TOTAL NUMBER OF MEDICAID COVERED DAYS FOR THE RECIPIENT IN AN NURSING FACILITY FOR THE CALENDAR YEAR.
(SAS USERS: ZONED DECIMAL - ZD3)
Comments
USER NOTE: DAYS MAY BE > 365 IN SOME STATES AND FOR SOME LONG-TERM CARE FACILITIES. THIS CAN HAPPEN IF THE NUMBER OF COVERED DAYS FOR AGIVEN MONTH WAS REPORTED ON MULTIPLE CLAIMS (E.G. A CLAIM FOR PER DIEM PAYMENT AND A CLAIM FOR SUPPLEMENTAL SERVICES). IT IS NOT POSSIBLE TO SEPARATELY IDENTIFY PER DIEM CLAIMS VERSUS SUPPLEMENTAL CLAIMS. SO, IF DAYS ARE >365, THIS SHOULD ALERT A DATA USER OF THE POTENTIAL OVERREPORTING OF THE NUMBER OF COVERED DAYS. WHEN DAYS ARE > 365, USERS MAY WANT TO EXAMINE RECORDS BY MONTH TO ESTIMATE THE ACTUAL NUMBER OF DAYS. DAYS ARE SET VALUE <= 998.
SOURCE: CREATED USING THE NUMBER OF MEDICAID NURSING FACILITY DAYS FROM MSIS CLAIMS FOR TOS = 07 (NURSING FACILITY SERVICES - NFS - ALL OTHER). AS THIS COUNT IS BEING AGGREGATED ACROSS CLAIMS, THERE IS A DECISION RULE THAT APPLIES: IF, IN AN INDIVIDUAL CLAIM, THE SUM OF COPAYMENTS AND DEDUCTIBLES IS GREATER THAN OR EQUAL TO MEDICAID PAYMENTS (E.G. IN A MEDICARE CROSSOVER CLAIM), THEN THESE DAYS ARE SET VALUE = 0. THIS IS BECAUSE MEDICAID WOULD BE PAYING ONLY COPAYMENT OR DEDUCTIBLE AMOUNTS, NOT FOR ACTUAL COVERED DAYS OF STAY. FOR 1995 AND EARLIER YEARS, THESE DAYS WERE NOT SET VALUE = 0 FOR MEDICARE CROSSOVER CLAIMS. IF THE CLAIM IS NOT A MEDICARE CROSSOVER CLAIM AND THESE DAYS ARE MISSING, THE CLAIM IS NOT EDITED. THIS IS BECAUSE IT IS NOT POSSIBLE TO DETERMINE WHETHER THE CLAIM IS FOR ACTUAL DAYS OF STAY (ROOM AND BOARD) OR ANCILLARY SERVICES (DURING THE STAY). BECAUSE OF THIS AMBIGUITY, EDITING THE CLAIM COULD INTRODUCE ERRORS AND/OR DOUBLE COUNT THESE DAYS.
USER NOTE: DAYS MAY BE > 365 IN SOME STATES AND FOR SOME LONG-TERM CARE FACILITIES. THIS CAN HAPPEN IF THE NUMBER OF COVERED DAYS FOR AGIVEN MONTH WAS REPORTED ON MULTIPLE CLAIMS (E.G. A CLAIM FOR PER DIEM PAYMENT AND A CLAIM FOR SUPPLEMENTAL SERVICES). IT IS NOT POSSIBLE TO SEPARATELY IDENTIFY PER DIEM CLAIMS VERSUS SUPPLEMENTAL CLAIMS. SO, IF DAYS ARE >365, THIS SHOULD ALERT A DATA USER OF THE POTENTIAL OVERREPORTING OF THE NUMBER OF COVERED DAYS. WHEN DAYS ARE > 365, USERS MAY WANT TO EXAMINE RECORDS BY MONTH TO ESTIMATE THE ACTUAL NUMBER OF DAYS. DAYS ARE SET VALUE <= 998.
SOURCE: CREATED USING THE NUMBER OF MEDICAID NURSING FACILITY DAYS FROM MSIS CLAIMS FOR TOS = 07 (NURSING FACILITY SERVICES - NFS - ALL OTHER). AS THIS COUNT IS BEING AGGREGATED ACROSS CLAIMS, THERE IS A DECISION RULE THAT APPLIES: IF, IN AN INDIVIDUAL CLAIM, THE SUM OF COPAYMENTS AND DEDUCTIBLES IS GREATER THAN OR EQUAL TO MEDICAID PAYMENTS (E.G. IN A MEDICARE CROSSOVER CLAIM), THEN THESE DAYS ARE SET VALUE = 0. THIS IS BECAUSE MEDICAID WOULD BE PAYING ONLY COPAYMENT OR DEDUCTIBLE AMOUNTS, NOT FOR ACTUAL COVERED DAYS OF STAY. FOR 1995 AND EARLIER YEARS, THESE DAYS WERE NOT SET VALUE = 0 FOR MEDICARE CROSSOVER CLAIMS. IF THE CLAIM IS NOT A MEDICARE CROSSOVER CLAIM AND THESE DAYS ARE MISSING, THE CLAIM IS NOT EDITED. THIS IS BECAUSE IT IS NOT POSSIBLE TO DETERMINE WHETHER THE CLAIM IS FOR ACTUAL DAYS OF STAY (ROOM AND BOARD) OR ANCILLARY SERVICES (DURING THE STAY). BECAUSE OF THIS AMBIGUITY, EDITING THE CLAIM COULD INTRODUCE ERRORS AND/OR DOUBLE COUNT THESE DAYS.