” potential problems with your
OASIS assessments that might affect your PPS Billing.
PPS and the OASIS Potential Problem
Log (cont.)
You may optionally select any combination of the following problems to be reported.
PPS and the Account Log
A patient discharged before the end of a plan of care would have the following adjustment
advice (PEP).
PPS and the Account Log (cont.)
A patient with 4 or fewer visits when the end of episode is detected will have the following
adjustment advice (LUPA).
PPS and the Sales Report
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The Sales report can be used to show PPS sales activity for Medicare. On
the report selection screen, choose your Medicare payer. Then un-select all
but “service” type items. Enter the service dates that cover the episode dates
for the sales you wish to see.
You can select to report Medicare “visits” and “service items” and choose
“Show Only PPS Sales.” This will report sales values only on the PPS RAP
and EOE service items, giving you a valid sales figure.
The report will show all PPS RAP, PPS EOE, and all adjustments to these. It
will also indicate what type of adjustment was done (PEP, LUPA, SCIC,
Outlier).
By exporting this to Excel, the adjustment description can be used to create
sums for PEP, LUPA, SCIC, and Outlier adjustments.
This report also offers Excel Output Options for reporting “By County and
Age”, “Client, Visits, Hours OT by Payerclass” and “Clients, Employees, Visits,
Hours by Skill” to assist in your Medicare reporting.
PPS and the Sales Report
PPS and the Medicare Episode Report
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This report is invaluable for your Medicare cost reporting.
You may enter a “average cost per visit per skill” and SAM will produce a report of all
of the information regarding the episode and calculated Gross Margin.
In addition, if you export this report to Excel, all of the OASIS M00 answers that
affected the episode are included in the Excel file.
If you select to “Exclude visits outside the date range” SAM will generate the following
.xls files specifically designed to help you with your Medicare cost reporting.
Visit totals – summarizes number of visits by MSA code, RAP adjustment type, EOE adjustment type, and
skill.
MSA SN patients – summarizes number of SN visits by MSA code, patient name, and patient number.
MSA PT patients – summarizes number of PT visits by MSA code, patient name, and patient number.
MSA OT patients– summarizes number of OT visits by MSA code, patient name, and patient number.
MSA ST patients– summarizes number of ST visits by MSA code, patient name, and patient number.
MSA MS patients – summarizes number of MSW visits by MSA code, patient name, and patient number.
MSA HA patients – summarizes number of HHA visits by MSA code, patient name, and patient number.
PPS and the Medicare Episode
Report
PPS and the Aging Report
PPS and the Utility Census Report
PPS and the General Ledger
The General Ledger reports will show cost and sales
from Medicare visits and supplies as well as the service
items and adjustments that represent the RAP and EOE
sales.
Your Glaccount table in SAM should be updated to place
the RAP and EOE service items into NEW accounts in
your general ledger.
Steps in SAM PPS Billing
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Make sure that the Medicare Payer is set to bill by “Calendar” and payer
class “Medicare.”
Create “patient” type client in SAM and associate to a Medicare Payer. Turn
“On” requirement “Signed Plan of Care (and billable visit)” if desired.
Admit the patient to the agency using Care Manager.
Create a plan of care, or at least a plan of care shell in SAM (patient, payer,
cert begin and end dates, physician, and ICD9 codes).
Create an OASIS assessment and link it to the Plan of Care.
Use PPS option of Create Invoices function to create PPS RAP service item,
invoice, and claim.
When the patient is discharged or the cert end has passed, the PPS option of
Create Invoices function can be used to create PPS EOE service items,
invoices, and claims.
View PPS billing log or client’s account log for any adjustment advice and
perform the proper adjustments to the PPS RAP and PPS EOE service items
so that the SAM aging will be accurate.
Review the final claim for correctness. Pay close attention to revenue codes
on supplies.
Apply cash and use your aging as you normally do.
Summary
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Remember, before you can bill via PPS in SAM, an OASIS must be attached
to the patient’s plan of care.
If you have ideas about how SAM’s PPS functions can be more useful to your
organization, email us your suggestion at helpdesk@riversoft.net