Home Health & Hospice Week

Watch out: The fourth digit is changing completely.

When the new HIPPS codes under the Patient-Driven Groupings Model talk, you should listen.

Under the drastic payment reform model taking effect Jan. 1, some of the digits in the HIPPS code will change altogether, while others will see only tweaks, noted a Centers for Medicare & Medicaid Services speaker in an Aug. 21 educational call, “Home Health Patient-Driven Groupings Model: Operational Issues.”

Remember: The five-digit HIPPS codes set your payment level for the period.

Take a look at what changes are in store for HIPPS codes.

1st Digit

Old way: The first digit of the HIPPS code started out in 2000 as a fixed value “H” indicating merely that the code was home health-specific, CMS notes on its website. But in 2010, when CMS switched HH PPS to the four equation model, the digit started indicating a combination of the episode sequence (early versus later) and therapy utilization level.

New way: Under PDGM, the first digit will also represent a combination of case mix factors, the CMS speaker told call attendees. But now, it will signal the admission source (institutional/community) and timing of the period (early/late), resulting in four groups: Community Early (HIPPS code digit 1), Institutional Early (2), Community Late (3), and Institutional Late (4). Remember, the claims system will recode claims based on claims submitted by you, other HHAs, or other facilities, the CMS staffer explained.

2nd Digit

Old way: Currently, the second digit indicates the clinical severity level based on a range of OASIS items — M1021/M1022/M1028 (Diagnosis codes), M1030 (Therapies), M1200 (Vision), M1242 (Pain), M1313 and M1324 (Pressure Ulcer Staging), M1334 (Stasis Ulcer Staging), M1342 (Surgical Wound Status), M1400 (Dyspnea), M1620 (Bowel Incontinence), M1630 (Ostomy), and M2030 (Injectable Medications).

New way: Under PDGM, the second digit will signal the clinical grouping based on the principal diagnosis code reported on the home health claim. None of the OASIS items currently used to generate this digit will be case mix factors any longer under PDGM. There are 12 clinical groupings or subgroupings: Musculoskeletal Rehabil­itation (HIPPS code digit E); Neuro/Stroke Rehabili­tation (B); Wounds — Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care (C); Behavioral Health Care (including Substance Use Disorder) (F); Complex Nursing Interventions (D); and seven Medication Management, Teaching and Assessment (MMTA) subgroups — MMTA– Surgical Aftercare (G); MMTA– Cardiac/Circulatory (H); MMTA– Endocrine (I); MMTA– GI/GU (J); MMTA– Infectious Disease/Neoplasms/Blood-forming Diseases (K); MMTA – Respiratory (L); and MMTA – Other (A).

3rd Digit

Old way: Currently, the third digit indicates the functional score based on six OASIS items: M1810 (Current ability to dress upper body safely), M1820 (Current ability to dress lower body safely), M1830 (Bathing), M1840 (Toilet Transferring), M1850 (Transferring), and M1860 (Ambulation/Locomotion).

New way: Under PDGM, the third digit will continue to indicate the functional impairment level, but it will be based on eight OASIS items — adding these two: M1800 (Grooming) and M1033 (Risk for hospitalization). M1800 and M1033 will be new to the case mix calculation under PDGM. Periods can fall into the “low” (HIPPS code digit A), “medium” (B), or “high” (C) functional levels.

4th Digit

Old way: This digit now indicates the number of therapy visits and resulting service level.

New way: Under PDGM, it will undergo the “biggest change” of any HIPPS digit and carry the comorbidity adjustment, the CMS staffer explained. PDGM will base the adjustment on up to 24 secondary diagnosis codes reported on the home health claim. PDGM will give episodes a “no” (HIPPS code digit 1), “low” (2), or “high” (3) comorbidity adjustment.

5th Digit

Old way: When HH PPS began, this digit contained verification information. Currently it indicates the Non-Routine Supply level, ranging from 1 to 6.

New way: Under PDGM, NRS payment will be incorporated into the base rate, and this HIPPS code digit will become a “placeholder,” the CMS official noted. As such, it will always be a “1.”

PDGM’s case mix steps result in one of 432 Home Health Resource Groups, which have 432 distinct HIPPS codes, CMS notes on its website.

For example: HIPPS code 2DC21 indicates an Early-Institutional/Complex Nursing/High Functional Impairment/Low Comorbidity Adjustment period, the speaker offered.