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Question: My resident was admitted on a Medicare Advantage (MA) plan and our facility beds are dual certified. However, the MA plan requires us to follow PPS Scheduling. How do I code A0410 on the resident’s PPS assessments that are not submitted?
Answer: The coding for A0410 is not based on the resident's method of payment. It is based on the certification or licensure for the facility where the bed is located. Many facilities have all of their beds certified for both Medicare and Medicaid, which is the code 3 at A0410 on the MDS. The key here it is not about the resident, but instead the type of unit the resident is on and what is it certified for.
See RAI User’s Manual pages A-12 and 13:
Steps for Assessment
1. Ask the nursing home administrator or representative which units in the nursing home are Medicare certified, Medicaid certified or dually certified (Medicare/Medicaid).
2. If some or all of the units in the nursing home are neither Medicare nor Medicaid certified, ask the nursing home administrator or representative if there are units that are state licensed and if the state requires MDS submission for residents on that unit.
3. Identify all units in the nursing home that are not certified or licensed by the state, if any.
• Code 1, Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State: if the MDS record is for a resident on a unit that is neither Medicare nor Medicaid certified, and neither CMS nor the state does not have authority to collect MDS information for residents on this unit, the facility may not submit MDS records to QIES ASAP. If any records are submitted under this certification designation, they will be rejected by the QIES ASAP system.
• Code 2, Unit is neither Medicare nor Medicaid certified but MDS data is required by the State: if the nursing home resident is on a unit that is neither Medicare nor Medicaid certified, but the state has authority under state licensure to collect MDS information for residents on such units, the facility should submit the resident's MDS records per the state's requirement to QIES ASAP or directly to the state.
Note that this certification designation does not apply to swing-bed facilities. Assessments for swing-bed residents on which A0410 is coded "2" will be rejected by the QIES ASAP system.
• Code 3, Unit is Medicare and/or Medicaid certified: if the resident is on a Medicare and/or Medicaid certified unit, regardless of payer source (i.e., even if the resident is private pay or has his/her stay covered under e.g., Medicare Advantage, Medicare HMO, private insurance, etc.), the facility is required to submit MDS records (OBRA and SNF PPS only) to QIES ASAP for these residents. Consult Chapter 5, page 5-1 of this Manual for a discussion of what types of records should be submitted to the QIES ASAP system
Reviewed and revised 12/5/19
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