Home Health & Hospice Week

Prepare for dummy HIPPS and diagnosis codes — and different procedures for each.

Starting Jan. 1, home health agencies will be under the gun to get requests for anticipated payment out the door — and a newly confirmed fact about RAP-claim matching edits can help.

Same: Like under the Patient-Driven Groupings Model now, a Medicare edit will match the RAP and the final claim in part by checking the HIPPS code.

Different: The Centers for Medicare & Medicaid Ser-vices confirmed in its November Home Health Open Door Forum that home health agencies may use a dummy/place­holder/default HIPPS code on the no-pay RAP, which must go out the door within five days or financial penalties occur. The Medicare claims system then will correct the final claim to the accurate, valid HIPPS code.

This scenario is also included in CMS’s update to CR 11855 on Oct. 27, points out M. Aaron Little with BKD in Springfield, Missouri. “HH PPS claims must report a 0023 revenue code line on which the first four positions of the HIPPS code match the code submitted on the RAP,” CMS says in the 57-page transmittal. “This HIPPS code is used to match the claim to the corresponding RAP that was previously paid. After this match is completed, grouping to determine the HIPPS code used for final payment of the period of care will occur in Medicare systems. At that time, the submitted HIPPS code on the claim will be replaced with the system-calculated code” (emphasis added).

With the HIPPS code matching edit in place, allowing a placeholder code is the only way for agencies to meet the five-day RAP submission deadline, experts acknowledge.

But submitting an incorrect HIPPS code on the final claim still leaves a bad taste in many HHAs’ mouths. “Since when is Medicare in the business of requiring bogus codes to be billed in HCPCS code claim fields?” Little asks.

It also makes reconciliation even more logistically difficult than it already is.

One small piece of good news, at least, is that the principal diagnosis codes do not have to match for no-pay RAPs and final claims. That’s been the case under PDGM this year, but wasn’t really noticeable because the HIPPS codes did have to match.

The fact that the principal diagnosis codes don’t have to match on the RAP and final claim isn’t in writing “at this point,” but it is true, a CMS official confirmed in the agency’s Dec. 16 Home Health Open Door Forum. That means agencies can use a placeholder principal diagnosis code on the RAP and the actual diagnosis code on the final claim.

In turn, that should take one more task off agencies’ plates before submitting the RAP, thus speeding the submission process, experts predict.

On the other hand, it may cause confusion and snarl things on the back end of the billing period.

Why? There will be two different procedures for the diagnosis code versus HIPPS code on RAPs and final claims. The dummy HIPPS code will be the same on both RAP and final claim. But the principal diagnosis code on the final claim must be the patient’s actual diagnosis and replace the RAP’s dummy code, so the Medicare claims system can use it to determine the final, accurate HIPPS code.

Note: Details about the new RAP process is at www.cms.gov/files/document/r10403CP.pdf.