Reimbursement Resources

IHCA/INCAL will be updating this page regularly as guidance and information from state and federal authorities changes. If you have questions related to payment & reimbursement, please contact Elizabeth Eichhorn at

Last updated on April 1 at 8:30 a.m.


April 2, 2020: MDS Isolation Coding Guidance Remains Unchanged

Members have been asking if CMS has made any changes to the MDS coding guidance associated with item O0100M – Isolation for active infectious disease (does not include standard precautions) located in Chapter 3 of the MDS 3.0 RAI Manual v 1.17.1 October 2019 . Below is an excerpt from the current coding requirements describing the four specific conditions that must be met to check the O0100M item box for the presence of isolation for active infectious disease.

Code for “single room isolation” only when all of the following conditions are met:

  1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
  2. Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
  3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
  4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.).

In a recent email received from CMS the Agency indicates that providers should continue to code residents for the O0100M isolation item per current MDS-RAI manual instructions

We recognize that many providers have applied recent CMS and CDC guidance and 1135 waivers during the COVID-19 emergency and have sometimes cohorted beneficiaries in the same isolation room when the residents have tested positive for COVID-19 or are presumed to be positive. We also recognize that with respect to payment models including PDPM, State case-mix, and Medicare Advantage, the current inability to code for isolation in situations where residents were required to be cohorted into the same room may result in a lower payment rate. CMS is aware of this concern. AHCA will share updates as they become available.      


April 2, 2020: CMS Updates PDPM ICD-10 Mappings for New COVID-19 Diagnosis Code

CMS has responded to member concerns that the ICD-10-CM diagnosis codes identified by the CDC as appropriate to code for COVID-19 were not compatible with the Medicare Part A SNF PPS PDPM payment model. Specifically, none of the CDC identified codes could be used to represent the Primary Reason for SNF Stay on the MDS assessment Item I0020B.
On March 31, CMS posted an updated FY 2020 PDPM ICD-10 Mappings file (.zip) which adds the ICD-10-CMS code ‘U07.1 - 2019-nCoV acute respiratory disease’ as an appropriate code to enter in the MDS I0020B Primary reason for SNF stay item field. If entered, this code will map to the PDPM ‘Pulmonary’ default clinical category used for the PT, OT, and SLP components. This new code does not impact the PDPM Nursing or NTA component classifications at present. 

This new code U07.1 is ONLY in effect for assessments with target date April 1, 2020 and later. For assessments with an assessment reference date March 31, 2019 or earlier, providers will need to enter the most appropriate ICD-10 code available that is not listed as a ‘return to provider’ code in the MDS I0020B item field.  

Additional files related to coding specifications necessary for software companies to implement this change are located on the MDS 3.0 Technical Information webpage. Providers do not need to review these files but should check with their MDS software vendors to confirm when these updated have been applied or you will see a ‘return to provider’ error in your MDS software.  


April 2, 2020: CMS Suspends Most Medicare Dee-For-Service Medical Review

CMS released a COVID-19 Provider Burden Relief FAQ document that states that the Agency has suspended most Medicare Part A and Part B Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic.  This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. 

This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud. Other topics in the FAQ are related to proof of delivery beneficiary signature waivers for drugs and DME, and for pausing non-emergent ambulance and home health review choice demonstrations Providers should contact their Medicare review contractor if there are questions. 


Medicaid Eligibility Updates

As some of the LTC proivders may have experienced, there have been Medicaid processing issues recently due to closure of local DFR offices as well as with faxing issues and obtaining required documentation.  We have heard that Medicaid members are getting termination notices as well during the emergency, which we assume are pre-programmed. The IHCA/INCAL worked with the NAELA (elder law attorneys) chapter to develop certain requests of OMPP during and due to the emergency.  The requests and OMPP’s responses are available here

PASRR Waiver Guidance

The Division of Aging has developed guidance to address the PASRR Level 1 and Level 11 assessment section of the 1135 waiver.

Telehealth Toolkit: CMS recently issued an electronic toolkit regarding telehealth and telemedicine for Long Term Care Nursing Home Facilities. CMS has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. 

This document contains electronic links to reliable sources of information regarding telehealth and telemedicine, including the significant changes made by CMS in response to the National Health Emergency.  Most of the information is directed towards providers who may want to establish a permanent telemedicine program, but there is information here that will help in the temporary deployment of a telemedicine program as well.  

There are specific documents identified that will be useful in choosing telemedicine vendors, equipment, and software, initiating a telemedicine program, monitoring patients remotely, and developing documentation tools. There is also information that will be useful for providers who intend to care for patients through electronic virtual services that may be temporarily used during the COVID-19 pandemic.   

Medicare and Coronavirus: What You Need To Know by Seema Verma

Southeastrans Pandemic Response Plan

  • Southeastrans has developed a plan that outlines its response to a pandemic outbreak, including steps the Company takes to safeguard employees' health while also maintaining essential operations and providing vital services to our customers and members. In addition, it provides guidance on how the Company intends to respond to specific operational and human resource issues in the event of a pandemic.

Factsheet: Medicare Coverage and Payment Related to COVID-19

  • Medicare covers all medically necessary hospitalizations, as well as brief “virtual check-ins,” which allows patients and their doctors to connect by phone or video chat.


March 20, 2020: Indiana Medicaid Announces Filing Extensions for Cost Reports and Other Filings

  • Due to the COVID-19 outbreak, the Office of Medicaid Policy & Planning will be postponing any onsite reviews and associated requests for documentation for 60 days.  This will apply to all our long term care providers, nursing facilities and group homes. 

March 17, 2020: CMS Issues 3-Day Stay Detailed Billing Guidance

  • CMS issued this guidance with all details on billing under the waiver of the 2 day inpatient hospital stay.  The waiver is a blanket waiver and applies to all states without any state-specific action.  The waiver is currently in effect. Read IHCA/INCAL summary here.

March 17, 2020: Area Agencies on Aging Guidance from Division of Aging

  • This guidance was issued by the Indiana Division of Aging to Area Agencies on Aging to clarify AAA operations during the national emergency.  The DA is permitting all Care Management and Options Counseling activities to be performed via telephone. This will likely create new challenges. As you encounter issues with these protocol please keep IHCA/INCAL aware as the DA has asked us to keep them informed of member issues.  Please contact Elizabeth Eichhorn at

March 12, 2020: CMS Releases COVID-19 Medicare FFS and Medicare Advantage Plan Guidance


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