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Back  RFI # 1963: Medicare RUG value

Formal vs. Informal Help Informal Formal

Submitter

Laura McCauley

Description

Our client has requested that we collect the Medicare RUG value for informational purposes only on 837I transactions. We will not be collecting any other Medicare information. Our recommendation is that this information be sent in 2400 NTE (positions 1-3). Please advise if there is an alternate loop/segment that should be used.

Submitter sent this additional information via email: Thank you for the information. I just noticed that the qualifier of TPO is missing from my request. Can you please add that to the request?

Submitter Assigned Keywords

Medicare RUG

Response

The situational rule on the 2400 loop NTE segment reads "Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send." Therefore, the 2400 loop NTE segment is not an appropriate location for the RUG value from providers.

The Appendix A abstract for external code source 716 (Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities) includes "Case mix classification groups include but may not be limited to resource utilization groups (RUGs) for skilled nursing facilities...." Code source 716 is used in the 2400 loop SV2 segment, element 02.

The 2400 loop SV202 situational rule states "Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics) or HIPPS code exists for this service line item. If not required by this implementation guide, do not send."

Therefore, HIPPS codes (which includes RUGs) for inpatient services would be reported in the SV2 segment, element 02, in SV202-02 , with element SV202-01 equal to "HP", meaning "Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code".
Submission 9/2/2014
Status Date 10/15/2014
Status F - Final
Primary References
Document 005010X223
Section2.4
Page441
Loop2400
Segment Position02
Segment IDNTE