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Understanding PDPM and HIPPS Coding

June 24, 2019
Reimbursement By Kay Hashagen, Senior Consultant

Health Insurance Prospective Payment System rate codes, known as HIPPS codes, represent specific sets of patient characteristics (or case-mix groups) on which payment determinations are made under several prospective payment systems (PPS). These HIPPS codes are reported on claims to insurers.

Understanding_PDPM_HIPPS_Coding

Under Resource Utilization Group (RUG)-IV PPS, the HIPPS codes that are on the claim form have become second nature to those who deal with the Minimum Data set (MDS) and billing for Medicare Part A. The first three letters of the five-digit code relates to the RUG category. For most, who were billed under a rehab RUG, the first two digits of the code would be indicative of the intensity of therapy minutes. RU for rehab ultra-high, RV for rehab very high, RH for rehab high and RM for rehab medium. The third digit reflects the ADL score of either A, B, C, X, or L. The last two characters are an assessment indicator (AI) code, to represent the assessment used to generate the patient classification. Under RUG-IV PPS, there are many assessments and each one has an AI code. For example, 10 was used for the 5-day MDS, 20 for the 14-day, and so on, with other codes for SOT, COT, EOT and significant change assessments. After eighteen plus years of working with these codes, they were familiar and like a second language. The code AAA, along with the assessment code, was used to identify a default payment. If there was a Provider Liable instance, no HIPPS code could be created.

The language of the Patient Driven Payment Model (PDPM) HIPPS coding is more complex. The HIPPS code is still five digits. The first character represents both the PT and OT Case Mix Group (CMG). The second character represent  the SLP CMG. The third digit correlates to the Nursing CMG. The fourth represents the non-therapy ancillary (NTA) CMG. And as under PPS, the fifth character represents the AI code. Because the CMG codes are more than one digit, CMS has created tables to take the CMG to the HIPPS coding. These tables are presented below and were contained in the CMS PDPM presentation which can be found, starting on page 79, at this link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MLN_CalL_PDPM_Presentation_508.pdf

PT/OT, SLP and NTA HIPPS CHARACTER CROSSWALK

PT/OT Payment Group SLP Payment Group NTA Payment Group HIPPS Character
TA SA NA A
TB SB NB B
TC SC NC C
TS SD ND D
TE SE NE E
TF SF NF F
TG SG   G
TH SH   H
TI SI   I
TJ SJ   J
TK SK   K
TL SL   L
TM     M
TN     N
TO     O
TP     P

 

NURSING HIPPS CHARACTER CROSSWALK

Nursing Payment Group HIPPS Character Nursing Payment Group HIPPS Character
ES3 A CBC2 N
ES2 B CA2 O
ES1 C CBC1 P
HDE2 D CA1 Q
HDE1 E BAB2 R
HBC2 F BAB1 S
HBC1 G PDE2 T
LDE2 H PDE1 U
LDE1 I PBC2 V
LBC2 J PA2 W
LBC1 K PBC1 X
CDE2 L PA1 Y
CDE1 M    

There are only 3 possible assessments under PDPM. These are the 5-Day PPS MDS, the Interim Payment Assessment or IPA, and the Discharge Assessment.

HIPPS Character Assessment Type
0 IPA
1 PPS 5-day
6 OBRA Assessment (not coded as a PPS Assessment)

code under PDPM represents the sum of the lowest per diem rate under each PDPM component, plus the non-case-mix component. In cases where the default code is used, the variable per diem schedule must still be followed.

Billing the default code under PDPM represents the equivalent of billing the following PDPM groups:

  • PT Payment Group: TP
  • OT Payment Group: TP
  • SLP Payment Group: SA
  • Nursing Payment Group: PA1
  • NTA Payment Group: NF

From the CMS FAQs updated 4/17/19: Question #9.3 How is the VPD affected by default billing?

For late assessments under PDPM, similar to under RUG-IV, the provider will bill the default HIPPS code for the number of days out of compliance and then the 5-day assessment HIPPS code for the remainder of the stay, unless an IPA is completed. One caveat is that the default billing will be assessed prior to the 5-day assessment HIPPS code, in terms of counting days for the variable per diem. For example, if a 5-day assessment is two days late, then Days 1 and 2 of the stay, with regard to the variable per diem adjustment, will be calculated using the default HIPPS code and then the 5-day assessment HIPPS code will control payment beginning on Day 3 of the variable per diem schedule.

If there is missing information in any one of the PDPM categories, and a CMG cannot be assigned, there will not be a HIPPS code. The facility will be Provider Liable, which means that CMS will not reimburse for those days. This is a very important detail under PDPM! An example of this might occur when the BIMS score is not calculated before the patient discharges, or is not completed timely, and neither is the CPS staff assessment. The SLP component cannot be converted into a CMG because of the missing information. This little slip up could cause the entire patient stay to be Provider Liable.

From the CMS FAQ updated 4/17/19: Question # 5.4 How is the patient classified under PDPM if neither the BIMS nor the CPS staff assessment is completed to determine cognitive level?

In order to receive a PDPM classification, all required items must be completed. Either a BIMS score or CPS score is necessary to classify the patient under the SLP component. If neither the BIMS nor the staff assessment is completed, then the patient will not be classified under PDPM and a PDPM HIPPS code will not be produced for this assessment.

For more information on preparing for the transition to PDPM, register for our 9-Part PDPM Webinar Series.

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