Medicare Compliance & Reimbursement

What CMS looks at when finding improper Medicare payments.

To understand your Program for Evaluating Payment Patterns Electronic Report (PEPPER), you need to know the definitions of the target areas. The Centers for Medicare & Medicaid Services (CMS) has defined these six target areas as follows:

• Therapy RUGs with High ADLs.
• Numerator: Count of days billed with RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLB.
• Denominator: Count of days billed for all therapy RUGs.
• Non-Therapy RUGs with High ADLs.
• Numerator: Count of days billed with RUGs equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III and HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IV.
• Denominator: Count of days billed for all non-therapy RUGs.
• Change of Therapy Assessment.
• Numerator: Count of assessment with A1 second digit “D.”
• Denominator: Count of all assessments.
• Ultrahigh Therapy RUGs.
• Numerator: Count of days billed with RUGs equal to RUX, RUL, RUC, RUB, RUA.
• Denominator: Count of days billed for all therapy RUGs.
• Therapy RUGs.
• Numerator: Count of days billed for all therapy RUGs.
• Denominator: Count of days billed for all therapy and non-therapy RUGs.
• 90+ Day Episode of Care.
• Numerator: Count of episodes of care at the SNF with LOS 90+.
• Denominator: Count of all episodes of care at the SNF.