3.1 HHA PPS Pricer
Requirements
All home health services billed
on Type Of Bill (TOB) 32X will be reimbursed based on calculations
made by the Home Health (HH) Pricer. The HH Pricer operates as a
call module within contractors’ systems. The HH Pricer makes all
reimbursement calculations applicable under HHA PPS, including percentage
payments on Requests for Anticipated Payment (RAPs), claim payments
for full Episodes Of Care (EOCs), and all payment adjustments, including
Low Utilization Payments (LUPAs), Partial Episode Payment (PEP)
adjustments, therapy threshold adjustments, and outlier payments. Contractors’
systems must send an input record to Pricer for all claims with
covered visits, and Pricer will send the output record back to the
contractors’ system. The following sections describe the elements of
HHA PPS claims that are used in the HHA PPS Pricer and the logic
that is used to make payment determinations.
3.1.1 General Requirements
3.1.1.1 Pricer
will return the following information on all claims: Output Health
Insurance Prospective Payment System (HIPPS) codes, weight used
to price each HIPPS code, payment per HIPPS code, total payment,
outlier payment and return code. If any element does not apply to
the claim, Pricer will return zeros.
3.1.1.2 Pricer
will wage index adjust all PPS payments based on the Metropolitan
Statistical Area (MSA) or Core Based Statistical Area (CBSA) reported
in value code 61 on the claim.
3.1.1.3 Pricer
will return the reimbursement amount for the HIPPS code in the 023
line of the claim for the RAPs and paid claims.
3.1.1.4 If input
is invalid, Pricer will return one of a set of error return codes
to indicate the invalid element.
3.1.1.5 Pricer
must apply the fiscal year rate changes to through date on claim.
3.1.2 Pricing of
RAPs
3.1.2.1 Pricer will employ RAP logic for TOB 322 only.
3.1.2.2 On the
RAP, Pricer will multiply the wage index adjusted rate by 0.60 if
the claim from date and admission date match and the initial payment
indicator is = 0.
3.1.2.3 On the
RAP, Pricer will multiply the wage index adjusted rate by 0.50 if
the claim from date and admission date do not match and the initial
payment indicator is = 0.
3.1.2.4 On the
RAP, Pricer will multiply the wage index adjusted rate by 0.00 if
the initial payment indicator equals 1.
3.1.2.5 Pricer
will return the payment amount on RAP with return code 03 for
0%, 04 for 50% payment and 05 for 60%
payment.
3.1.3 Pricing of Claims
3.1.3.1 Pricer
will employ claim logic for TOB 329, 327, 32G, 32I, 32J, 32M, 32P,
32Q, and 33Q only.
3.1.3.2 Pricer
will make payment determinations for claims in the following sequence:
• LUPA
• Recoding of claims
based on episode sequence and therapy thresholds
• Home Health Resource
Group (HHRG) payments [including PEP]
• Outlier, in accordance
with logic in the Pricer
3.1.3.3 Pricer
will pay claims as LUPAs when there are less than 5 occurrences
of all HH visit revenue codes: 42X, 43X, 44X, 55X, 56X, and 57X.
3.1.3.4 Pricer
will pay visits on LUPA claims at national standardized rates, and
the total visit amounts will be final payment for the episode.
3.1.3.5 If Pricer
determines the claim to be a LUPA, all other payment calculations
will be bypassed.
3.1.3.6 Pricer
will return claim LUPA payments, with return code 06.
3.1.3.7 DHA will
supply Pricer with a table of “fall back” HIPPS codes so HIPPS can
be downcoded when thresholds are not met.
3.1.3.8 If one
of the HIPPS codes that indicate therapy is present, Pricer will
check for the presence of 10 therapy visits by revenue code (42X,
43X, 44X). Ten therapies in total for an episode is the threshold.
3.1.3.9 If 10 occurrences
of therapy revenue codes are not found when HIPPS code indicates therapies,
Pricer will reprice the claim based on the table of “fall back”
HIPPS codes.
3.1.3.10 Pricer
will return both the input HIPPS code and an output HIPPS code.
The output code will be different from the input code only if the
therapy threshold is not met.
3.1.3.11 If the
PEP indicator is Y, Pricer will multiply the wage index
adjusted rate by the number of HHRG days over 60 (days divided by
60).
3.1.3.12 If the PEP indicator is Y and
there are two or more HIPPS codes on the claim, Pricer will multiply
each HHRG payment by the number of PEP days/60. Each result will
then be multiplied by the number of HHRG days/the number of PEP
days. The sum of these amounts is the total HHRG payment for the
episode.
3.1.3.13 Pricer will perform the outlier calculations
on all claims unless the claim is a LUPA.
3.1.3.14 Pricer
passes back to the system a single outlier amount, no matter how
many HIPPS codes are on the claim.
3.1.3.15 Pricer
will perform an outlier calculation that requires total number of
visits per discipline to be multiplied by national standard per
visit rates. Effective January 1, 2017, the methodology to calculate
the outlier payment will utilize a costperunit approach rather
than a costpervisit approach. The national pervisit rates are
converted into per 15 minute unit rates. The perunit rate by discipline will
be used along with the visit length data reported on the home health
claim to calculate the estimated cost of an episode to determine
whether the claim will receive an outlier payment and the amount
of payment for an EOC. The amount of time per day used to estimate
the cost of an episode for the outlier calculation is limited to
eight hours or 32 units per day (care is not limited, only the number of
hours/units eligible for inclusion in the outlier calculation).
For rare instances when more than one discipline of care is provided
and there is more than eight hours of care provided in one day,
the episode cost associated with the care provided during that day
will be calculated using a hierarchical method based on the cost
per unit per discipline shown in
Addendum K (CY 2017), Figure 12.K.20175. The
discipline of care with the lowest associated cost per unit will
be discounted in the calculation of episode cost in order to cap
the estimation of an episode’s cost at eight hours of care per day.
The total result is compared to an outlier threshold which is determined
by adding the rate for the HIPPS code to a standard fixedloss amount.
If the total result is greater than the threshold, Pricer will pay
80% of the difference between the two amounts in addition to the
episode rate determined by the HIPPS code.
3.1.3.16 Pricer will return claim payment with no outlier
payment with return code 00.
3.1.3.17 Pricer will return claim payments with outlier
payment with return code 01.
3.1.3.18 Pricer will return the following additional
information on claims:
• The dollar rate used
to calculate revenue code costs, and
• The costs calculated
for each revenue code.
3.1.3.19 If any
revenue code is submitted with zeros, Pricer will return zeros in
these fields.
3.1.3.20 Rate and
weight information used by the HH Pricer is updated periodically,
usually annually. Updates occur each January, to reflect the fact
that HH PPS rates are effective for a calendar year. Following are
the annual updated items:
• The Federal standard episode amount;
• The Federal conversion
factor for nonroutine supplies;
• The fixed loss amount
to be used for outlier calculations;
• A table of casemix
weights to be used for each Health Resource Group (HRG);
• A table of supply
weights to be used to adjust the nonroutine supply conversion factor;
• A table of national
standardized per visit rates and per unit rates;
• The prefloor, prereclassified
hospital wage index; and
• Changes, if any, to
the RAP payment percentages, the outlier losssharing percentage and
the labor and nonlabor percentages.
3.1.4 Interface
with Pricer
3.1.4.1 Provide specification for a 650byte Pricer
input record layout.
3.1.4.2 Contractor’s
claims processing system will pass the following claim elements
to Pricer for all claims:
• National Provider
Identifier (NPI)
• Health Insurance
Claim (HIC) number
• Provider number
• TOB
• Statement from
and through dates
• Admission date
and HIPPS codes
3.1.4.3 The system
will place the return code passed back from Pricer on the header
of all claims.
3.1.4.4 If the
claim is a LUPA, the system will apportion the payment amounts returned
from Pricer to the visit lines.
3.1.4.5 The system
will pass a Y medical review indicator to Pricer if
a HIPPS code is present in the panel field on a line, and the line
item pricing indicator shows that the change came from medical review
(MR). In all other cases an N indicator will be passed.
3.1.4.6 The system
will assure all claims with covered visits will flow to Pricer,
but only covered visits will be passed to Pricer.
3.1.4.7 The system
will pass Pricer all six home health visit revenue codes sorted
in ascending order, with a count of how many times each code appears
on the claim, and those that do not appear on claims will be passed
with a quantity of zero.
3.1.4.8 If there
is one HIPPS code on the claim and the patient status is 06, the
standard systems will pass 60 days of service for the HIPPS code,
regardless of visit dates on the claim.
3.1.4.9 If the
claim is a PEP, the standard systems will calculate the number of
days between the first service date and the last service date and
pass that number of days for the HIPPS code.
3.1.4.10 If the
claim is a SCIC, the standard systems will calculate the number
of days for all HIPPS codes from the inclusive span of days between
first and last service dates under the HIPPS code.
3.1.4.11 The system
will pass a Y/N medical review indicator to Pricer
for each HIPPS code on the claim.
3.1.4.12 The system
will pass Pricer a Y PEP indicator if the claim shows
a patient status of 06. Otherwise, the indicator will
be N.
3.1.4.13 The system
will place the payment amount returned by Pricer in the total charge
and the covered charge field on the 023 line.
3.1.4.14 The system
will place any outlier amount on the claim as value code 17 amount
and plug condition code 61 on the claim.
3.1.4.15 When Pricer
returns an 06 return code (LUPA payment), the system will place
it on the claim header in the return code field and create a new L indicator
in the header of the record.
3.1.4.16 Pricer
will be integrated into the system for customer service and create
a new online screen to do it.
3.1.5 Input/Output Record Layout
The HH Pricer input/output file will be 650 bytes
in length. The required data and format are shown below:
File Position

Format

Title

Description

110

X(10)

NPI

This field will
be used for the NPI if it is sent to the HH Pricer in the future.

1122

X(12)

HIC

Input
Item: The HIC number of the beneficiary, copied from the
claim form.

2328

X(6)

PRONO

Input
Item: The six digit OSCAR system provider number, copied
from FL 51 of the claim form.

2931

X(3)

TOB

Input
Item: The TOB code, copied from the claim form.

32

X

PEPINDICATOR

Input
Item: A single Y/N character to indicate if a claim must
be paid a PEP adjustment. Standard systems must set a Y if
the discharge status code on the claim is 06. An N is
set in all other cases.

3335

9(3)

PEPDays

Input
Item: The number of days to be used for PEP payment calculation. Standard
systems determine this number from the span of days from and including
the first line item service date on the claim, to and including the
last line item service date on the claim.

36

X

INITPAYINDICATOR

Input
Item: A single character to indicate if normal percentage payments
should be made on RAP, or whether payment should be based on data
drawn by the standard systems from Medicare’s provider specific file.
Valid Values:
0 = Make normal percentage payment
1 = Pay 0%
2 = Make final payment reduced
by 2%
3 =
Make final payment reduced by 2%, pay RAPs at 0%

3741

X(5)

COUNTY
CODE

Input
item: The FIPS State and County
Code copied from the value code 85 amount on the claim form.

4245

X(4)

FILLER

Blank.

4650

X(5)

CBSA

Input
Item: The CBSA code, copied from the value code 61 amount
on the claim form.

5152

X(2)

FILLER

Blank.

5360

X(8)

SERFROMDATE

Input
Item: The statement covers period “From” date, copied from the claim
form. Date format must be CCYYMMDD.

6168

X(8)

SERVTHRUDATE

Input
Item: The statement covers period “Through” date, copied from the
claim form. Date format must be CCYYMMDD.

6976

X(8)

ADMITDATE

Input
Item: The admission date, copied from the claim form must
be CCYYMMDD.

77

X

HRGMEDREVIEW INDICATOR

Input
Item: A single Y/N character to indicate if a HIPPS code has
been changed by medical review. Standard systems must set a Y if
an ANSI code on the line item indicates medical review change. An N must
be set in all other cases.

7882

X(5)

HRGINPUTCODE

Input
Item: Standard systems must copy the HIPPS code reported
by the provider on each 023 revenue code line. If an ANSI code on
the line indicates medical review change, standard systems must
copy the additional HIPPS code placed on the 023 revenue code line
by the medical reviewer.

8387

X(5)

HRGOUTPUTCODE

Output
Item: The HIPPS code used by Pricer to determine the reimbursement
amount on the claim. This code will match the input code unless
the claim is recoded due to therapy thresholds or changes in episode
sequence. If recoded, standard systems stores this output item in
the APCHIPPS field on the claim record.

8890

9(3)

HRGNOOFDAYS

Input
Item: A number of days calculated by the standard systems
for each HIPPS code. The number is determined by the span of days
from and including the first line item service date provided under
that HIPPS code, to and including the last line item service date
provided under that HIPPS code.

9196

9(2)V9
(4)

HRGWGTS

Output
Item: The weight used by Pricer to determine the payment amount
on the claim.

97105

9(7)V9
(2)

HRGPAY

Output
Item: The reimbursement amount calculated by Pricer for each HIPPS
code on the claim.

106250

Defined above

Additional
HRG data

Fields for five
more occurrences of all HRG/HIPPS code related fields defined above. NOT
USED.

251254

X(4)

REVENUECODE

Input
Item: One of the six home health disciplines revenue codes
(42X, 43X, 44X, 55X, 56X, 57X). All six revenue codes must be passed
by the standard systems even if the revenue codes are not present
on the claim.

255257

9(3)

REVENUEQTYCOVVISITS

Input
Item: A quantity of covered visits corresponding to each
of the six revenue codes. Standard systems must count the number
of covered visits in each discipline on the claim. If the revenue
codes are not present on the claim, a zero must be passed with the
revenue code.

258262

9(5)

REVENUEQTYOUTLIERUNITS

Input
Item: The sum of the units reported on all covered lines corresponding
to each of the six revenue codes. The standard systems accumulate
the number of units in each discipline on the claim, subject to
a limit of 32 units per date of service. If any revenue code is
not present on the claim, a zero must be passed with that revenue
code.

263270

9(8)

REVENUEEARLIESTDATE

Input
Item: The earliest line item date for the corresponding revenue code.
Date format must be CCYYMMDD.

271279

9(7)V9
(2)

REVENUEDOLLRATE

Output
Item: The dollar rates used by Pricer to calculate the payment for the
visits in each discipline if the claim is paid as a LUPA. Otherwise,
the dollar rates used by Pricer to impute the costs of the claim
for purposes of calculating an outlier payment, if any.

280288

9(7)V9
(2)

REVENUECOST

Output
Item: The dollar amount determined by Pricer to be the payment for
the visits in each discipline if the claim is paid as a LUPA. Otherwise,
the dollar amounts used by Pricer to impute the costs of the claim
for purposes of calculating an outlier payment, if any.

289297

9(7)V9(2)

REVENUEADDONVISITAMT

Output
Item: The addon amount to be applied to the earliest line
item date with the corresponding revenue code.
If revenue code 055X, then this is the
national pervisit amount multiplied by 1.8714.
If revenue code 042X, then this is the
national pervisit amount multiplied by 1.6841.
If revenue code 044X, then this is the
national pervisit amount multiplied by 1.6293.

298532

Defined above

Additional
REVENUE data

Five more occurrences
of all REVENUE related data defined above.

533534

9(2)

PAYRTC

Output
Item: A return code set by Pricer to define the payment circumstance
of the claim or an error in input data.
Payment return codes:
00 = Final payment, where no outlier applies
01 = Final payment where outlier applies
02 = Final payment where outlier applies,
but is not payable due to limitation
03 = Initial percentage payment, 0%
04 = Initial percentage payment, 50%
05 = Initial percentage payment, 60%
06 = LUPA payment only
07 = Not used
08 = Not used
09 = Final payment, PEP
11 = Final payment, PEP with outlier
12 = Not used
13 = Not used
14 = LUPA payment, first episode addon payment
applies
Error
return codes:
10
= Invalid TOB
15 = Invalid
PEP Days
16 = Invalid
HRG days, greater than 60
20
= PEP indicator invalid
25
= Med review indicator invalid
30 = Invalid MSA/CBSA code
31 = Invalid/missing country
code
35
= Invalid Initial Payment Indicator
40 = Dates before October 1, 2000 or invalid
70 = Invalid HRG code
75 = No HRG present in first occurrence
80 = Invalid revenue code
85 = No revenue code present on 3X9 or adjustment
TOB

535539

9(5)

REVENUESUM
13QTYTHR

Output
Item: The total therapy visits used by the Pricer to determine
if the therapy threshold was met for the claim. This amount will
be the total of the covered visit quantities input with revenue
codes 42X, 43X, and 44X.

540544

9(5)

REVENUESUM
16QTYAll

Output
Item: The total number of visits used by the Pricer to determine if
the claim must be paid as a LUPA. This amount will be the total
of all the covered visit quantities input with all six home health
discipline revenue codes.

545553

9(7)V9
(2)

OUTLIERPAYMENT

Output
Item: The outlier payment amount determined by Pricer to
be due on the claim in addition to any HRG payment amounts.

554562

9(7)V9
(2)

TOTAL
PAYMENT

Output
Item: The total reimbursement determined by Pricer to be
due on the RAP or claim.

563567

9(3)V9 (2)

LUPAADDONPAYMENT

Output
Item: For claim “Through” dates before January 1, 2014, the
addon amount to be paid for LUPA claims that are the first episode
in a sequence. This amount is added by the standard systems to the
payment for the first visit line on the claim.
For claim “Through” dates on or after
January 1, 2017, zero filled.

568

X

LUPASRCADM

Input
Item: Standard systems set this indicator to B when
condition code 47 is present on the RAP or claim. The indicator
is set to 1 in all other cases.

569

X

RECODEIND

Input
Item: A recoding indicator set by standard systems in response
to identifying that the episode sequence reported in the first position
of the HIPPS code must be changed. Valid values:
0 = Default value
1 = HIPPS code shows later episode, should
be early episode
2 =
HIPPS code shows early episode, but this is not a first or only
episode
3 = HIPPS code
shows early episode, should be later episode

570

9

EPISODETIMING

Input
Item: A code indicating whether a claim is an early or late
episode. Standard systems copy this code from the 10th position
of the treatment authorization code. Valid values:
1 = Early episode
2 = Late episode

571

X

CLINICALSEVEQ1

Input
Item: A hexavigesimal code that converts to a number representing
the clinical score for this patient calculated under equation 1
of the casemix system. The standard systems copy this code from
the 11th position of the treatment authorization code.

572

X

FUNCTIONSEVEQ1

Input
Item: A hexavigesimal code that converts to a number representing
the functional score for this patient calculated under equation
1 of the casemix system. The standard systems copy this code from
the 12th position of the treatment authorization code.

573

X

CLINICALSEVEQ2

Input
Item: A hexavigesimal code that converts to a number representing
the clinical score for this patient calculated under equation 2
of the casemix system. The standard systems copy this code from
the 13th position of the treatment authorization code.

574

X

FUNCTIONSEVEQ2

Input
Item: A hexavigesimal code that converts to a number representing
the functional score for this patient calculated under equation
2 of the casemix system. The standard systems copy this code from
the 14th position of the treatment authorization code.

575

X

CLINICALSEVEQ3

Input
Item: A hexavigesimal code that converts to a number representing
the clinical score for this patient calculated under equation 3
of the casemix system. The standard systems copy this code from
the 15th position of the treatment authorization code.

576

X

FUNCTIONSEVEQ3

Input
Item: A hexavigesimal code that converts to a number representing
the functional score for this patient calculate under equation 3
of the casemix system. The standard systems copy this code from
the 16th position of the treatment authorization code.

577

X

CLINICALSEVEQ4

Input
Item: A hexavigesimal code that converts to a number representing
the clinical score for this patient calculate under equation 4 of
the casemix system. The standard systems copy this code from the 17th
position of the treatment authorization code.

578

X

FUNCTIONSEVEQ4

Input
Item: A hexavigesimal code that converts to a number representing
the functional score for this patient calculate under equation 4
of the casemix system. The standard systems copy this code from
the 18th position of the treatment authorization code.

579588

9(8)V99

PROVOUTLIERPAYTOTAL

Input
Item: The total amount of outlier payments that have been
made to this HHA for episodes ending during the current calendar
year.

589599

9(9)V99

PROVPAYMENTTOTAL

Input
Item: The total amount of HH PPS payments that have been
made to this HHA for episodes ending during the current calendar
year.

600604

9V9(5)

PROVVBPADJFAC

Input
Item: The standard systems move this information from field
30 of the provider specific file.

605613

9(7)V9 (2)

VBPADJAMT

Output
Item: The HHVBP adjustment amount, determined by subtracting
the HHVBP adjustment total payment from the HH PPS payment that
would otherwise apply to the claim. Added to the claim as a value
code QV amount.

614622

9(7)V9 (2)

PPSSTDVALUE

Output
Item: The standardized payment amount – the HH PPS payment without
applying any providerspecific adjustments. Informational only. Subject
to additional calculations before entered on the claim in PPSSTNDRDVALUE
field.

623650

X(28)

FILLER

Blank.

3.1.5.1 Input records
on RAPs will include all input items except for “REVENUE” related
items, and input records on RAPs will never report more than one
occurrence of “HRG” related items. Input records and claims must
include all input items. Output records will contain all input and
output items. If an output item does not apply to a particular record,
Pricer will return zeros.
3.1.5.2 The standard
systems will move the following Pricer output items to the claim
record.
• The
return code will be placed in the claim header.
• The HRGPAY amount
for each HIPPS code will be placed in the total charges and the covered
charges field of the appropriate revenue code 023 line.
• The OUTLIERPAYMENT
amount, if any, will be placed in a value code 17 amount.
• If the return code
is 06 (indicating a LUPA), the standard systems will
apportion the REVENUECOST amounts to the appropriate line items
in order for the pervisit payments to be accurately reflected on
the remittance advice.
3.1.6 Decision
Logic Used by Pricer on RAPs
On input records
with TOB 322, Pricer will perform the following calculations in
the numbered order:
3.1.6.1 Determine the applicable Federal
standard episode rate to apply by reading the values in “INITPYMNTINDICATOR.”
If the value is 0 or 1, use the full standard
episode rate in subsequent calculations. If the value is 2 or 3,
use the standard episode rate which has been reduced by 2% due to the
failure of the provider to report required quality data. For certain
dates of service when required by law, read “CBSA” and “COUNTYCODE”
to determine if a rural addon payment applies. If yes, use the appropriate
rural episode rate with or without quality data in subsequent calculations.
3.1.6.2 Find weight
for “HRGINPUTCODE” from the table of weight for the Federal fiscal
year in which the “SERVTHRUDATE” falls. Multiply the weight times
Federal standard episode rate for the Federal fiscal year in which
the “SERTHRUDATE” falls. The product is the casemix adjusted
rate. This casemix adjusted rate must also be wageindex adjusted
according to labor and nonlabor portions of the payment established
by DHA. Multiply the casemix adjusted rate by the current labor
related percentage to determine the labor portion. Multiply the
labor portion by the wage index corresponding to CBSA.
Multiply the Federal adjusted rate by the current nonlabor related
percentage to determine the nonlabor portion. Sum the labor and
nonlabor portions. The sum is the casemix and wage index adjusted
payment for this HRG.
3.1.6.3 Find the
nonroutine supply weight corresponding to the fifth positions of
the “HRGINPUTCODE” from the supply weight table for the calendar
year in which the “SERVTHRUDATE” falls. Multiply the weight times
the Federal supply conversion factor for the calendar year in which
the “SERVTHRUDATE” falls. Sum the HRG payment and nonroutine
supply payments.
3.1.6.3.1 If the
“INITPYMNTINDICATOR” equals 0 or 2,
perform the following: Determine if the “SERVFROMDATE” is equal
to the “ADMITDATE.” If yes, multiply the wage index and casemix
adjusted payment by 0.6. Return the resulting amount as “HRGPAY”
and as “TOTALPAYMENT” with return code 05. If no,
multiply the wage index and casemix adjusted payment by 0.5. Return
the resulting amount as “HRGPAY” and as “TOTALPAYMENTS” with a
return code 04.
3.1.6.3.2 If the “INITPAYMNTINDICATOR” equals 1 or 3,
perform the following: Multiply the wage index and casemix adjusted
payment by 0. Return the resulting amount as “HRGPAY” and as “TOTALPAYMENT”
with return code 03.
3.1.7 Decision
Logic Used By Pricer on Claims
On input records
with TOB 329, 327, 32F, 32G, 32H, 32I, 32J, 32K, 32M, 32P, 32Q, or 33Q (that is,
all provider submitted claims and provider or intermediary initiated
adjustments), Pricer will perform the following calculations in
the numbered order:
3.1.7.1 Prior to these calculations, determine the
applicable Federal standard episode rate to apply by reading the
value in “INITPAYMENTINDICATOR.” If the value is 0 or 1,
use the full standard episode rate in subsequent calculations. If
the value is 2 or 3, use the standard
episode rate which has been reduced by 2% due to the failure of
the provider to report required quality data.
Note: Since the TRICARE
Program is not following Medicare’s requirement for a 2% reduction
in the standard episode rate due to the failure of the provider
to report required quality data, all four values (0, 1, 2,
or 3) appearing in “INITPAYMENTINDICATOR” will result
in full payment of standard episode rate.
3.1.7.2 LUPA
Calculations
3.1.7.2.1 If the
“REVENUESUM16QTYALL” (the total of the six revenue code quantities, representing
the total number of visits on the claim) is less than 5, read the
national standard pervisit rate for each of the six “REVENUEQTYCOVVISITS”
fields from the revenue code table for the calendar year in which
the “SERVTHRUDATE” falls. Multiply each quantity by the corresponding
rate. Wage index adjust each value and report the payment in the
associated ‘REVENUECOST” field.
3.1.7.2.2 If the following conditions are met, calculate
an additional LUPA addon payment:
• The
dates in the “SERVFROMDATE” and “ADMITDATE” fields match;
• The
first position of the HIPPS code is a 1 or a 2;
• The
value in “LUPASRCADM” is not a B; and
• The
value in RECODEIND” is not 2.
Compare the earliest line item dates for revenue
codes 042X, 044X, and 055X and select the revenue code with the
earliest date. If the earliest date for revenue codes 042X or 044X
match the revenue code 055X date, select revenue code 055X. If the
earliest date for revenue codes 042X and 044X match and revenue
code 055X is not present, select revenue code 042X.
3.1.7.2.3 Apply the appropriate LUPA
addon factor to the selected earliest dated line.
• If
revenue code 055X, multiply the national pervisit amount by 1.8451.
• If
revenue code 042X, multiply the national pervisit amount by 1.6700.
• If
revenue code 044X, multiply the national pervisit amount by 1.6266.
Return the resulting payment amount in the
“REVENUEADDONVISITAMT” field.
3.1.7.2.4 Return the sum of all “REVENUECOST” amounts
and the “REVENUEADDONVISITAMT”, if applicable, the “TOTALPAYMENT”
field. If the LUPA payment includes LUPA addon amount, return 14
in the “PAYRTC” field. Otherwise, return
06 in the
“PAYRTC” field. These distinct return codes assist the standard
systems in apportioning visit payments to claim lines. No further
calculations are required. If “REVENUESUM16QTYALL” is greater
than or equal to 5, proceed to the recoding process in
paragraph 3.1.7.3.
3.1.7.3 Recoding
of claims based on episode sequence and therapy thresholds.
• Read the “RECODEIND.”
If the value is
0, proceed to
paragraphs 3.1.7.3.2 and
3.1.7.3.4 below
(therapy visit recoding) based on the claim “Through” date.
• If
the value in “RECODEIND” is 1, find the number of
therapy services reported in “REVENUESUM13QTYTHR.” If the number
of therapy services is in the range 013, recode the first position
of the HIPPS code to 1. If the number of therapy services is in the
range 1419, recode the first position of the HIPPS code to 2.
• If
the value in “RECODEIND” is 3, find the number of
therapy services reported in “REVENUESUM13QTYTHR.” If the number
of therapy services is in the range 013, recode the first position
of the HIPPS code to 3. If the number of therapy services
is in the range 1419, recode the first position of the HIPPS code
to 4.
• Read the alphabetic
values in the “CLINICALSEVEQ” field and “FUNCTIONSERVEQ” field
for which the number at the end of the field names corresponds to
the recoded first position of the HIPPS code determined above. Translate
the alphabetic value from a hexavigesimal code to its corresponding
numeric valve. These are the severity scores in the clinical and
functional domains of the case mix model under the payment equation
that applies to the claim.
3.1.7.3.1 For claims with “Through” dates on or after
January 1, 2016 and before January 1, 2017, use the following translation:
• If the recoded first
position of the HIPPS code is
1, use the numeric values
for the clinical and functional severity levels and the number of
therapy visits in the “REVENUESUM13QTYTHR” field to recode the
second, third, and fourth positions of the HIPPS code as follows:
• Recode the second
position of the HIPPS code according to the table below:
Treatment
Authorization Code position 11  CLINICALSEVEQ1 value

CLINICALSEV
EQ1 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through B

0  1

C1 (Min)

A

C through D

2  3

C2 (Low)

B

E+

4+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 12  FUNCTIONSEVEQ1 value

FUNCTIONSEV
EQ1 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through O

0  14

F1 (Min)

F

P

15

F2 (Low)

G

Q+

16+

F3 (Mod)

H

• Recode
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth 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 numeric values for the clinical and functional severity
levels and the number therapy visits in the “REVENUESUM13QTYTHR”
field to recode the second, third, and fourth positions of the HIPPS
code as follows:
• Recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 13  CLINICALSEVEQ2 value

CLINICALSEV
EQ2 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through B

0  1

C1 (Min)

A

C through H

2  7

C2 (Low)

B

I+

8+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 14  FUNCTIONSEVEQ2 value

FUNCTIONSEV
EQ2 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through G

0  6

F1 (Min)

F

H through N

7  13

F2 (Low)

G

Q+

14+

F3 (Mod)

H

• Change
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth position value

14  15

K

16  17

L

18  19

M

• If
the recoded first position of the HIPPS code is
3,
use the numeric values for the clinical and functional severity
levels and the number therapy visits in the “REVENUESUM13QTYTHR”
field to recode the second, third, and fourth positions of the HIPPS
code as follows:
• Recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 15  CLINICALSEVEQ3 value

CLINICALSEV
EQ3 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A

0

C1 (Min)

A

B

1

C2 (Low)

B

C+

2+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 16  FUNCTIONSEVEQ3 value

FUNCTIONSEV
EQ3 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through G

0  6

F1 (Min)

F

H through K

7  10

F2 (Low)

G

L+

11+

F3 (Mod)

H

• Recode
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth 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 numeric values for the clinical and functional severity
levels and the number therapy visits in the “REVENUESUM13QTYTHR”
field to recode the second, third, and fourth positions of the HIPPS
code as follows:
• Recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 17  CLINICALSEVEQ4 value

CLINICALSEV
EQ4 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through D

0  3

C1 (Min)

A

E through M

4  12

C2 (Low)

B

N+

13+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 18  FUNCTIONSEVEQ4 value

FUNCTIONSEV
EQ4 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A

0

F1 (Min)

F

B through H

1  7

F2 (Low)

G

I+

8+

F3 (Mod)

H

• Change
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth position value

14  15

K

16  17

L

18  19

M

• Move
the resulting recoded HIPPS code to the HRGOUTPUTCODE” fields.
Proceed to HRG payment calculations. Use the weights associated
with the code in the “HRGOUTPUTCODE” field for all further calculations.
3.1.7.3.2 Recoding
steps for claims with “Through” dates on or after January 1, 2016
and before January 1, 2017:
• If
the first position of the HIPPS code submitted in “HRGINPUTCODE”
is 5 and the number of therapy services in “REVENUESUM13QTYTHR”
is less than 20, read the value in the “EPISODETIMING” field.
• If
the value in the “EPISODETIMING” field is a 1, and
the number of therapy services is in the range 013, recode the
first position of the HIPPS code as 1.
If the number of therapy services is in the range 1419, recode
the first position of the HIPPS code to 2.
• If
the value in the “EPISODETIMING” field is a 2, and
the number of therapy services is in the range 013, recode the
first position of the HIPPS code to 3. If the number of
therapy services is in the range 1419, recode the first position
of the HIPPS code to 4.
• Return
to the start of
paragraph 3.1.7.3.1 and recode the remaining
positions of the HIPPS code as described above.
• In
all cases, read only the “REVENUESUM13QTYTHR” field and recode
the fourth positions of the HIPPS code according to the table below,
if possible.
HIPPS
codes beginning with 1 or 3

HIPPS
codes beginning with 2 and 4

REVENUESUM
13QTYTHR value

Resulting
HRGOUTPUTCODE fourth position value

REVENUESUM
13QTYTHR value

Resulting
HRGOUTPUTCODE fourth position value

0  5

K

14  15

K

6

L

16  17

L

7  9

M

18  19

M

10

N



11  13

P



• Move
the resulting recoded HIPPS code to the “HRGOUTPUTCODE” fields.
Proceed to HRG payment calculations. Use the weight associated with
the code in the “HRGOUTPUTCODE field for all further calculations.
• If
the HIPPS code begins with
1 and the value in “REVENUESUM13QTYTHR”
is greater than 13 and less than 20, change the first position of
the HIPPS code to
2, and set the “RECODEIND” to
1.
Return to
paragraph 3.1.6.2 and recode the remaining
positions of the HIPPS as described above.
• If
the HIPPS code begins with
3 and value in “REVENUESUM13QTYTHR”
is greater than 13 and less than 20, change the first position of
the HIPPS code to 4, and set the “RECODEIND” to 3. Return to
paragraph 3.1.6.2 and
recode the remaining positions of the HIPPS as described above.
• If
the HIPPS code begins with
2 and the value “REVENUESUM13QTYTHR”
is less than 14, change the first position of the HIPPS code to
1, and set the “RECODEIND” to
1. Return to
paragraph 3.1.6.2 and
recode the remaining positions of the HIPPS code as described above.
• If
the HIPPS code begins with
4 and the value in “REVENUESUM13QTYTHR”
is less than 14, change the first position of the HIPPS code to
3, and set the “RECODEIND” to
3. Return to
paragraph 3.1.6.2 and
recode the remaining positions of the HIPPS code as described above.
• If
the HIPPS code begins with
1 or
2 and
the value in “REVENUESUM13QTYTHR” is 20 or more:
• Change
the first position of the HIPPS code to
5 and recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 13  CLINICALSEVEQ2 value

CLINICALSEV
EQ2 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through D

0  3

C1 (Min)

A

E through Q

14  16

C2 (Low)

B

R+

17+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 14  FUNCTIONSEVEQ2 value

FUNCTIONSEV
EQ2 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through C

0  2

F1 (Min)

F

D through G

3  6

F2 (Low)

G

H+

7+

F3 (Mod)

H

• Change
the fourth position of the HIPPS code to K.
• If
the HIPPS code begins with
3 or
4 and
the value in “REVENUESUM13QTYTHRU” is 20 or more.
• Change
the first position of the HIPPS code to
2 and recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 17  CLINICALSEVEQ4 value

CLINICALSEV
EQ4 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through D

0  3

C1 (Min)

A

E through Q

4  16

C2 (Low)

B

R+

17+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 18  FUNCTIONSEVEQ4 value

FUNCTIONSEV
EQ4 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through C

0  2

F1 (Min)

F

D through G

3  6

F2 (Low)

G

H+

7+

F3 (Mod)

H

• Change
the fourth position of the HIPPS code to K.
3.1.7.3.3 For claims
with “Through” dates on or after January 1, 2017, use the following translation:
• If the recoded first
position of the HIPPS code is
1, use the numeric values
for the clinical and functional severity level and the number of
therapy visits in the “REVENUESUM13QTYTHR” field to recode the
second, third, and fourth positions of the HIPPS as follows:
• Recode the second
position of the HIPPS code according to the table below:
Treatment
Authorization Code position 11  CLINICALSEVEQ1 value

CLINICALSEV
EQ1 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through B

0  1

C1 (Min)

A

C through D

2  3

C2 (Low)

B

E+

4+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 12  FUNCTIONSEVEQ1 value

FUNCTIONSEV
EQ1 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through N

0  13

F1 (Min)

F

O

14

F2 (Low)

G

P+

15+

F3 (Mod)

H

• Change
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth 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 numeric values for the clinical and functional severity
levels and the number therapy visits in the “REVENUESUM13QTYTHR”
field to recode the second, third, and fourth positions of the HIPPS
code as follows:
• Recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 13  CLINICALSEVEQ2 value

CLINICALSEV
EQ2 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through B

0  1

C1 (Min)

A

C through H

2  7

C2 (Low)

B

I+

8+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 14  FUNCTIONSEVEQ2 value

FUNCTIONSEV
EQ2 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through G

0  6

F1 (Min)

F

H through N

7  13

F2 (Low)

G

Q+

14+

F3 (Mod)

H

• Recode
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth position value

14  15

K

16  17

L

18  19

M

• If
the recoded first position of the HIPPS code is
3,
use the numeric values for the clinical and functional severity
levels and the number therapy visits in the “REVENUESUM13QTYTHR”
field to recode the second, third, and fourth positions of the HIPPS
code as follows:
• Recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 15  CLINICALSEVEQ3 value

CLINICALSEV
EQ3 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through B

0  1

C1 (Min)

A

C

2

C2 (Low)

B

D+

3+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 16  FUNCTIONSEVEQ3 value

FUNCTIONSEV
EQ3 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through G

0  6

F1 (Min)

F

H through K

7  10

F2 (Low)

G

L+

11+

F3 (Mod)

H

• Recode
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth 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 numeric values for the clinical and functional severity
levels and the number therapy visits in the “REVENUESUM13QTYTHR”
field to recode the second, third, and fourth positions of the HIPPS
code as follows:
• Recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 17  CLINICALSEVEQ4 value

CLINICALSEV
EQ4 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through B

0  1

C1 (Min)

A

C through J

2  9

C2 (Low)

B

K+

10+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 18  FUNCTIONSEVEQ4 value

FUNCTIONSEV
EQ4 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through B

0  1

F1 (Min)

F

C through J

2  9

F2 (Low)

G

K+

10+

F3 (Mod)

H

• Recode
the fourth position of the HIPPS code according to the table below:
REVENUESUM13QTYTHR
value

Resulting
HRGOUTPUTCODE fourth position value

14  15

K

16  17

L

18  19

M

• Move
the resulting recoded HIPPS code to the HRGOUTPUTCODE” fields.
Proceed to HRG payment calculations. Use the weights associated
with the code in the “HRGOUTPUTCODE” field for all further calculations.
3.1.7.3.4 Recoding
steps for claims with “Through” dates on or after January 1, 2016
and before January 1, 2017:
• If
the first position of the HIPPS code submitted in “HRGINPUTCODE”
is a 5 and the number of therapy services in “REVENUESUM13QTYTHR”
is less than 20, read the value in the “EPISODETIMING” field.
• If
the value in the “EPISODETIMING” field is 1, and the
number of therapy services is in the range 013, recode the first
position of the HIPPS code to 1. If the number of therapy
services is in the range 1419, recode the first position of the
HIPPS code to 2.
• If
the value is the “EPISODETIMING” field is a 2, and
the number of therapy services is in the range 013, recode the
first position of the HIPPS code to 3. If the number of
therapy services is in the range 1419, recode the first position
of the HIPPS code to 4.
• Return
to
paragraph 3.1.7.3.3 and recode the remaining
positions of the HIPPS code as described above.
• In
all cases, read only the “REVENUESUM13QTYTHR” field and recode
the fourth positions of the HIPPS code according to the table below,
if possible.
HIPPS
codes beginning with 1 or 3

HIPPS
codes beginning with 2 and 4

REVENUESUM
13QTYTHR value

Resulting
HRGOUTPUTCODE fourth position value

REVENUESUM
13QTYTHR value

Resulting
HRGOUTPUTCODE fourth position value

0  5

K

14  15

K

6

L

16  17

L

7  9

M

18  19

M

10

N



11  13

P



• Move
the resulting recoded HIPPS code to the “HRGOUTPUTCODE” fields.
Proceed to HRG payment calculations. Use the weight associated with
the code in the “HRGOUTPUTCODE field for all further calculations.
• If
the HIPPS code begins with 1 and the value in “REVENUESUM13QTYTHR”
is greater than 13 and less than 20, change the first position of
the HIPPS code to 2, and set the “RECODEIND” to 1.
Recode the remaining positions of the HIPPS as described above.
• If
the HIPPS code begins with
3 and value in “REVENUESUM13QTYTHR”
is greater than 13 and less than 20, change the first position of
the HIPPS code to
4, and set the “RECODEIND” to
3.
Return to
paragraph 3.1.6.2 and recode the remaining positions
of the HIPPS as described above.
• If
the HIPPS code begins with
2 and the value “REVENUESUM13QTYTHR”
is less than 14, change the first position of the HIPPS code to
1,
and set the “RECODEIND” to
1. Return to
paragraph 3.1.6.2 and
recode the remaining positions of the HIPPS code as described above.
• If
the HIPPS code begins with
4 and the value in “REVENUESUM13QTYTHR”
is less than 14, change the first position of the HIPPS code to
3,
and set the “RECODEIND” to
3. Return to
paragraph 3.1.6.2 an
recode the remaining positions of the HIPPS code as described above.
• If
the HIPPS code begins with
1 or
2 and
the value in “REVENUESUM13QTYTHR” is 20 or more:
• Change
the first position of the HIPPS code to
5 and recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 13  CLINICALSEVEQ2 value

CLINICALSEV
EQ2 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through D

0  3

C1 (Min)

A

E through Q

14  16

C2 (Low)

B

R+

17+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 14  FUNCTIONSEVEQ2 value

FUNCTIONSEV
EQ2 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through C

0  2

F1 (Min)

F

D through G

3  6

F2 (Low)

G

H+

7+

F3 (Mod)

H

• Change
the fourth position of the HIPPS code to K.
• If
the HIPPS code begins with
3 or
4 and
the value in “REVENUESUM13QTYTHRU” is 20 or more.
• Change
the first position of the HIPPS code to
5 and recode
the second position of the HIPPS code according to the table below:
Treatment
Authorization Code position 17  CLINICALSEVEQ4 value

CLINICALSEV
EQ4 converted point value

Clinical
Severity Level

Resulting
HRGOUTPUTCODE second position value

A through D

0  3

C1 (Min)

A

E through Q

4  16

C2 (Low)

B

R+

17+

C3 (Mod)

C

• Recode
the third position of the HIPPS code according to the table below:
Treatment
Authorization Code position 18  FUNCTIONSEVEQ4 value

FUNCTIONSEV
EQ4 converted point value

Functional Severity
Level

Resulting
HRGOUTPUTCODE third position value

A through C

0  2

F1 (Min)

F

D through G

3  6

F2 (Low)

G

H+

7+

F3 (Mod)

H

• Change
the fourth position of the HIPPS code to K.
3.1.7.4 HRG
Payment Calculations
3.1.7.4.1 If the
“PEPINDICATOR” is an
N:
• If the weight for
the first four positions the “HRGOUTPUTCODE” from the weight table
for the calendar year in with the “SERVTHRUDATE” falls. Multiply
the weight times the Federal standard episode rate for the calendar
year in which the “SERVTHRDATE” falls. The product is the casemix
adjusted rate. Multiply the casemix adjusted rate by the current
laborrelated percentage to determine the labor portion. Multiply
the labor portion by the wage index corresponding to the CBSA field.
Multiply the casemix adjusted rate by the current nonlaborrelated percentage
to determine the nonlabor portion. Sum the labor and nonlabor portions.
The sum is the wage index and casemix adjusted payment for the
HRG.
• Find
the nonroutine supply weight corresponding to the fifth positions
of the “HRGOUTPUTCODE” from the supply weight table for the calendar
year in which the “SERVTHRDATE” falls. Multiply the weight times
the Federal supply conversion factor for the calendar year in which
the “SERVTHRUDATE” falls. The result is the casemix adjusted
payment for nonroutine supplies.
• Sum the payment results
for both portions of the “HRGOUTPUTCODE” and proceed to the outlier
calculations in paragraph 3.1.7.6.
3.1.7.4.2 If the
“PEPINDICATOR” is a
Y:
• Perform the calculation
of the casemix and wage adjusted payment for the HRG and supply
amount as above. Determine the proportion to be used to calculate
this PEP by dividing the “PEPDays” amount by 60. Multiply the casemix
and wage index adjusted payment by this proportion. The result is
the PEP payment due on the claim. Proceed to the outlier calculation
(see
paragraph 3.1.7.5).
3.1.7.5
Outlier
Calculations
3.1.7.5.1 Wage adjust
the outlier fixed loss amount for the Federal fiscal year in which
the “SERTHRUDATE” falls, using the CBSA code in the “CBSA” field.
Add the resulting wage index adjusted fixed loss amount to the total
dollar amount resulting from all HRG payment calculations. This
is the outlier threshold for the episode.
3.1.7.5.2 Claims with “Through” dates before January
1, 2017: For each quantity in the six “REVENUEQTYCOVVISITS” fields,
read the national standard per visit rates from the revenue code table
for the year in which the “SERVTHRUDATE” falls. Multiply each
quantity by the corresponding rate. Sum the six results and wage
index adjust this sum as described above, using the
CBSA code
in the “CBSA” field. The result is the wage index adjusted imputed
cos for the episode.
• Claims
with “Through” dates on or after January 1, 2017: For each quantity
in the six “REVENUEQTYOUTLIERUNITS” fields, read the national
standard per unit rates from the revenue code table for the year
in which the “SERVTHRUDATE” falls. Multiply each quantity by the
corresponding rate. Sum the six results and wage index adjust this
sum as described above, using the CBSA code in the
“CBSA” field. The result is the wage index adjusted cost for the
episode.
3.1.7.5.3 Subtract the outlier threshold for the episode
from the imputed cost for the episode.
3.1.7.5.4 If the result determined in
paragraph 3.1.7.6.3 is greater than $0.00,
calculate .80 times the result. This is the outlier payment amount.
3.1.7.5.5 Determine whether the outlier payment is subject
to the 10% annual limitation on outliers as follows:
• Multiply
the amount in the “PROVPAYMENTTOTAL” field by 10% to determine
the HHA’s outlier limitation amount.
• Deduct
the amount in the “PROVOUTLIERPAYTOTAL” from the outlier limitation amount.
This result is the available outlier pool for the HHA.
• If
the available outlier pool is greater than or equal to the outlier
payment amount calculated in
paragraph 3.1.7.5.4 return the outlier payment
amount in the “OUTLIERPAYMENT” field. Add this amount to the total
dollar amount resulting from all HRG payment calculations. Return
the sum in the “TOTALPAYMENT” field, with return code 01.
• If
the available outlier pool is less than the outlier payment amount
calculated in
paragraph 3.1.7.5.4 return no payment amount
to the “OUTLIERPAYMENT” field. Assign return code 02 to this record.
3.1.7.5.6 If the result determined in
paragraph 3.1.7.6.3 is less than or equal
to $0.00, the total dollar amount resulting from all HRG payment
calculations is the total payment for the episode. Return zeros
in the “OUTLIERPAYMENT” field. Return the total of all HRG payment
amounts in the “TOTALPAYMENT” field, with return code 00.
3.1.7.6 Home
Health ValueBased Purchasing (HH VBP) Model
3.1.7.6.1 In the Calendar Year (CY) 2016 HHA PPS Final
Rule, CMS finalized its proposal to implement the HH VBP Model in
nine states representing each geographic area in the nation. For
all Medicarecertified HHAs that provide services in Arizona, Florida,
Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee,
and Washington, payment adjustments will be based on each HHA’s
total performance score on a set of measures already reported via
Outcome and Assessment Information Set (OASIS) and Hospital Consumer
Assessment of Healthcare Providers and Systems (HHCHAHPS) for all
patients serviced by the HHA, or determined by claims data, plus
three new measures where performance points are achieved for reporting
data.
3.1.7.6.2 Revisions
have been made to the HH Pricer program to accept the necessary adjustment
factor to apply the HH VBP adjustment and to capture the adjusted
amount on the claim record. The HH VBP adjustment amount will be
placed on the claim as a value code
QV amount.
• Effective January
1, 2018, the HH VBP adjustment factor will be reported in the “PROVVBPADJFAC”
field.
• If no factor is provided,
enter 1.00000.
3.1.7.6.3 The HHAs in the nine HH VBP states will have
their payments adjusted (upward or downward) in the following manner:
• A maximum payment
adjustment of 3% in CY 2018;
• A
maximum payment adjustment of 5% in CY 2019;
• A
maximum payment adjustment of 6% in CY 2020;
• A
maximum payment adjustment of 7% in CY 2021; and
• A
maximum payment adjustment of 8% in CY 2022.
Note: Since the TRICARE
Program is not following Medicare’s payment performance adjustment process
(HH VBP Model), 1.00000 will be reported in field “PROVVBPADJFAC”
for all HH claims resulting in full payment of standard episode
rates.