3.1 HHA PPS Pricer
Requirements
All home health services billed
on Type Of Bill (TOB) 32X shall 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 cost-per-unit approach rather
than a cost-per-visit approach. The national per-visit rates are
converted into per 15 minute unit rates. The per-unit 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. 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 fixed-loss 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 non-routine
supplies;
• The fixed loss
amount to be used for outlier calculations;
• A table of case-mix weights to be used
for each Health Resource Group (HRG);
• A table of supply weights to be used to
adjust the non-routine supply conversion factor;
• A table of national standardized per visit
rates and per unit rates;
• The pre-floor, pre-reclassified hospital
wage index; and
• Changes, if
any, to the RAP payment percentages, the outlier loss-sharing percentage and
the labor and non-labor percentages.
3.1.4 Interface
with Pricer
3.1.4.1 Provide
specification for a 650-byte Pricer input record layout.
3.1.4.2 Contractor’s
claims processing system
shall 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 shall 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 shall apportion
the payment amounts returned from Pricer to the visit lines.
3.1.4.5 The system shall 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 shall be
passed.
3.1.4.6 The system shall assure
all claims with covered visits shall flow
to Pricer, but only covered visits shall be
passed to Pricer.
3.1.4.7 The system shall 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 shall 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 shall pass
a Y/N medical review indicator to Pricer for each HIPPS
code on the claim.
3.1.4.12 The system shall pass
Pricer a Y PEP indicator if the claim shows a patient
status of 06. Otherwise, the indicator shall be N.
3.1.4.13 The system shall 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 shall 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 shall 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 shall be
integrated into the system for customer service and create a new
on-line 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 described
in the CMS Internet-Only Manuals Publication #100-04, Medicare Claims
Processing Manual, Chapter 10, Sections 70.2, 70.3, and 70.4.
3.1.6 Home
Health Value-Based Purchasing (HH VBP) Model
3.1.6.1 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 Medicare-certified 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.
3.1.6.2 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
shall be
placed on the claim as a value code
QV amount.
• Effective
January 1, 2018, the HH VBP adjustment factor shall be
reported in the “PROV-VBP-ADJ-FAC” field.
• If no factor
is provided, enter 1.00000.
3.1.6.3 The HHAs
in the nine HH VBP states
shall 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
“PROV-VBP-ADJ-FAC” for all HH claims resulting in full payment of
standard episode rates.