PPS Review
Acronyms
PPS - Prospective Payment System
RAP - Request for Anticipated Payment
EOE - End of Episode
COP - Conditions Of Participation (Medicare regulations for Home Health Agencies)
PEP - Partial Episode Payment
SCIC - Significant Change In Condition
ROC - Resumption Of Care (after inpatient stay)
SOC - Start Of Care; the date of the first billable visit to a patient
RFA - Reason For Assessment
01 - SOC, further visits planned
03 - ROC
04 - Recertification (follow-up)
05 - Other follow-up (SCIC)
06 - transfer to an inpatient facility, not discharged
07 - transfer to an inpatient facility, discharged from agency
08 - death at home
09 - discharge from agency
M0090 - for RFA 01-05, the date of the OASIS visit;
for RFA 06-09, the date the OASIS documentation was completed
M0100 – the OASIS identifier for the RFA
M0150 - current payment sources for home care
0 - none
1 - Medicare
2 - Medicare HMO
3 - Medicaid
4 - Medicaid HMO
5 - Workers' comp
6 - Title programs
7 - other gov't (champus, va)
8 - private insurance
9 - private HMO/managed care
10 - self
11 - other
UK - unknown
OASIS - Outcome and Assessment Information Set
HIPPS - Health Insurance Prospective Payment System
HHRG – Home Health Resource Group
The difference between HIPPS and HHRG is the format – there is a one-to-one correspondence between these codes.
HIPPS rate codes represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under PPS systems. Case-mix groups are developed based on research into utilization patterns among Home Health agencies. Clinical assessment data (the OASIS form) is the basic input used to determine which case-mix group applies to a particular patient. The OASIS answers are interpreted by case-mix grouping software algorithms, which assign the case mix group. For payment purposes, at least one HIPPS code is defined to represent each case-mix group. These HIPPS codes are reported on claims to insurers.
HIPPS codes are alpha-numeric codes of five characters. Each code contains intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional information.
Under the home health prospective payment system (HH PPS), a case-mix adjusted payment for up to 60 days of care is made using one of 80 Home Health Resource Groups (HHRG). On Medicare claims these HHRGs are represented as HIPPS codes. HIPPS codes are determined based on assessments made using the OASIS. Grouper software run at a home health agency site uses specific data elements from the OASIS data set to assign beneficiaries to a HIPPS code. The Grouper outputs the HIPPS code and the Treatment Authorization Code, which must be entered on the claim.
For HH PPS episodes beginning October 1, 2000 thru December 31, 2007, the following scheme has been developed to create distinct 5-position, alphanumeric home health HIPPS codes: The first position is a fixed letter “H” to designate home health, and does not correspond to any part of the HHRG case mix grouping. The second, third and fourth positions of the code are a one-to-one crosswalk to the three domains of the HHRG coding system. There are 80 different HIPPS codes: position 2 is A-D; position 3 is E-I; position 4 is J-M; position 5 is always a 1.
For HH PPS episodes beginning on and after January 1, 2008, the distinct 5-position, alphanumeric home health HIPPS code is created as follows:
• The first position is no longer a fixed value. The refined HH PPS uses a four-equation case-mix model which assigns differing scores in the clinical, functional and service domains based on whether an episode is an early or later episode in a sequence of adjacent episodes. To reflect this, the first position in the HIPPS code is a numeric value that represents the grouping step that applies to the three domain scores that follow.
• The second, third, and fourth positions of the code remain a one-to-one crosswalk to the three domains of the HHRG coding system.
• The fifth position indicates a severity group for non-routine supplies (NRS). The HH PPS grouper software will assign each episode into one of 6 NRS severity levels and create the fifth position of the HIPPS code with the values S through X. If the HHA is aware that supplies were not provided during an episode, they must change this code to the corresponding number 1 through 6 before submitting the claim.
Position #1 / Position #2 / Position#3 / Position #4 / Position #5
Grouping Step / Clinical Domain / Functional Domain / Service Domain / Supply Group – supplies provided
Early Episodes
(1st & 2nd ) / 1
(0-13 Visits) / A
(HHRG: C1) / F
(HHRG:
F1) / K
(HHRG: S1) / S
(Severity Level: 1)
Early Episodes
(1st & 2nd ) / 2
(14-19 Visits) / B
(HHRG: C2) / G
(HHRG: F2) / L
(HHRG: S2) / T
(Severity Level: 2)
Late Episodes
(3rd & later) / 3
(0-13 visits) / C
(HHRG: C3) / H
(HHRG: F3) / M
(HHRG: S3) / U
(Severity Level: 3)
Late Episodes
(3rd & later) / 4
(14-19 Visits) / N
(HHRG: S4) / V
(Severity Level: 4)
Early or Late Episodes / 5
(20 + Visits) / P
(HHRG: S5) / W
(Severity Level: 5)
X
(Severity Level: 6)
Based on this coding structure:
• 153 case-mix groups defined in the 2007 HH PPS final rule are represented by the first four positions of the code.
• Each of these case-mix groups can be combined with any NRS severity level, resulting in 918 HIPPS codes in all (i.e., 153 case-mix groups times 6 NRS severity levels).
• Each HIPPS code will represent a distinct payment amount, without any duplication of payment weights across codes.
Medicare implemented a new set of billing rules in October 2000 that changed the payment system from FFS (Fee For Service: bill one visit, get paid for one visit) to PPS. They determined that a billing period would be 60 days, and would exactly match the dates on the 485 (the signed doctor's orders for treatments/goals). In order to maintain a reasonable cash flow, Medicare established a billing pattern that allowed agencies to receive a partial payment at the beginning of an episode (RAP) and receive the balance (plus or minus certain adjustments) when the EOE claim was sent and approved.
A RAP is not a true "claim", because there are no charges on it - only the HIPPS code and the date of the first visit made during that episode.
Three requirements to be met before a RAP claim can be sent
there must be orders
there must be an OASIS with a HIPPS code
there must be a billable visit charged to that PPS payer
How these requirements are implemented in Barnestorm:
When a 485 is printed in BSOffice (not in POC), if payer#1 or payer#2 for that patient has PPS=Yes, then an episode is created in PPS tracking for that 60-day period (the 485 from/thru dates) and for that specific program/payer. The status of that episode is "485 no OASIS".
[Billing] - [PPS Billing] - [RAP Claims] - [Update Episodes]
Look at the Episodes From and thru dates - when troubleshooting, make sure the episode from date is in this range. The default is the most recent 12 months, minus 10 days (time to complete the oasis and key the visit charges).
This process will select every episode in PPS tracking that has not had a RAP claim sent and search for the OASIS to be used to bill the episode. If this is a SOC episode (the first episode, which starts on the patient's admit date), then an OASIS is looked for with RFA=01 and with a M0090 date within the first five days starting with the admit date; if this is not a SOC episode, then an OASIS is looked for with a M0090 date in the five days just before the episode start date with RFA=04. If no RFA=04 is found, then that same five day window is searched for either RFA=03 or RFA=05.
If an OASIS is found, but it doesn't have a HIPPS code, skip it.
If it does have a HIPPS code, then update the PPS tracking with the M0090 date, RFA, Doc Id, HIPPS Code and HIPPS $amount, and change the status to "OASIS no Visit".
The next step in this process selects every episode in PPS tracking that has a status of "OASIS no Visit" or "Visit no RAP".
A visit with dollars must be charged to the PPS program/payer that was on the patient referral screen at the time the 485 was printed. For a SOC episode, the visit must be on the start of care date.
If it is not a SOC episode, then the visits are searched in date order from the start date thru the end date of the episode.
If a visit is found that meets these requirements, then that date is saved in the tracking and the status is changed to "Visit no RAP".
Status="485 no OASIS", and the From Date is more than 5 days old:
(01) Is there an OASIS?
Yes - go to step (02)
No - either the OASIS was not done or it has not been entered
(02) Is the OASIS locked - it's not considered finished until it's locked
(03) Is the M0090 date in the correct time window?
Yes - go to step (04)
No - verify that the OASIS you see is the one to be used for billing the episode:
(a) the M0090 date is close to what you are looking for
(b) the OASIS has a HIPPS code
(c) there is no other OASIS that can be used
(d) use [Billing] - [PPS Billing] - [Edit PPS Episodes] - select the chart# and episode - [Select a Different OASIS]
(04) Does the OASIS have a HIPPS code?
Yes - is the RFA correct for the episode (01 for SOC, 03, 04, 05 for recert)?
Yes - [Billing] - [PPS Billing] - [RAP Claims] - [Update Episodes] should match it up
No - is the RFA 03 or 05?
Yes - use (03) (d) above to fix
No - are there 2 OASIS with the same sequencedate - if so, this is an error
No - is M0110 = NA - that makes the HIPPS code blank
Status = "OASIS no Visit" and the From date is more than 30 days old:
(01) If the patient is discharged from the PPS Payer, make sure that the discharge date is the date of the last billable visit (visit$ > 0) charged to that payer. If that date is before the start date of the episode in question, then [Billing] - [PPS Billing] - [Edit PPS Episodes] - select the chart# and episode - [Delete this Episode]
(02) Determine what date can be used to search for visits. This is the date through which all visit log sheets have been turned in and keyed and checked, which will be referred to below as the "visit search date".
(03) Is the episode completed on or before the visit search date?
No - go to step (04)
Yes - use menu 14 #39 to search for visits from the episode start date thru the episode
end date. Are there any PPS Payer billable visits?
No - check the chart to make sure this is true, then use menu 15 #15 to mark the
episode as "No Visits". If the visits are all billed to a different pay
source, find out if the PPS Payer should be discharged
Yes - use menu 14 #02 and enter the visit search date as the cutoff date
If the episode still does not have a date of first visit and a status of "Visit no RAP" then call me
(04) Use [Billing Inquiry] to select the 485 and look at the visits during the episode
Are there any PPS payer billable visits?
No - if the visits are all billed to a different pay source, find out if the PPS payer should be discharged; otherwise, just wait until either there is a visit or the end of the episode is reached
Yes - if the first visit is less than 10 days old, and the agency always waits 10 days, then it won't be updated until the visit date is 10 days old