Correction to the Editing of Health Insurance Prospective Payment System (HIPPS) Codes on Home Health Prospective Payment System (HH PPS) Claims
MLN Matters® Number: MM6393
Related Change Request (CR) #: 6393
Related CR Release Date: April 24, 2009
Effective Date: Episodes beginning on or after January 1, 2008
Related CR Transmittal #: R1714CP
Implementation Date: October 5, 2009
Provider Types Affected
Home health agencies (HHAs) submitting claims to Medicare contractors (A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services/supplies provided to Medicare beneficiaries during a home health episode.
Provider Action Needed
This article is based on Change Request (CR) 6393 which creates a payment safeguard that ensures home health agencies (HHAs) can no longer incorrectly change the supply severity level reflected in the 5th position of Home Health Prospective Payment System (HH PPS) Health Insurance Prospective Payment System (HIPPS) codes. The fifth position of the HIPPS on the final claim can only differ from the fifth position of that code on the Request for Anticipated Payment (RAP) in cases where supplies were initially expected to be required, but were not supplied. Then, the code can only change from the S-X letter code on the RAP to its corresponding number (1-6) code on the final claim.
Background
The Centers for Medicare & Medicaid Services (CMS) changed the format of the Health Insurance Prospective Payment System (HIPPS) codes that carry the case-mix group on HH PPS claims with the implementation of case-mix refinements to the home health prospective payment system (HH PPS). One of the changes required the fifth position of the code to carry a value that represents the non-routine supply (NRS) severity level.
The six letters in the range S - X in the fifth position of the HIPPS code represent each of the six NRS severity levels in the payment system.
In an effort to improve the quality of supply data reporting, CMS issued Change Request (CR) 5776 which established editing of an alternate set of values to represent episodes in which supplies were not actually provided to the beneficiary. The MLN Matters® article related to CR 5776 is available at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5776.pdf on the CMS Web site.
The six numbers in the range one through six in the fifth position of the HIPPS code represent the same six NRS severity levels (S-X) but also allow the HHA to attest that the absence of supply revenue codes on the claim is not an error or omission.
Because it is not certain at the beginning of an HH episode whether supplies will or will not be provided, Medicare grouping software always produces the HIPPS code with a letter value to show that supplies will be provided. This code is typically used on the RAP for the episode.
If at the end of the episode it is determined that supplies were not provided, the fifth position of the HIPPS code is changed on the final claim for the episode. In order to allow this, Medicare systems were revised to relax an edit that required the HIPPS code on the final claim to always match the one that had been submitted on the RAP. The edit now allows the fifth position of the code to change, with the expectation that the only change will be to replace a letter value with its corresponding number.
CMS has found that, in some cases, HHAs are instead incorrectly billing a different NRS severity level on the final claim. CR 6393 instructs that HHAs should change the fifth position of the HIPPS code on HH PPS claims only in order to report cases where supplies were or were not provided during the episode. Medicare systems will ensure that the only changes allowed are those which replace a letter with the number that corresponds to the same NRS severity level or which replace a number with the corresponding letter.
Additional Information
The official instruction, CR 6393, issued to your A/B MAC and RHHI regarding this change may be viewed at www.cms.hhs.gov/Transmittals/downloads/R1714CP.pdf on the CMS Web site.
If you have any questions, please contact our provider service center at our toll-free number, (866)-801-5301.
Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
Note: In the content of this article, the following links open a PDF document:
www.cms.hhs.gov/MLNMattersArticles/downloads/MM5776.pdf (PDF, 344KB )
www.cms.hhs.gov/Transmittals/downloads/R1714CP.pdf (PDF, 111KB )