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.