Home Health & Hospice Week

Can you handle 1,836 new HIPPS code?

Home health agencies are doing a double take about the vastly increased number of new HIPPS codes required by the revised prospective payment system.

Starting Jan. 1, HHAs must use 1,836 HIPPS codes, the Centers for Medicare & Medicaid Services’ Wil Gehne said in an Oct. 9 session at the National Association for Home Care & Hospice’s annual meeting in Denver. That’s 11 times more than the current 153 HIPPS codes.

And the codes themselves are getting a major makeover, CMS explains in the Oct. 5 Transmittal 1348 (CR 5746) detailing the changes. Here are the main differences:

• 1st digit. The current HIPPS code always starts with an “H,” Gehne pointed out in the session. Starting Jan. 1, the first digit will correspond to the group the episode belongs to. The choices range from assigning a “1” for an early episode with 0-14 therapy visits to a “five” for an episode with more than 20 therapy visits. 

• Digits 2-4. These digits will remain the most unchanged from the current HIPPS code. They still will reflect the Clinical, Functional and Service dimension scores as they do currently. However, they will represent them with letters instead of numbers. So a Clinical dimension HHRG score of C1 will translate to an “A” in the HIPPS code.

Note: CMS did not use “O” in the Service dimension letters because it often gets confused with zero, Gehne explained.

• 5th digit. Currently this digit is a validity indicator for the OASIS data used to generate the HIPPS code, Gehne noted. Under the prospective payment system revisions, it will indicate the level of Nonroutine Supplies (NRS) usage.

Wrinkle: But it’s not just a straightforward NRS level indicator. There’s a set of letters (S-X) for NRS severity levels when the billing agency does furnish supplies and a set of numbers (1-6) for when the HHA does not furnish them.

The dual set of NRS indicators is necessary because CMS plans to return to provider (RTP) claims that don’t include required supplies line items, Gehne explained to conference attendees.

Example: A patient in an early episode with an HHRG of C1F1S1, 0 therapy visits and a NRS level of 2 would have a HIPPS code of 1AFKT if the agency furnished supplies and 1AFK2 if it didn’t.

Supplies Edits Not Far Behind Implementation

A breather: HHAs don’t have to worry about reporting supplies immediately. CMS will hold off on NRS edits until April, the agency says in the transmittal. And it first will implement informational edits during a “grace period” before RTP’ing claims, Gehne added.

How it will work: When agencies furnish supplies, they’ll use the letter NRS indicators and the Medicare claims system will check the claim for supplies line items. If the supplies charges aren’t on the claim, the system will RTP it so the provider can correct it.

If agencies don’t furnish supplies, they’ll have to manually change the last digit of the HIPPS code to one of the number values, Gehne explained. Then the claims system won’t edit for the NRS line items.

Caution: HHAs should beware of changes they must make by hand, warns consultant M. Aaron Little with BKD in Springfield, MO. “I hate the thought of manually having to change this,” Little tells Eli.

HHAs may get an assist from their software, which may automatically change the last digit to a numeral if there are no supplies charges on the claim, Little says. But that will add to the problem CMS is trying to remedy in the first place--a lack of supplies data to formulate the NRS severity categories and payment levels.

Such auto-adjustment won’t “do much to further CMS’ desire for improved billing accuracy of supplies,” Little observes. “It is important for billers to modify their processes so that they question when supplies are not billed.” They need to ensure that if an HHA furnished the supplies, it didn’t just skip reporting them. “This information is extremely important for future Medicare payment purposes,” Little stresses.

Get To Know Your Treatment Authorization Code

Just becoming familiar with the new HIPPS code structure isn’t enough to master billing under the PPS refinements. You also need to understand the new treatment authorization code.

The number formerly known as the OASIS-claims matching key is now the 18-digit treatment authorization code. This code is vitally important because it gives the Medicare claims system the information to recode your claim if it must be regrouped--for example, if the episode is different than the one included on the RAP or if therapy utilization is in a different group than originally stated.

Here’s what the code includes:

• Digits 1-8. Start of care and assessment dates.
• 9th digit. Reason for Assessment.
• 10th digit. Early or late episode indicated by a 1 or 2.
• Digits 11 & 12. Letter codes for Clinical and Functional levels under Equation 1.
• Digits 13 & 14. Letter codes for Clinical and Functional levels under Equation 2.
• Digits 15 & 16. Letter codes for Clinical and Functional levels under Equation 3.
• Digits 17 & 18. Letter codes for Clinical and Functional levels under Equation 4.

“This new system has created a new and extremely important relationship between the HIPPS code and the OASIS matching string,” Little explains. “If the episode needs to be paid under a different payment grouping due to variances in early/late status or actual therapy utilization, the OASIS matching string will provide the [claims system] pricer with the information to do so.”

Providers must realize that “the OASIS matching string now actually has payment implications,” Little highlights. Currently agencies report it but no payment edits apply. This change should spur agencies to ensure accurate reporting of the code.

The new grouping mechanism makes auto-correction of claims for early/late episodes and therapy challenging, Gehne said in the NAHC presentation via telephone. The whole HIPPS code could change based on a re-grouping, he noted.

You Should Submit Incorrect Claims

One thing that may be hard for agencies to get used to under the revised system is submitting claims that they know have incorrect HIPPS codes. Because the claims system will now auto-adjust for early/late episodes and therapy utilization, agencies no longer have to cancel and resubmit corrected RAPs if their therapy utilization is different from the level stated on the RAP, Gehne instructed.

But the requirement for the HIPPS code to match on RAPs and claims will stand--mostly. CMS actually will suspend the matching rule for the fifth digit of the HIPPS code, which indicates NRS usage, but will retain it for the first four digits, Gehne said.

The final claim HIPPS code must match the RAP HIPPS code. So if agencies vary in therapy usage or find out about a different episode designation, they still will submit a final claim with the original HIPPS code, which they’ll know to be incorrect.

The only other alternative is to cancel and resubmit the RAP as before, and that’s a bad idea, Little maintains. “To cancel and rebill RAPs to correct for early/late episode or therapy would make for more accurate accounting records but would, in turn, cause considerably more work than is necessary,” he says. That “would ultimately slow down cash flow.”

The result: Billing departments will have a big challenge on their hands to reconcile all their claims payments with the claims submitted. “Make absolutely certain that every episode is paid correctly,” Little urges.

First, investigate differences in expected and actual payment due to early/late episode status or therapy. Then confirm the differences as being correct or incorrect. Finally, adjust the accounting records at the time of payment posting so that patient balances are corrected, he advises.

More Challenges Await You

You’ll have some more big billing obstacles ahead under the new system. As with M0175 currently, you’ll most likely have to depend on the Common Working File to get information for the patient’s early/late episode designation for the RAP. And the claims system will use the CWF to auto-adjust final claims. But the CWF is only as updated as the claims submitted to it.

“If one agency is slow to bill its claims it could mean that the CWF is not accurate,” Little cautions. That “may cause subsequent providers’ claims to pay incorrectly for early/late episode status.”

And agencies themselves must make sure their own claims are right. HHAs that don’t accurately bill therapy visits could see their claims grouped incorrectly, Little points out. “While there has always been some emphasis on claim accuracy, I believe PPS refinements make this emphasis even more relevant.”

Another thing: The claims system won’t accept claims with more than one 0023 line starting Jan. 1, thanks to elimination of the significant change in condition (SCIC) adjustment, Gehne noted in the NAHC session. That means you need to make sure your software doesn’t produce claims with multiple 0023 lines and your billers keying claims into Direct Data Entry (DDE) don’t enter more than one 0023 line per claim.

Resources: CMS’ billing instructions to intermediaries are in CR 5746 at www.cms.hhs.gov/transmittals/downloads/R1348CP.pdf-- but only about 20 of the transmittal’s 91 pages contain substantive billing changes, Gehne reassured listeners of CMS’ Oct. 10 Open Door Forum for home care providers. A Medlearn Matters article about the changes is at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5746.pdf.

Note: To learn more about billing under the PPS changes, sign up for M. Aaron Little’s Eli-sponsored audioconference, “Home Health PPS Refinements: Crucial How-To’s Your Billing Staff Must Know Now,” Oct. 24 at 3 pm. More information is at www.audioeducator.com/industry_conference.php?id=620, including how to order recordings of the conference, or call 1-800-508-2582.