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Understanding Home Health Prospective Payment System (HH PPS) Health Insurance Prospective Payment System (HIPPS) Code Changes

The following information is to be used to assist in determining how the Fiscal Intermediary Standard System (FISS) modifies the original HIPPS code submitted on home health final claims to reflect changes in the number of therapy visits billed and placement of the episode within the beneficiary's home health episode history posted to the Common Working File (CWF).

Instructions

Step 1:

Log on to FISS.

Step 2:

From the Main Menu, enter "01" and press <ENTER>.

Step 3:

Enter "12" and press <ENTER>.

Step 4:

MAP 1741 will appear. Enter the patient's HIC number, your provider identifier and the "FROM DATE" and "TO DATE" of the episode in question. Press <ENTER>.

Step 5:

Select the final claim for the episode you are researching and go to FISS Page 05 to determine the last 8 alpha characters of the Claim-OASIS Matching Key code entered into the "TREAT AUTH CODE" field. You may wish to print a copy of this page.

Step 6:

Go to FISS Page 02. Press the "F2" key, then the "F10" key to view the information on MAP 171A.

Step 7:

Ensure the letter "P" is present underneath the "OCE FLAGS 1" field. This indicates the HIPPS code was changed by the Pricer program in FISS.

Step 8:

If the letter "P" is present, review the HIPPS code displayed beside the "PAY/HCPC APC CD" field on MAP 171A. This is the HIPPS code with which the claim was paid.

Step 9:

Press the "F11" key. Review the HIPPS code displayed to the right of the "0023" field on this screen. This is the HIPPS code that was originally submitted on the claim.

Step 10:

By reviewing the first position of the two HIPPS codes, you can determine if the change was due to the placement of the episode within the beneficiary's home health episode history posted to the CWF (episode timing). The valid values and definitions are:

Number of Therapy Visits	Early episode (1st or 2nd in series)	Late episode (3rd or greater in a series)
0 – 13	1	3
14 – 19	2	4
20+	5	5

Step 11:

Find the number on the following pages that matches the 1st position of the HIPPS code you reviewed in step 8 to determine other reasons for HIPPS code changes.

If the recoded first position of the HIPPS code is 1, use the Treatment Authorization Code and the number of therapy visits to determine the values of the remaining characters in the HIPPS code. Recode the 2nd, 3rd and 4th positions of the HIPPS code as follows:

Recode the 2nd position of the HIPPS code according to the table below:

Treatment Authorization Code position 11	CLINICAL-SEV-EQ1 converted point value	Clinical Severity Level	Resulting HRG CODE - 2nd position value
A thru D	0-4	C1 (Min)	A
E thru H	5-8	C2 (Low)	B
I +	9+	C3 (Mod)	C

Recode the 3rd position of the HIPPS code according to the table below:

Treatment Authorization Code position 12	FUNCTION-SEV-EQ1 converted point value	Functional Severity Level	Resulting HRG CODE - 3rd position value
A thru E	0-5	F1 (Min)	F
F	6	F2 (Low)	G
G +	7+	F3 (Mod)	H

Change the 4th position of the HIPPS code according to the table below:

Total number of therapy visits billed	Resulting HRG CODE - 4th position value
0-5	K
6	L
7-9	M
10	N
11-13	P

If the recoded first position of the HIPPS code is 2, use the Treatment Authorization Code and the total number of therapy visits to determine the values of the remaining characters in the HIPPS code. Recode the 2nd, 3rd and 4th positions of the HIPPS code as follows:

Recode the 2nd position of the HIPPS code according to the table below:

Treatment Authorization Code position 13	CLINICAL-SEV-EQ2 converted point value	Clinical Severity Level	Resulting HRG CODE - 2nd position value
A thru F	0-6	C1 (Min)	A
G thru N	7-14	C2 (Low)	B
O+	15+	C3 (Mod)	C

Recode the 3rd position of the HIPPS code according to the table below:

Treatment Authorization Code position 14	FUNCTION-SEV-EQ2 converted point value	Functional Severity Level	Resulting HRG CODE - 3rd position value
A thru F	0-6	F1 (Min)	F
G	7	F2 (Low)	G
H +	8+	F3 (Mod)	H

Change the 4th position of the HIPPS code according to the table below:

Total number of therapy visits billed	Resulting HRG CODE - 4th position value
14-15	K
16-17	L
18-19	M

If the recoded first position of the HIPPS code is 3, use the Treatment Authorization Code and the total number of therapy visits to determine the values of the remaining characters in the HIPPS code. Recode the 2nd, 3rd and 4th positions of the HIPPS code as follows:

Recode the 2nd position of the HIPPS code according to the table below:

Treatment Authorization Code position 15	CLINICAL-SEV-EQ3 converted point value	Clinical Severity Level	Resulting HRG CODE - 2nd position value
A thru B	0-2	C1 (Min)	A
C thru E	3-5	C2 (Low)	B
F+	6+	C3 (Mod)	C

Recode the 3rd position of the HIPPS code according to the table below:

Treatment Authorization Code position 16	FUNCTION-SEV-EQ3 converted point value	Functional Severity Level	Resulting HRG CODE - 3rd position value
A thru H	0-8	F1 (Min)	F
I	9	F2 (Low)	G
J +	10+	F3 (Mod)	H

Change the 4th position of the HIPPS code according to the table below:

Total number of therapy visits billed	Resulting HRG CODE - 4th position value
0-5	K
6	L
7-9	M
10	N
11-13	P

If the recoded first position of the HIPPS code is 4, use the Treatment Authorization Code and the total number of therapy visits to determine the values of the remaining characters in the HIPPS code. Recode the 2nd, 3rd and 4th positions of the HIPPS code as follows:

Recode the 2nd position of the HIPPS code according to the table below:

Treatment Authorization Code position 17	CLINICAL-SEV-EQ4 converted point value	Clinical Severity Level	Resulting HRG CODE - 2nd position value
A thru H	0-8	C1 (Min)	A
I thru P	9-16	C2 (Low)	B
Q+	17+	C3 (Mod)	C

Recode the 3rd position of the HIPPS code according to the table below:

Treatment Authorization Code position 18	FUNCTION-SEV-EQ4 converted point value	Functional Severity Level	Resulting HRG CODE - 3rd position value
A thru G	0-7	F1 (Min)	F
H	8	F2 (Low)	G
I +	9+	F3 (Mod)	H

Change the 4th position of the HIPPS code according to the table below:

Total number of therapy visits billed	Resulting HRG CODE - 4th position value
14-15	K
16-17	L
18-19	M

If the first position of the HIPPS code contains a 5, the system will check the total number of therapy visits billed. If the total number of therapy visits is 19 or less, the HIPPS will be recoded based on the number of therapies and the placement of the episode.

If the HIPPS code begins with 1, 2, 3, or 4 and the total number of therapy visits is 20 or more:

Change the first position of the HIPPS code to 5

Recode the 2nd position of the HIPPS code according to the table below:

Treatment Authorization Code position 13 (early) or position 17 (late)	CLINICAL-SEV-EQ2 converted point value	Clinical Severity Level	Resulting HRG CODE - 2nd position value
A thru G	0-7	C1 (Min)	A
H thru N	8-14	C2 (Low)	B
O +	15+	C3 (Mod)	C

Recode the 3rd position of the HIPPS code according to the table below:

Treatment Authorization Code position 14 (early) or position 18 (late)	FUNCTION-SEV-EQ2 converted point value	Functional Severity Level	Resulting HRG CODE - 3rd position value
A thru F	0-6	F1 (Min)	F
G	7	F2 (Low)	G
H +	8+	F3 (Mod)	H

Change the 4th position of the HIPPS code to K.

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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Understanding Home Health Prospective Payment System (HH PPS) Health Insurance Prospective Payment System (HIPPS) Code Changes

Instructions

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